By Christopher Moriates, MD; Neel T. Shah, MD, MPP; Vineet M. Arora, MD, MAPP
JAMA, July 8, 2013
“First, do no harm” is a well-established mantra of the medical profession, but it may need to be reconceptualized in an era of unsustainable health care spending. Medical bills are now a leading cause of financial harm and physicians decide what goes on the bill. The possible consequential harm is substantial, often leading to lost homes and depleted savings. While the Affordable Care Act will ensure expanded coverage, newly insured Americans will not necessarily be immune from increased costs of their care. More Americans than ever before are enrolled in high-deductible insurance plans, meaning that seemingly simple decisions that physicians make about testing could directly lead to thousands of dollars in out-of-pocket costs. This strain on household budgets can cause further erosion of personal health.
Just as physicians play an important role in preventing serious infections, physicians can also help patients avoid experiencing financial harm as a result of medical care.
SCREEN FOR FINANCIAL HARM
First, physicians can help patients avoid financial harm by screening each patient to determine financial risk and preferences.
ADOPT A UNIVERSAL APPROACH
In 2007, the majority of medical debtors had health insurance at the beginning of their illness, and an estimated 25 million Americans were underinsured. Hence, it is increasingly difficult to know which patients will be faced with insurmountable medical bills in the near future. Since physicians cannot be sure which patients will ultimately have unaffordable medical bills, they should treat all patients as if they could be.
This approach applies to both inpatient and outpatient encounters because patients often face significant financial obligations in both settings. Although physicians may assume that hospitalizations for insured patients are automatically covered by health plans, in reality these patients may still face large co-payments. Thus, in some instances whether hospitalization can be avoided should be discussed. In addition, the payer may refute the appropriateness of admission or leave coverage gaps due to high deductibles, caps, or other cost-sharing mechanisms. In the ambulatory care setting, patients may pay a percentage of the fees for services.
UNDERSTAND FINANCIAL RAMIFICATIONS AND VALUE OF RECOMMENDATIONS
Many studies demonstrate that physicians are unaware of the cost of routinely ordered tests, let alone the potential financial risks for patients seeking care. To explain potential options and their fiscal implications to patients, physicians will need to take responsibility for knowing the financial ramifications of the care they are providing.
OPTIMIZE CARE PLANS FOR INDIVIDUAL PATIENTS
Physicians also should learn how to optimize personalized health care decisions for patients’ financial health.
CONCLUSIONS
Financial concerns are important to patients and physicians need to be prepared to address this aspect of their care. Although these financial discussions may present some challenges, physicians already participate in difficult discussions with patients about opiate abuse, domestic violence, and end-of-life decisions. To provide truly patient-centered care, physicians can live up to the mantra of “First, do no harm” by not only caring for their patients’ health, but also for their financial well-being.
For the full JAMA article (free access):
http://jama.jamanetwork.com/article.aspx?articleID=1709839
Comment:
By Don McCanne, M.D.
In these days of outrageous health care costs physicians now have not only the obligation to provide care as close to optimal as the circumstances will allow, they also have an obligation to prevent personal financial harm to the patient that could result from their medical decisions. But should the latter really be the physicians’ obligation?
The authors of this JAMA article list steps to be followed during patient encounters designed to prevent financial harm to patients. Doesn’t the physician already have enough to do without having to become the keeper of the patients’ pocketbooks? Unfortunately, under our current dysfunctional system of financing health care, too many patients face significant financial barriers to care. The physician remains the person in charge of determining the magnitude of those barriers, simply based on the medical management selected.
The Affordable Care Act will not help much since the new standard for private insurance is low actuarial value, high-deductible plans. In fact, the financial barriers will become more commonplace as employers are now greatly expanding the use of consumer-driven, high-deductible plans.
Patients who previously weren’t concerned much about their out-of-pocket costs are now going to want more information from physicians about what their own plans will or will not cover, how much they will have to pay out-of-pocket, whether the specialists or diagnostic facilities are in or out of their networks, which prescriptions are covered and under what tier, and many other spending issues for which the physicians frequently do not have the answers. Yet knowing the answers is now becoming the responsibility of physicians?
Why do we have a system with so much financial exposure to patients when other nations have much lower national health expenditures with cost sharing usually at negligible levels? It is because of the nutty idea that only patients can control costs when they have to pay out-of-pocket (consumer-driven health care), when we know that is absolutely untrue. Other nations have proven that there are far more effective methods of controlling costs that not only provide financial security for the patients, but also improve the allocation of health care dollars, providing higher quality and greater value.
Physicians should be leading the bandwagon in first doing no financial harm by supporting a system that totally separates financing from the clinical environment. If they could convince the nation that we need a single payer national health program then they could proceed with tending to patients’ health care needs while letting our own public administrators deal with the financing of the system.
Financial barriers harm patients. It is our obligation to first do no harm by removing those barriers – for everyone. Then we can get on with simply taking care of the patients.