Considering costs and coverage in treatment

A column that answers questions on ethical issues in medical practice

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted July 5, 2004.

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How do you discuss diagnosis and treatment options with patients without knowing what medical services their insurance plans cover, what they can afford, what specialists are in their network, etc?


"The art of necessities is strange, That can make vile things precious." -- William Shakespeare, "King Lear"

Complexity can be trying, but also an inviting challenge. Physicians eagerly take on complicated medical problems of their patients. Nonmedical complications of the clinical encounter, such as coverage and paperwork issues, however, are increasingly frustrating. They can be detrimental to strong patient-physician relationships of trust and to the good care we want to provide.

Regardless of financial arrangements or the health care setting, promoting the best interests of the patient must be the physician's primary commitment. Easier said than done? Unfortunately, the plethora of health plans and variations in coverage makes it seem so.

Suppose the best medication for a particular patient is one that is not covered or that she cannot afford. Should she know that and raise the issue with the physician during the office visit? "Well, doctor, I understand, but I don't think my plan covers drug X." Or would she find out at the pharmacy after she has left the office, leading her to ask, "What do you mean my plan doesn't cover drug X? That's what my doctor says I must have."

Professional (and probably personal) experience tells us that patients don't always anticipate that they will need certain benefits, and, when they do, they are sometimes shocked and angry to discover that they are not available-- even if they have chosen a plan with coverage restrictions in order to get a lower premium. If patients have no choice about their plan, such as Medicaid patients or those with only one work-related plan, they may not review their benefits carefully because no other plan is available. The scenario above assumes that most patients do not know the details of their plans.

How, then, to promote the patient's best interests in the real world?

The American College of Physicians' Ethics Manual says that in implementing that fundamental duty, the physician's professional role is to make recommendations based on medical merit and to pursue options that comport with the patient's unique situation and preferences.

This requires sufficient patient and physician communication, an engaged relationship, and an informed patient. Communication takes time, which is limited in the office visit and subject to increasing pressures. But it does not necessarily take a lot of time.

In our example, it may be a matter of a brief conversation including a statement such as, "I usually prescribe drug X for this condition and would like to give you a prescription for that. But if there are cost problems, let me know; we'll try something else and I will call it in."

Or for referrals, "I often refer patients to Dr. Smith for consultation in these kinds of circumstances, but let's have the front desk check to see if she is in your plan network. If she is not, we can find you another specialist or, of course, you could opt to pay out of plan to see Dr. Smith." If a needed test or procedure is disputed, the physician must serve as the patient's advocate with the health plan. But that is a subject for another time.

If physicians write prescriptions, schedule tests, or make referrals that turn out to be uncovered or if the patient is unable or unwilling to pay, health outcomes and the physician's relationship with the patient may be damaged. Therefore, it may actually save time, preserve the patient-physician relationship, and promote health outcomes to have a brief discussion and open up the possibility of alternatives at the time they are recommended, rather than suggest a care plan that ultimately has to be changed to the patient's surprise.

In summary, physicians should advocate for open, clear, and effective communication about benefits available to patients and encourage patients to be more knowledgeable about their covered benefits. Health plans, purchasers, clinicians, patients, and the public share responsibility for the appropriate stewardship of health care resources. We serve our patients best and uphold the standards of professionalism when patients are well-informed about care and treatment options and all financial and benefit issues that affect the provision of care -- and when patients actually get the care that they need.

Jay A. Jacobson, MD, Professor of Internal Medicine and Infectious Diseases; Chief of the Division of Medical Ethics at LDS Hospital and the University of Utah School of Medicine, Salt Lake City

Lois Snyder, Director, Center for Ethics and Professionalism, American College of Physicians; Adjunct Assistant Professor of Bioethics, Center for Bioethics, University of Pennsylvania, Philadelphia.


Primum non nocere.

Given that patients expect the best possible care, how would a patient feel if his or her doctor provided substandard care because the patient's insurance carrier refused to cover the care that was best? How would that affect a patient's faith in that physician? Would the patient lose respect for the medical profession? Is blaming the problem on the insurance company exculpatory?

I posit that it is not, and I challenge physicians to advocate vigorously for appropriate patient care and services. It erodes the patient-doctor relationship to view physicians only as dispensers of advice against an economic backdrop.

Knowing that the outcome of a treatment plan will be subject to insurance approval causes anxiety for both patient and physician. The good physician must engage the patient in discussion of the treatment options and transmit clear and credible medical information without considering payment for services or insurance coverage.

Although in reality insurance constraints make it impossible for physicians to guarantee access to all services, they must strive to discuss clinically superior treatment options first and then work with the patient on how to obtain coverage for these services.

Patients purchase insurance coverage in response to uncertainty, and they expect that when they become ill the insurance will alleviate much of the financial burden of illness. The health care market, however, uses embedded incentives to promote cost-restricting behavior among individual physicians.

Medical professionalism demands that the physician resist market attempts to restrict treatment solely on the basis of cost. The physician's treatment decisions must be driven primarily by the patient's interest. And, while they should be as cost-effective as possible, they must not be cost-driven.

Even where pharmacy formularies limit a physician's ability to prescribe preferred medications, and utilization review decisions curtail the ordering of certain tests and referrals, physicians can adopt creative strategies to overcome these hurdles.

Faced with patients who lack insurance coverage for medications and services, physicians should express sympathy about this lack of coverage and candidly discuss different medications and alternative sources of services.

They should find out, if possible, about the patient's financial resources; how much he or she can contribute to a particular course of care; would she be willing to try a generic version of the drug or to have a procedure that is unauthorized by her insurance plan provided out of network at a less expensive government or public safety-net hospital? Does he or she have veterans' benefits?

It is imperative that physicians work with patients to ensure that core medical services remain available to them.

Imagine looking a patient in the eye, informing her that her mammogram result was suspicious, and then advising her to pay out-of-pocket for a follow-up mammography, breast ultrasound or visit to a breast surgeon because delaying until her next reimbursed mammogram could mean tumor growth and spread of cancer.

Physicians who abdicate the role of advocate and healer by not seeking ways to provide the best possible care within the constraints of the insurance plan also shirk their responsibility to "first do no harm." And, they expose themselves to direct liability for failure to uphold the proper standard of care.

In this era of managed health care, medical necessity is the mantra under which all physicians practice. The determination of medical necessity is not an easy one; most definitions of medical necessity incorporate the principle of providing services which are "reasonable and necessary" or "appropriate" in light of clinical standards of practice. The lack of objectivity inherent in these terms often leads to widely varying interpretations by physicians and insurance companies on what care to provide.

Without discarding veracity, physicians can offer most of the necessary patient care by clearly delineating and documenting the problem and the reason for the medical course of action. By being familiar with insurers' treatment guidelines and their review and appeals processes, physicians can act effectively on behalf of patients. Physicians should also be aware that most hospitals are nonprofit or 501(c)(3) organizations and, as such, may have hidden programs through which portions of patients' bills for both inpatient and outpatient services can be written off. Obtaining access to these benefits can be time-consuming for the physician, but hospital patient relations departments can be valuable sources of assistance.

We enter into patient relationships that are founded on mutual trust, reinforced by respect and free of monetary distractions. It is through these relationships that we find the strength to persevere as advocates for our patients. What we receive from the patient-physician relationship nourishes our souls and fortifies us for the next insurance battle down the road.

June M. McKoy, MD, MPH, Instructor of medicine, Northwestern University Feinberg School of Medicine, Chicago

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.

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