Tips on talking money with patients

One afternoon in November, Jim Hardee, MD, an internist in Westminster, Colo., saw a patient in his late 40s who was complaining of back pain. The problem was nothing life-threatening, but Dr. Hardee recommended the patient see a neurosurgeon and talk about scheduling surgery.

"He said, 'I can't afford it,' " Dr. Hardee recounted. It turned out that the man, who had a good job and comprehensive health insurance, was still paying for previous bariatric surgery and also couldn't afford to take time off from work to recover from a second operation.

The physician said he and the patient decided to hold off on back surgery, but continue chiropractic care, physical therapy and pain medication. Eventual weight loss from the bariatric surgery might also help ease the patient's back pain and make spinal surgery unnecessary, Dr. Hardee said.

That was one of the easier conversations about out-of-pocket costs Dr. Hardee has had. He's developed his own protocol to get through the more awkward ones, and to prepare for an increasing number of financial discussions with patients.

Experts advise more doctors to develop effective ways to talk about costs.

Research suggests that while physicians and patients recognize cost is a significant factor for whether a patient will follow a given treatment, and that physicians know they should talk about cost, most visits omit that critical conversation.

"I read a point-counterpoint online where a physician wrote that costs should never be an issue when it comes to care," Dr. Hardee said. "That's true in a perfect world, where no one worries about the cost of care. But they do. And so given that reality, what can we do to help them?"

Experts say there are some powerful trends at work making it imperative to talk frankly with patients about what treatments will cost, and to be ready for patients to bring it up.

One cause, the growing prevalence of consumer-directed health plans, was the impetus for a paper reviewing the best ways to discuss costs with patients. The study was published online in November by the Journal of Family Practice.

Co-author Mark A. Hall, professor of law and public health and director of the Center for Bioethics, Health and Society at Wake Forest University, in Winston-Salem, N.C., said that before health insurance shielded patients from the true cost of care, physicians were much more comfortable talking about costs and making judgment calls about treatment based on a patient's ability to pay.

Insurance now is more likely to come with high levels of cost-sharing, so physicians need to return to thinking about how to discuss treatment options and payment, Hall said. "This is something doctors should no longer disregard, because it's now becoming important to the patient in the way it was prior to their having insurance."

American Medical Association policy encourages physicians to "continue to volunteer fee information to patients, to discuss fees in advance of service where feasible, to expand the practice of accepting any third-party allowances as payment in full in cases of financial hardship, and to communicate voluntarily to their patients their willingness to make appropriate arrangements in cases of financial need."

Trends pushing physicians to do a better job talking about money with patients include the economic recession, which has left many patients who once had comprehensive coverage through work either uninsured or on Medicaid.

Many of those who still have jobs will find out in January 2010 that their employer has switched to a more limited health plan, with a higher deductible. If they have kept the same benefits, the deductible will reset, leaving patients to pay out of pocket for care received early in the year.

Dr. Hardee, who wrote a paper in the Journal of General Internal Medicine in 2005 about the best ways to talk to patients about costs, said the recession has pushed more patients to ask about what a prescription or specialist visit will cost.

Some are relieved when he brings it up. "I've had several patients thank me for asking."

Dr. Hardee advises physicians to find a way to talk about costs in a nonjudgmental, neutral tone, and to look for cues that a patient may be worried about paying for care.

Researchers have found that the reasons these conversations are rare include embarrassment on the part of both physicians and patients, ignorance of treatment costs, and lack of time.

Roland Goertz, MD, a family physician from Waco, Texas, who is also president-elect of the American Academy of Family Physicians, said the barriers to talking about costs with patients go beyond just awkwardness to a longtime taboo.

When he was in medical school, he said, some professors taught never to talk about cost with patients. He now disagrees with that advice, but he recognizes that making the jump from "never" to "always" is challenging.

"I think it's part of treatment protocol to ascertain what a patient can afford," Dr. Goertz said. "The classic story is that you write a person a prescription for diabetes or hypertension, then don't find out until later that they didn't have enough money to fill the prescription. That certainly is not helping the patient or your relationship."