I grew up in a lower middle class household. My dad was an insurance salesman, and we needed to live within a budget. The thought that we might buy something without considering the cost was unfathomable. As a doctor now, I wonder how we expect our patients to make healthcare purchases without this information. Why do we need to even justify discussing cost with patients?
For a long time, patients have been insulated from the total cost of healthcare. Employer-subsidized health insurance, which came into its own after World War II, has been the predominant mechanism by which working-age Americans obtain healthcare. Employers historically paid the majority of the premium costs. Patients historically paid a portion of the premium, a modest deductible, and a copay and/or coinsurance in return for healthcare services and treatments. Medicare beneficiaries have been responsible for a 20% coinsurance for Medicare Part B benefits. Unless the cost of care became so great that it approached the maximum benefit, few people paid attention.
To make things more confusing, healthcare continues to be billed separately by each provider in a byzantine array of charges and discounts. An explanation-of-benefits form may outline the majority of the costs, although most people cannot really understand these documents.
But healthcare insurance is changing. The financial stability of families, employers, and the government is impacted by escalating, unsustainable healthcare costs. The patient has much more financial responsibility and risk in the new healthcare system. Many employers who remain committed to providing healthcare benefits have shifted financial responsibility to their employees. More of the premium cost is now borne by the employee. In addition, employees are responsible for more out-of-pocket expenses through higher deductibles, coinsurance, and copays.
Health plans have aggressively implemented solutions to help control these rising costs, such as creating networks of high-value providers and tiering pharmacy benefits. Medicare is also exploring novel delivery methods to increase value. The emergence of health exchanges has also aided a new influx of patients with insurance benefit designs that build on highly managed care to optimize value and benefit. Many of the plans include high deductibles and high copays. What does all of this mean? Patients are feeling it in the pocketbook.
Patients with cancer are a special high-cost group. Active treatment is expensive. The deductible is almost always met in the first month of therapy. Coinsurance of many high-cost services requires that patients pay more out of pocket. Specialty pharmacy is especially expensive. Most patients are totally unprepared for these expenses, and many cannot afford them. Medical costs are now the most common cause of personal bankruptcy. Growing evidence (and common sense) suggests that concerns regarding cost of care have a significant impact on patient quality of life. This is such a widely recognized problem that it has even earned a name: “financial toxicity.”
In general, oncologists have been ill-equipped to manage this type of toxicity. Most physicians have a fundamental understanding of health insurance, but they do not always understand the difference between Medicare Part A, B, C, and D, or the relationship among patients’ deductibles, coinsurance, and copays. And in oncology, they almost never really know the cost of the treatment plan they recommend. They may know in a qualitative way what is expensive, and what is really expensive, but when the incredible variety of insurance benefit designs is added, they are incapable of providing even a ballpark quantitative estimate.
Many practices offer financial counseling services, which do allow patients the opportunity to review out-of-pocket costs after a plan has been formulated. But only in cases where patients really cannot afford the expense is this plan changed. After all, patients trust that the doctor recommended the best personalized plan.
This view of the oncology world is wrong. There are many factors that contribute to a particular treatment plan, including efficacy and toxicity. Cost should be one of them. This is especially true when there are a number of equivalent options. Honesty and a fair presentation of efficacy, toxicity, as well as cost is the moral responsibility of the physician.
Several immediate actions will help to achieve evaluation and transparency of costs. First, physicians need to have access to the cost of care at the point of care. Several electronic medical record systems and clinical pathway tools are offering this information now. Second, physicians need to be educated about the “value” of the many options available to patients. In other words, they need to understand the quality of care provided for the costs. The National Comprehensive Cancer Network and the American Society of Clinical Oncology have projects to objectively present this information to oncologists.
Finally, medical students, residents, and fellows need education in the economics of healthcare. Less than 15% of oncologists will pursue academic careers, and the rest will be directly impacted by how healthcare is paid for in this country. Doctors are responsible for discussing how healthcare decisions affect the whole patient, and our next generation of physicians should learn this at the same time they learn to read electrocardiograms.
Attention to cost is a patient-centric approach. Patients must plan for out-of-pocket costs. Cost and quality should be discussed transparently with patients as a component of shared decision-making. Ignorance on the part of the physician is not an excuse. When patients can make decisions that are informed by all aspects of their care—from risks to benefits to costs—they will have more confidence in their path and with the physician guiding their care.