Discussing Costs or Bills With Patients

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DrDrummer

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I was reading this article: http://www.theatlantic.com/health/archive/2015/05/the-agony-of-surprise-medical-bills/393785/ that discusses the increasing spread of free-standing "emergency departments" (I use the scare quotes because I have a hard time seeing how something that is free-standing can, by definition, be a department of anything unless it's a branch office) and the high probability of patients who present to these or hospital EDs receiving out-of-network billing for in-network hospitals.

It got me thinking about the discussions that providers (usually not physicians, but I'm sure sometimes them) have with patients in the ED about the costs of tests-- once you're in the door of course, you're stuck with certain charges, but moving forward with a workup confers additional costs. How many of you ever discuss these costs with patients? If you do, how do you frame these?

I'm heading off to start residency this summer, so this is a question asked from the perspective of a learner. From my vantage point, it seems like in an ideal world you could have these discussions, but if you're ordering tests appropriately it is to rule out or diagnose dangerous conditions in an undifferentiated patient, making worrying about cost less appropriate. In the ED setting, there isn't a huge role for discussions of where one could cut corners or save money on the workup, and discussions of payor status seem like that might be putting at hazard your objectivity or even risk violating some sort of law. Would appreciate the perspectives of any attendings who have figured out a way to strike a balance here, or who have thought about it and decided for reasons x, y, or z that it's not their job and that they shouldn't worry about it.

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It got me thinking about the discussions that providers (usually not physicians, but I'm sure sometimes them) have with patients in the ED about the costs of tests-- once you're in the door of course, you're stuck with certain charges, but moving forward with a workup confers additional costs. How many of you ever discuss these costs with patients? If you do, how do you frame these?

I think it's somewhat easy to frame these discussions in the ED, especially when your pre-test gestalt is that there's nothing really emergent going on.

"Here in the ED we always think in terms of worst case scenarios; we are trained to think about what is the most life threatening thing that could be happening and rule that out. Now, in terms of probabilities, what you have going on isn't all that dangerous. But that's not why I'm here. I'm not here to tell you what you do have. I'm here to tell you all of the bad things that you don't have. In order to do that I need to run test A, B, and C. These tests aren't cheap but it's the only way to get peace of mind that you don't have a dangerous life threatening condition. Your primary care doctor, who knows you far better than I do, might be able to look at you and say 'this is normal for you, don't worry'. And if they order the tests as an outpatient it also doesn't come with a significant up-charge for the same test. But it would take time. And if the life threatening condition does actually exist, then you'd be letting it go on for a lot longer than it needs to and it could have some very serious consequences. Now, my job is only to recommend what is best for you medically. You have to weigh that recommendation along with whatever is happening in your life socially, financially, etc, etc. I think we should do these tests to make sure nothing bad is going on. Think about it and I'll be back in a few minutes."

If my pre-test gestalt is higher, then it goes like this.

"I'm ordering tests A, B, and C, and I'll be back to discuss the results when they're done."
 
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In general, I think it is something that is important for physicians to do.

However, when you chose to go to something with Emergency in the name, those discussions become much less practical/relevant. If I call 911 because my kitchen is on fire, I don't care that they destroy my lawn, trample my flowers, hack down the back door and destroy everything in the room with water. Consent for such action is presumed to be given once you call 911 and implicitly declare an emergency.

Without EMTALA, I thnk it is reasonable in triage/reception to let patients know potential costs. "You say your 12 year old has had some belly pain, feels 'icky' but is eating fine. We will be glad to see him. However, we have to let you know that the bill will likely be $3,000, and there is a good chance you will have to pay all of it yourself. On the other hand,..."

But if you come in and essentially say it is an emergency, then we have to treat it as such and price considerations are not an initial concerns. When everything has been ruled out, and options are being discussed, then it probably should be discussed.
 
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Determining what a patients ultimate bill is going to be is like answering the question, "Doc, how much longer do I have to live?"

You can guess but half the time you'll over shoot, half the time you undershoot and 100% of the time you'll end up looking like a fool.

There is no way to accurately predict. The system is so complex, with physician fees, hospital facility fees, in network, out of network, different prices negotiated depending on what insurance the patient has, if any. These, amongst many other variables, ultimately effect the final cost of a seemingly simple healthcare encounter.

It's not like ordering off the dollar menu at McDonalds. It's an overly complex, cluster*bleep* of epic proportions. It's almost impossible to accurately answer this simplest sounding of healthcare cost questions.
 
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One problem is that I don't know how much a lot of this costs, and the pricing process is so opaque that it's quite difficult to determine in advance what the patient's eventual bill will actually look like.
 
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Determining what a patients ultimate bill is going to be is like answering the question, "Doc, how much longer do I have to live?"

You can guess but half the time you'll over shoot, half the time you undershoot and 100% of the time you'll end up looking like a fool.

There is no way to accurately predict. The system is so complex, with physician fees, hospital facility fees, in network, out of network, different prices negotiated depending on what insurance the patient has, if any. These, amongst many other variables, ultimately effect the final cost of a seemingly simple healthcare encounter.

It's not like ordering off the dollar menu at McDonalds. It's an overly complex, cluster*bleep* of epic proportions. It's almost impossible to accurately answer this simplest sounding of healthcare cost questions?

Looks like we posted almost the same thing at almost the same time.

This is one of the worst aspects of medicine in the US. How can we expect patients to make informed decisions if we, as the doctors, don't even know what things cost?
 
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Looks like we posted almost the same thing at almost the same time.

This is one of the worst aspects of medicine in the US. How can we expect patients to make informed decisions if we, as the doctors, don't even know what things cost?
We can't. The cost inflation train is off the track.
 
Looks like we posted almost the same thing at almost the same time.

This is one of the worst aspects of medicine in the US. How can we expect patients to make informed decisions if we, as the doctors, don't even know what things cost?

Yeah, I think it sounds like my understanding of the complexity and difficulty of this issue jibes with the experience of attendings: predicting or discussing costs in medicine is difficult if not impossible, and even harder in the ED. It also sounds like there's a range of attitudes out thre in terms of how much of an attempt people make to give patients a heads-up or choice or "shared decision making" (a buzzword I know can be sorta hypertension inducing for some, but a concept I think is important if you're pragmatic about it). Guess I'll have to figure out my own balance (or more accurately during training, my attendings').

I know there have been studies done on the effect of giving providers estimates of costs of various lab tests, imaging studies on their ordering of those things-- definitely had an impact, seemingly without increasing adverse events, but it's a slippery slope and nobody wants to be on a witness stand trying to explain how they didn't order a CT or something because the indication was questionable and the patient didn't get it due to cost.

Xaelia- you have mentioned you incorporate cost into your SDM practice-- any tips or examples of how you did this at your two former workplaces or how it plays into things (if it does) in a Kaiser-esque setting?
 
The other problem with giving a rather expensive quote...
Without EMTALA, I thnk it is reasonable in triage/reception to let patients know potential costs. "You say your 12 year old has had some belly pain, feels 'icky' but is eating fine. We will be glad to see him. However, we have to let you know that the bill will likely be $3,000, and there is a good chance you will have to pay all of it yourself.
...is that "Without EMTALA" bit. With EMTALA, that statement could be construed as a violation or an attempt to discourage the patient from seeking care.

I tell people that the insurance policies etc are so complicated that they would have to talk to their insurance company to figure out what a test might cost. Even if the hospitals gave us menus, they would change the prices because the big companies negotiate cut rates. Nobody can really make an informed decision in that setting.

When I explain to a patient that a test is not necessary or appropriate, I will often include a positive comment about cost savings. Mutually beneficial. Except for the disheartening responses of the fully non-self-insured, societally cushioned patient: "I don't care, I'm not paying for it!"
 
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