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Subject: qotd: Patients object to physicians' focusing on costs
Date: Tue, 5 Feb 2013 08:37:33 -0800
From: Don McCanne <firstname.lastname@example.org>
To: Quote-of-the-Day <email@example.com>
Focus Groups Highlight That Many Patients Object To Clinicians' Focusing
Roseanna Sommers, Susan Dorr Goold, Elizabeth A. McGlynn, Steven D.
Pearson and Marion Danis
Having patients weigh costs when making medical decisions has been
proposed as a way to rein in health care spending. We convened
twenty-two focus groups of people with insurance to examine their
willingness to discuss health care costs with clinicians and consider
costs when deciding among nearly comparable clinical options. We
identified the following four barriers to patients' taking cost into
account: a preference for what they perceive as the best care,
regardless of expense; inexperience with making trade-offs between
health and money; a lack of interest in costs borne by insurers and
society as a whole; and noncooperative behavior characteristic of a
"commons dilemma," in which people act in their own self-interest
although they recognize that by doing so, they are depleting limited
resources. Surmounting these barriers will require new research in
patient education, comprehensive efforts to shift public attitudes about
health care costs, and training to prepare clinicians to discuss costs
with their patients.
From a discussion of Implications
The focus-group discussions revealed the following barriers to
participants' choosing less expensive care: the salience of unlikely but
highly upsetting possibilities; a desire for zero risk, rather than for
reasonable risk reduction; an assumption that price always signals
quality; the misperception that health care sustainability can be
achieved by eliminating wasteful spending alone, without needing to
forgo some marginally beneficial care; and the belief that choosing more
expensive care constitutes a kind of victory for patients over the
If patients and clinicians do not discuss and consider costs during the
clinical encounter, the alternatives are problematic. Clinicians might
make cost-conscious decisions—for example, judging when high-priced
resources such as operating room times, hospital beds, imaging, and
specialty referrals are warranted—without informing patients that cost
considerations influenced their decisions. Evidence from other countries
indicates that clinicians do occasionally limit the use of medical
interventions on the basis of concerns about cost. Yet another
alternative would be to make cost-conscious allocation decisions at the
organizational level, with minimal clinician involvement.
Given the long-term projections about health care costs in the United
States, it is inevitable that physicians will face increasing pressures
to deliver cost-effective care to their patients. Doing so openly, in a
way that allows patients an opportunity to hear the justification for
cost-conscious decisions and to be active agents in thinking through
treatment choices when feasible, is consistent with physicians' ethical
duties to be transparent with patients and to provide patient-centered care.
But this study's findings suggest that for cost to be an explicitly
recognized and discussed factor in clinical decisions, public attitudes
about health care costs must first undergo a significant shift.
Comment: Much attention is being directed today toward the very high
costs that plague the U.S. health care system. That attention has not
equated with effectiveness in controlling costs, as we witness continued
increases in spending in spite of introduction of policies that may be
well-meaning but not very effective, that may add to the administrative
excesses of our system, and that sometimes are detrimental such as when
we erect financial barriers to beneficial health care services.
Some of the emphasis has been directed toward increasing the engagement
of the "medical consumer" in the decision process, often through the
policies of consumer-directed health care. These policies are designed
to make patients "better health care shoppers" by forcing them to
recognize costs as they spend some of their own money on health care.
The most common measure is to increase the deductibles and other forms
of cost sharing that the patient must face when accessing care.
This important study used focus groups to determine the attitudes of
potential patients toward injecting cost considerations into the
delivery of health care. Patients don't like it. They feel that they
should receive the care that they should have without insurers or public
programs making decisions on covering care based on cost considerations.
Even if it is their own money, they do not want to compromise their care
based on cost.
Other high-quality systems that are much less expensive than ours are
able to provide care with first dollar coverage, eliminating the
requirement that the patient be involved or even concerned about the
costs of the care that they receive. We do not need to create an
environment of distrust by the patient that would be engendered by
thoughts of health care services being withheld for reasons of cost.
We can make far better clinical decisions based on studies generating
guidelines such as those by the British National Institute for Health
and Clinical Guidance (NICE). An example of how this works is in their
guidance for "Cetuximab, bevacizumab and panitumumab for the treatment
of metastatic colorectal cancer after first-line chemotherapy,"
available at this link:
If we replaced our fragmented, dysfunctional financing system with an
efficient single payer system, and then applied rational decision making
processes for diagnostic and therapeutic interventions, we would not
have to have the patient involved in spending decisions. Those decisions
could be made on a macro-system basis by better planning of system
capacity and distribution, and then incorporating a greater element of
evidence-based decision making.
We really don't need angry, me-first patients provoked by having cost
decisions forced upon them, particularly when the cost transparency
demanded by the advocates of consumer-directed health care creates
hostility towards health care professionals and third party payers whom
they believe are withholding care that they should have, whether it is
true or not.