Tuesday, July 9, 2013

Fwd: qotd: First do no financial harm

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-------- Original Message --------
Subject: qotd: First do no financial harm
Date: Tue, 9 Jul 2013 11:36:37 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

July 8, 2013
First, Do No (Financial) Harm
By Christopher Moriates, MD; Neel T. Shah, MD, MPP; Vineet M. Arora, MD,

"First, do no harm" is a well-established mantra of the medical
profession, but it may need to be reconceptualized in an era of
unsustainable health care spending. Medical bills are now a leading
cause of financial harm and physicians decide what goes on the bill. The
possible consequential harm is substantial, often leading to lost homes
and depleted savings. While the Affordable Care Act will ensure expanded
coverage, newly insured Americans will not necessarily be immune from
increased costs of their care. More Americans than ever before are
enrolled in high-deductible insurance plans, meaning that seemingly
simple decisions that physicians make about testing could directly lead
to thousands of dollars in out-of-pocket costs. This strain on household
budgets can cause further erosion of personal health.

Just as physicians play an important role in preventing serious
infections, physicians can also help patients avoid experiencing
financial harm as a result of medical care.


First, physicians can help patients avoid financial harm by screening
each patient to determine financial risk and preferences.


In 2007, the majority of medical debtors had health insurance at the
beginning of their illness, and an estimated 25 million Americans were
underinsured. Hence, it is increasingly difficult to know which patients
will be faced with insurmountable medical bills in the near future.
Since physicians cannot be sure which patients will ultimately have
unaffordable medical bills, they should treat all patients as if they
could be.

This approach applies to both inpatient and outpatient encounters
because patients often face significant financial obligations in both
settings. Although physicians may assume that hospitalizations for
insured patients are automatically covered by health plans, in reality
these patients may still face large co-payments. Thus, in some instances
whether hospitalization can be avoided should be discussed. In addition,
the payer may refute the appropriateness of admission or leave coverage
gaps due to high deductibles, caps, or other cost-sharing mechanisms. In
the ambulatory care setting, patients may pay a percentage of the fees
for services.


Many studies demonstrate that physicians are unaware of the cost of
routinely ordered tests, let alone the potential financial risks for
patients seeking care. To explain potential options and their fiscal
implications to patients, physicians will need to take responsibility
for knowing the financial ramifications of the care they are providing.


Physicians also should learn how to optimize personalized health care
decisions for patients' financial health.


Financial concerns are important to patients and physicians need to be
prepared to address this aspect of their care. Although these financial
discussions may present some challenges, physicians already participate
in difficult discussions with patients about opiate abuse, domestic
violence, and end-of-life decisions. To provide truly patient-centered
care, physicians can live up to the mantra of "First, do no harm" by not
only caring for their patients' health, but also for their financial

For the full JAMA article (free access):

Comment: In these days of outrageous health care costs physicians now
have not only the obligation to provide care as close to optimal as the
circumstances will allow, they also have an obligation to prevent
personal financial harm to the patient that could result from their
medical decisions. But should the latter really be the physicians'

The authors of this JAMA article list steps to be followed during
patient encounters designed to prevent financial harm to patients.
Doesn't the physician already have enough to do without having to become
the keeper of the patients' pocketbooks? Unfortunately, under our
current dysfunctional system of financing health care, too many patients
face significant financial barriers to care. The physician remains the
person in charge of determining the magnitude of those barriers, simply
based on the medical management selected.

The Affordable Care Act will not help much since the new standard for
private insurance is low actuarial value, high-deductible plans. In
fact, the financial barriers will become more commonplace as employers
are now greatly expanding the use of consumer-driven, high-deductible plans.

Patients who previously weren't concerned much about their out-of-pocket
costs are now going to want more information from physicians about what
their own plans will or will not cover, how much they will have to pay
out-of-pocket, whether the specialists or diagnostic facilities are in
or out of their networks, which prescriptions are covered and under what
tier, and many other spending issues for which the physicians frequently
do not have the answers. Yet knowing the answers is now becoming the
responsibility of physicians?

Why do we have a system with so much financial exposure to patients when
other nations have much lower national health expenditures with cost
sharing usually at negligible levels? It is because of the nutty idea
that only patients can control costs when they have to pay out-of-pocket
(consumer-driven health care), when we know that is absolutely untrue.
Other nations have proven that there are far more effective methods of
controlling costs that not only provide financial security for the
patients, but also improve the allocation of health care dollars,
providing higher quality and greater value.

Physicians should be leading the bandwagon in first doing no financial
harm by supporting a system that totally separates financing from the
clinical environment. If they could convince the nation that we need a
single payer national health program then they could proceed with
tending to patients' health care needs while letting our own public
administrators deal with the financing of the system.

Financial barriers harm patients. It is our obligation to first do no
harm by removing those barriers - for everyone. Then we can get on with
simply taking care of the patients.

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