Roseanna Sommers, Susan Dorr Goold, Elizabeth A. McGlynn, Steven D. Pearson and Marion Danis

Health Affairs, February 2013

Abstract

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 insurance companies.

Conclusion

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.

http://content.healthaffairs.org/content/32/2/338.abstract

Comment:

By Don McCanne, M.D.

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: http://guidance.nice.org.uk/TA242/Guidance/pdf/

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.