Should Physicians Be Experts on Cost?

It was during my third year of medical school when I was first identified as a medical expert. A college friend asked my opinion about his father’s medical condition and assumed I would be helpful. “I don’t know anything, why is he asking me,” I thought. When it happened again, this time about a rash, I asked my colleagues, “Do your friends and family treat you as a medical expert?” Many replied they had been “experts” since those close to them found out they had been accepted to medical school. When I declared an interest in psychiatry I became the psychiatric expert. Friends still asked what I knew about a particular procedure or wanted me to advocate with their doctor for them, but they also asked questions about whether family members were manic, if I thought someone needed an antidepressant, or even whether I thought someone else was “crazy.”

Today, 4 years out of training, I am more comfortable dealing with these questions. I am willing to answer or look for an answer if I think it can be helpful. Perhaps this is because I find myself more often in the role of the patient. I better understand how important trusted information is and how frustrating it can be to feel unheard. When someone asks me a medical question, I draw on my experiences as both physician and patient. I find myself participating more in conversations about medical issues and sharing my experiences. Recently, many of these conversations have focused on cost—frustration that costs are unknowable in advance; disappointment when claims are denied; confusion about what might constitute medically necessary treatment or how the appeals process for a denied claim works.

In my circle no one knows much about financial issues in medicine: how much procedures really cost; how cost impacts medical decision-making; whether cost or outcome should determine direction of care.^1-3 Moreover, no one thinks that I might be an expert on these issues. Of all the questions I’ve been asked, I’ve never been asked about cost or reimbursement. Why might that be? The issue is clearly in the national consciousness: health care cost is cited as likely to bankrupt the US; the recently passed health care bill is called “The Affordable Care Act”; discussions are more prevalent in the media—on TV, in print, and online. Governments, insurance companies, and entrepreneurs are trying to make cost information more available to patients with the idea this will drive down cost.⁴

We physicians are late to the conversation. Granted, we too are publishing articles and editorials on this topic. We’ve done surveys that show how bad we are at knowing the cost of the medications, procedures, and treatments we provide. Several studies have even attempted to see if providing cost information prospectively to physicians could modify their behavior and lower costs of treatment without sacrificing care.

Still, how often do we have conversations with our patients about how much treatment will cost?⁵ Clearly issues of quality remain paramount in medicine, ie, which treatment is likely to provide the best outcome. While it is appropriately pragmatic to include cost in this calculus, it should remain a part of the decision, not the only parameter in decisions about treatment. How to balance price and quality in treatment planning should not be left solely to the patient; the fact is patients want help from their physician in deciding what treatment is most appropriate. How can we help if we do not understand all aspects of a patient’s care, including cost?

Earlier this year the American College of Physicians had to spell out that it is ethically appropriate for physicians to talk about cost with patients. This speaks to how far we as physicians have to go to be fully engaged in this conversation. Cost issues have been changing the way we practice medicine for a long time, and we need to become experts, for our friends, family, and ourselves.