The Elusive Cost of Care

My right knee started bothering me on a long run a month ago. After weeks of pain, fruitless physical therapy, and no clear diagnosis, I had an MRI scan of my knee. Thankfully, nothing major showed up – just a persistent case of tendonitis. As a competitive runner hoping to compete in the Olympic Trials, I asked my doctor several questions: When will I be able to run again? What kind of cross-training should I do in the meantime? How many times a day should I ice? What can I do to keep this tendonitis from recurring? Should I hold off on buying plane tickets to that big race in December? I failed to ask one important question, though: How much money will I have to pay for treatment? This failure is especially frustrating and surprising since my year-long Master’s Project focuses on clinical conversations about healthcare costs. I spend hours each week reading, writing, thinking, and talking about how doctors and patients can more effectively discuss out-of-pocket costs. If anybody should have the knowledge and resources to discuss medical costs, I should.

Yet here I was, a patient so focused on my running career that I completely forgot to ask how much my knee injury would cost. That MRI had a price tag worth more than just time, but my doctor and I did not discuss my ability or willingness to pay for it. Later, I felt stupid for agreeing to an expensive test without first knowing the toll it would take on my bank account.

I justified my experience somewhat by knowing the high value I placed on the information an MRI could offer. Even if I had known the exact stomach-churning price of my MRI, I probably still would have gotten the test. Others in my position may not have placed as high a premium on that information, however, and would have chosen a few more weeks of watchful waiting over high-priced MRI test results. The absence of cost information makes it nearly impossible for most patients to decide whether such tests are worth it for them.

Once I returned for my follow-up visit, I investigated the cost of my MRI in earnest. I spoke with half a dozen Duke Sports Medicine employees to try and learn how much I would pay for this test. None of these people could give me an answer. I have the same insurance as most Duke students – Blue Cross Blue Shield Student Blue – so I pay 20% coinsurance for most treatments, tests, and procedures. This means that, to learn the amount I pay for an MRI, I must first know the total cost of the MRI (then I pay 20% of what’s left after I pay the co-pay). No one at the clinic could tell me the total cost – not even the patient financial counselor. I had no possible way of knowing my out-of-pocket cost.

Patients have experiences like mine all the time. Most patients, however, do not study health policy and are even less well equipped to find, discuss, and consider healthcare costs. This is a huge problem. Duke Professor Peter Ubel argues that healthcare providers should make patients aware of the “financial toxicity” of treatment options, just as they discuss other potentially toxic side effects. Rule Number One of functional, competitive markets is that consumers – patients, in this case – should have access to the information necessary to make rational economic decisions. To the extent that healthcare is a market in this country and patients pay for their care with “skin in the game,” their ability to make good decisions is severely limited by the absence of treatment cost information.

Both healthcare providers and patients have a responsibility to consider patients’ out of pocket costs when making treatment decisions. Policy can enable these discussions by making cost information more accessible. Price transparency laws, cost calculators, and clinical communication aids are just a few of the alternatives that policymakers and healthcare administrators are currently exploring.

But policy alone cannot drive this major change in clinical culture. Insurance companies and other stakeholders must also shift to more patient-centered perspectives to foster good communication and create truly competitive healthcare markets. This means designing user-friendly insurance policies with less fine print, making all out-of-pocket costs available for patients and their doctors to discuss when deciding on treatments, and creating a healthcare culture that encourages and rewards effective communication around cost issues.

Until these changes occur, the onus will remain on patients to include cost queries in their litany of questions for medical providers. But even then, clinicians may not have the resources to provide answers.

Who is responsible for the health of this child?

Did you know there’s an election Tuesday?