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Shopping for health care: These doctors commit to doing no (financial) harm



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Dear Impatient readers, you may have noticed that we're writing a lot about the importance of asking about the cost of your health care. It's part of our ongoing mission to give you the tools to navigate our rapidly changing medical system, particularly with regard to how much care costs. 

Along the way we've talked about how patients - especially those on high-deductible health plans - should broach issues of cost with their doctors, even if it means having potentially awkward conversations. These discussions, experts advise, could spur doctors to be more cost-conscious when ordering tests or prescribing medications.

This week, we turn the tables and talk to some doctors who think they and their colleagues also need to be prepared to have these conversations.

Do no (financial) harm

Many doctors don't think about health care costs, says Dr. Neel Shah, an assistant professor at Harvard Medical School. One reason for that, he says, is that they haven't been trained to do so.

"In medical school, not only was I not taught anything about health care costs, but I was specifically taught that health care costs were not my concern," says Shah, who's also the founder and executive director of the non-profit Costs of Care.

Dr. Jeff Kullgren, an assistant professor at the University of Michigan Medical School, takes that a step further.

Kullgren went to medical school "not that long ago," he says. The professors there taught him that a patient's "ability to pay for a service should not be a major factor in deciding what kind of health care that patient needs," adds Kullgren, who is also a research scientist at the Center for Clinical Management Research at the Veterans Affairs Ann Arbor Health System.

Both doctors have since rebelled against this part of their education. They say they've realized that as the health care system changes, the ethos to "do no harm" must include patients' finances.  Shah and Kullgren argue that turning a blind eye to the cost of care only allows costs to mount - both on the system and on individual patients.

Shah recalls that as an intern at a hospital, he would order MRIs without knowing their cost. (Impatient readers might recall that another doctor told us last summer that he, too, had ordered thousands of ultrasounds and CAT scans over the course of his career without ever knowing their prices.)

"If you're ordering off a menu that doesn't have any prices on it, it's very easy to get filet mignon everyday," he explains. And more and more patients are struggling to pay for that filet mignon out of their own pockets, Kullgren points out.

What patients care about

Doctors may not have been taught to consider health costs, but that doesn't mean they're averse to discussing them.

You could dive headfirst into that awkward conversation I mentioned a few weeks ago, or ask some of these questions that patient advocates suggested last week.

No matter how it begins, the conversation is worthwhile - and should he happening more regularly, says Dr. Peter Ubel, a physician and behavioral scientist at Duke University who frequently writes about health costs.

Like Shah and Kullgren, Ubel believes doctors need to take a more proactive role.

Just as a financial advisor talks to a client about short- and long-term goals before suggesting a retirement savings plan, doctors should spend five minutes finding out what their patients care about before giving medical advice, he argues.

"Sometimes the best alternative is what the patient cares about," adds Ubel.

These types of conversations are especially important for those patients who aren't following their doctors' recommendations - regarding things such as medications or tests - because they're unaffordable, he says.

"If you’re not doing what your doctor thinks you're doing because of cost, it's a warning sign to talk," Ubel says, noting that a doctor can often prescribe alternative tests or medications, or connect a patient with financial assistance programs.

These conversations can be hard for patients to start, but "a lot of times they're very helpful," he says, adding, "I've seen very little conflict that arises by bringing this topic up."

More thoughtful

The doctors I spoke to say that once they know patients are concerned about costs, they can adapt their medical recommendations to fit patients' individual needs.

"A lot of times, a doctor is just going to think about what’s the number one thing for you medically, even if the number two thing is cheaper and almost as good," Ubel says. "If the doctor is unaware that you have financial concerns, it's just not going to be on their minds."

Shah agrees, noting that a lot of doctors are accustomed to a one-size-fits-most form of medicine. They're taught to treat the average person, rather than taking a more individualized approach to, for example, ordering a panel of tests, he says.

"If a patient is telling you that they want you to be thoughtful about which tests they truly need, there's almost always an opportunity to get that one test, wait for the rest, and then think if you need the other four," he says.

Doctors can also alter their prescribing habits to accommodate patients' budgets, Ubel says.

He says doctors don't know what a particular medication will cost an individual patient. So they can offer prescription contingency plans: If one is too expensive, try this one instead.

Your experience

As I mentioned, I'll be returning to this topic frequently. My goal is to help you know what questions to ask about the costs of your care, so you can cut through the layers of secrecy that often enshroud these issues.

Now, I want to hear from you: If you're new to these cost conversations, what questions do you have about obtaining affordable care? If you're already a super-shopper, or you're a medical professional, or you study this field, what advice do you have for consumers?

Join the ongoing discussion in the comments section below, or e-mail me at Impatient@scpr.org. Look forward to hearing from you!