OK I want to get this out of the way at the beginning. This is not a one-way conversation. I’m not suggesting that you tell your doctor how to do his job or discuss all your financial secrets with your doctor.
You know how if you have to give a speech in public you should picture the audience naked and then it will seem so ridiculous that you’ll relax and be able to speak more comfortably. Well picture your physician financially naked. We all think of physicians as being quote rich and quote. But many of them went to school until they were in their early to mid 30s and have hundreds of thousands of dollars of student loan debt. Many more of them also make bad financial decisions and buy houses they can’t afford and spend more money than they earn. X percent of people making more than $200,000 a year living month to month.
That would just be an appropriate. But I do believe it’s in your best interest to be honest about your ability to pay for your treatment. I believe that a large portion of the responsibility also lies with the physician. For this reason I wrote a sister piece to this article called talk to your patients about money that was published on kevinmd.com and on my website business is the best medicine. But health care is a partnership between the patient and the physician and open communication is key to better care.
So picture your doctor financially naked and you should be more comfortable speaking about the medication that it might be difficult for you to afford. He might have a difficult time too period now does this mean you should feel bad for your physician that makes so much money? No. Does it lessen the impact of their own bad financial decisions? No. I’m not saying that you should feel bad for them for living month to month just that everyone has their own financial problems. Part of what I do is I try to educate physicians on all aspects of personal finance and business so that they’re not making these poor financial decisions.
Acknowledgment
I want to start by acknowledging that this is a difficult subject, which is probably why no one talks about it. And that is precisely the point. Let’s get uncomfortable and go through some objections to what I’m saying. “This should be the doctor’s job.” “I don’t know anything about medicine.” “A rich doctor isn’t going to understand my financial problems.”
My answer is that you are right on all three counts. It should be the doctor’s job to broach the subject. But, for reasons we will discuss, they usually don’t. I also wrote a sister piece to this post called Talk to Your Patients About Money to try and educate doctors about this topic.
I don’t expect you to question your doctor about your medical treatment.
Ultimately, it is your money, and no one will be better steward of it than you.
Introduction
A patient arrives at the E.R. for evaluation of high blood pressure. She was prescribed medicine for blood pressure by her primary care provider but isn’t taking it. It costs $300/month, and she can’t afford it. When asked if she talked to her doctor about a less expensive alternative, she says no.
Unfortunately, this type of interaction occurs far too frequently. People have a difficult time talking about money in any situation, so why should the physician-patient relationship be any different? Doctors are actively taught not to think about money, while patients are too embarrassed or deferential to bring it up. In this article, I will discuss why talking about money matters in healthcare, why it is difficult for physicians and patients to have this conversation, and what you can do about it. It is important to have a voice in the cost of healthcare, regardless of which side of the stethoscope you are on.
Why Talking About Money Matters
Healthcare In the U.S. is Expensive and Complicated
Healthcare in the U.S. is expensive. There is no way to sugarcoat that fact nor truly combat it. Let me clearly state that I am not the one to fix this broken machine. I am not a politician. I am not going to be at the head of a physician-led revolt against the status quo. But I am simply offering a few suggestions to patients to minimize their healthcare expenditures around the edges.
Because the U.S. healthcare system is so complicated, with insurance companies acting as intermediaries between the service and the payment, price often gets overlooked. Those without insurance feel the effects more acutely, often paying for service in real time. For those with insurance, the effect is often delayed. You receive the service now with a co-pay, and the bill comes later. We know from credit card use that separating the purchase from the payment is never a good idea.
You may think, if my insurance covers it, who cares what it costs? You will when your premiums increase next year. This time delay between cause and effect makes the problem seem less pressing. But make no mistake, medical insurance costs are soaring and will continue to rise. Insurance companies are not in the habit of losing money. Both doctors and patients can play a role in keeping costs down.
Let’s start with what should be obvious: It’s OK to talk to your doctor about money. We need to normalize this. Providers and patients are on the same side, with a shared goal of getting and keeping the patient healthy. Money matters because if the patient can’t afford what the doctor recommends, then the recommendation is useless.
There is More than One Way to Skin a Cat
I will let all you non-medical readers in on a little secret. Much of what doctors do is habit or protocol, especially when prescribing medicines and ordering tests. In the Emergency Department, we rarely consider the cost of tests. Our job is to prove there is no emergency, which often requires extensive testing. However, we get into routines, ordering the same batch of tests on patients who might not need all of them in the order set. Since federal law (EMTALA) dictates that we see and stabilize everyone regardless of their ability to pay, we aren’t considering our patient’s insurance status when ordering tests.
I also have experience owning Urgent Care clinics, where EMTALA doesn’t apply. The patient’s ability to pay plays a more significant role in a private medical business. Cash-pay patients and those with a high-deductible insurance plan will more regularly question whether a test is necessary. Do you have to run that Strep test? Do you have to perform that chest x-ray, or can you make a clinical diagnosis? Can we close that laceration here instead of sending me to the E.R.?
As the very strange saying goes, there is more than one way to skin a cat. Likewise, there is more than one way to treat a patient.
Why it is Difficult for Physicians to Talk to Their Patients About Money
There are many reasons medical professionals are reluctant to discuss money. We are just like everyone else, and most people simply don’t think about money when it comes to their jobs. If they think about it at all, it’s about their money, not yours. This is not nefarious; it’s just human nature. There are some Medicine-specific reasons as well, which I will outline now.
Philosophy
In our training, we are taught NOT to think about money. We are trained to treat everyone equally regardless of race, religion, sexual orientation, or socioeconomic status, regardless of their ability to pay. Unfortunately, this creates equity as the cost of financial responsibility.
Ignorance
Most doctors don’t know how much the medicine they prescribe or the tests they order cost. This is partly because the cost of anything in the U.S. healthcare system is opaque. Different prices exist depending on whether you have insurance, and each insurance company negotiates rates with individual hospitals and clinics. It’s also partly because they just haven’t taken the time to learn.
The Best
Doctors generally prescribe what they think is “best” for their patients without regard for price. This is only natural, but unless that recommendation comes with a discussion about the patient’s ability to afford it, it is potentially useless. I would rather prescribe my patient the fourth best blood pressure medicine they can actually afford than the absolute best that they cannot.
Time and Habit
Doctors are busy. 74% of physicians are employees with a boss and metrics to meet. Doctors are constantly pressured to see more patients in less time. So, we all create habits and shortcuts. There are literally thousands of medications we can prescribe, so we prescribe the same ones repeatedly. It’s a lot easier to remember 50 medications than 500.
What Patients Should Do
As a patient, you must actively participate in your care, including the cost. There are four things you can do to be a fiscally responsible patient.
1. Educate yourselves.
Learn the basics of finance in health care. Do you know the most cost-effective place to receive treatment? 50% of E.R. visits could be appropriately handled elsewhere. Do you know how your insurance works? The F.I. Guide to Emergency Healthcare is a great place to start at www.BusinessIsTheBestMedicine.com.
2. Shop Around for Your Medication.
Prices for prescription medications are not fixed. Medication prices can vary by pharmacy, so shop around. There are also usually three prices for a medication. One – The price your insurance company has negotiated with the pharmacy. Two – the cash price. Three – A negotiated price less than the cash pay price that requires a coupon. Understand that paying cash for a medication is often cheaper than using your insurance, especially if you have not met your deductible.
Ask the pharmacist what the cash price is. Pharmacies have agreements with insurance companies stipulating that a pharmacist cannot voluntarily tell a patient if the cash price is lower than the insurance price. Messed up, right? Additionally, check out medication discount sites like GoodRx. These sites can help you compare prices at each pharmacy in your area and offer coupons that discount the cash price on various medications.
3. Get comfortable.
There’s a saying, “Don’t lie to your doctor, accountant, or priest.”
Ask your provider how much the treatment will cost. If they don’t know, ask them to find out. Discuss your financial situation with your provider. How much can you reasonably pay for medication? How much if it is just a one-time prescription? How much if it will be monthly?
Nobody wants to pay $300 a month for medication, no matter how much money you make, especially if there might be an alternative that’s five dollars a month. It may not be quite as “good,” but it might work for you. It would be better to start with a cheaper option; if it doesn’t work, move your way up to a more expensive one.
4. Don’t be embarrassed or ashamed.
We ALL have money issues. You know how they say that if you’re nervous about speaking to an audience, you should picture them naked? Well, picture your doctor financially naked, with $300,000 of student loans and a giant mortgage, struggling to make the payments. Understand that 39% of Americans making over $200,000 per year live month-to-month (1). This may be your doctor, so don’t be embarrassed if you can’t afford an expensive medication. Your provider may not be able to either!
You don’t have to be in financial hardship to want to pay less for medicine, you just have to be a good steward of your money. I don’t want to pay too much for a prescription, either. If I have the option of a medicine that costs $200 or one that costs $4 and might be 80% as effective, I’m going to try the $4 one first. If it doesn’t work, I will go to a more expensive one.
5. Trust your provider.
Often, medical professionals will order unnecessary tests and medications simply to appease a patient or parent. This drives up the cost for the patient and the entire healthcare system. If your provider tells you your child has a virus, you don’t need a $700 viral panel to determine which virus.
Conclusion
Healthcare is a partnership. Both medical providers and patients must learn to communicate about money openly and honestly. I am not suggesting you accept substandard care. I’m suggesting that our healthcare system is needlessly complex and that there is often a vested interest in keeping prices purposefully hidden or opaque. I am also suggesting that waste is inherently built into how physicians practice. Patients must be empowered to speak up about the cost of their care. There are often more economical treatments available that are still effective.
I am fully aware that we need more than the suggestions outlined here to solve our healthcare system’s affordability problems, but this is a start. Every bit helps. Please leave a comment below to debate/discuss. I do not have all the answers, but I would love to normalize the conversation around money in the physician-patient relationship. For further discussion about personal finance and the business of medicine, subscribe below.
