Presenting Options For Patients With High Deductible Insurance

While podiatric physicians are trained to address the foot ailments of their patients, they are not trained to discuss the costs of care. We want to put off having these conversations about cost or we delegate this to our staff. However, staff may be even less capable than us of having this important conversation with patients who are already anxious about their uncertain foot condition diagnosis, let alone what it will cost them to resolve their pain or condition.

However, for their family’s financial health, patients need to know what they will pay prior to being able to accept your medical recommendations and treatment. We all have seen the price of health insurance premiums increase by 55 percent in the past decade, according to a 2017 Kaiser Family Foundation report.¹ As a result, patients are facing greater out-of-pocket expenses and more high-deductible health plans. 

After studying this problem, the Robert Wood Johnson Foundation, found that conversations about costs of care took as little as a minute “when done well” and resulted in changes important to care plans as well as advice for how to find a less expensive drug.² 

The study suggests strategies that physicians can utilize to help lower costs without changing the care plan. These strategies include:

• changing logistics of care (i.e. the timing, source or location);
• facilitating co-pay assistance;
• providing free samples; and
• changing/adding insurance plans.²

The study also recommends four strategies for reducing costs by changing the care plan. These strategies include:

• switching to lower-cost alternative treatment or tests;
• switching from brand name to generic medications;
• changing medication dosage/frequency; and
• stopping/withholding interventions for a time to allow a patient to save the money required for the medication or procedure.²

I feel having this conversation is quite important for patients to be able to accept the plan of care I have offered and resolve the condition. However, some of the strategies suggested appear to be quite challenging from a medicolegal perspective as well as an administrative perspective.

Physician offices are already stressed with added administrative functions for the Merit-based Incentive Payment System/Medicare Access and CHIP Reauthorization Act (MIPS/MACRA). Practices are adding more tasks for staff members and this may push some of our already overloaded team members to seek other professions. 

Changing the timing and location for some services is quite doable along with changing medication dosage. However, our not so friendly malpractice attorneys may point fingers at us that we are prescribing medications off-label, not providing care based on current evidence and/or are not providing the medication in a therapeutic fashion, etc. I think you get the picture.

As for assisting with co-payment assistance, many of the device and drug companies provide this service. When we offer this information to patients, many do not follow through with the steps needed to seek assistance. Many of us already use generic drugs when available. However, many of the newer cellular therapies and/or new medications do not have generic equivalents yet they tend to have the more evidence and research to support their efficacy.

The last item recommended by the study authors really concerns me: stopping and/or withholding interventions while the patient is saving money.² Again, a sharp attorney may pick this up as a delay of care so now we have to get a patient to sign another form about the delay in care that he or she chose as an option.

There are no easy solutions. The one thing for sure is that we should advise patients of the cost of the care for their condition. We should also know, prior to seeing patients if possible, the patient’s outstanding deductible portions and what copays our offices expect to collect. We should then communicate this information to the patient to manage everyone’s expectations. We should tell patients of all of the options available for their care regardless if they are affordable. It is ultimately the patient’s decision to accept a treatment plan and assume the financial responsibilities to get the results he or she expects. It is our job to explain the risks of not following the most optimum treatment plan that should lead patients to the goal or answers they were seeking in the first place.

We help our patients by referring them to a document published by the non-profit Consumer Health Choices on five questions patients should ask their doctor before a test, procedure or treatment.³ The questions are:

• Do I really need this test or procedure?
• What are the risks?
• Are there simpler, safer options?
• What happens if I don’t do anything?
• How much does it cost?

Also, we remind our patients to become familiar with mechanisms of their health insurance plans: “If you have a high-deductible health plan, what may be the result if you paid off your deductible late in the calendar year and then require some sort of expensive treatment or surgery? Although it might be covered in December, if you wait until January of the next year, you will have to pay out of pocket. It’s important to know those kinds of things.” 

We use scripts for the staff so they are better able to have these conversations. We encourage our staff to be advocates for the patient as well as for the practice. This way we both can — if not win — at least continue to play a game for which none of us had an opportunity to make the rules.

References

1. Henry J. Kaiser Family Foundation. 2017 employer health benefits survey. Available at https://www.kff.org/health-costs/report/2017-employer-health-benefits-survey/view/print/ . Published Sept. 19, 2017.  

2. Rosenfeld J. Navigating cost-of-care conversations with patients. Medical Economics. Available at https://www.medicaleconomics.com/business/navigating-cost-care-conversations-patients . Published May 2, 2018.

3. Consumer Reports. Available at www.consumerhealthchoices.org/report/do-you-really-need-that-medical-test-or-treatment/ .