Patients Are Feeling Crushed by Health Care Cost Sharing: How Can Physicians Be Part of the Solution?

By Lucy Berrington, M.S.
Vital Signs Editor

Illustration by Chris TwichellHealth care costs are shifting onto consumers, with disturbing implications for patients, physicians, and other stakeholders. Patients are increasingly likely to avoid care. They are less able to pay their medical bills. As individuals and families grapple with rising cost sharing, their experience is raising challenging questions in medical, legislative, and regulatory circles. To what extent should patient costs drive decisions about care? Is it physicians’ responsibility to consider patients’ financial burden? How can physicians effectively partner with patients on this issue, as they do on other aspects of care?

The Medical Society is approaching this from several angles, including legislative advocacy, an informational report on high deductibles and other cost-sharing mechanisms, and evolving support and services for medical practices. At the state level, legislators — long used to wrestling with health care costs as a share of the state budget — are increasingly confronted with the impact on constituents’ wallets. “In the State House it has become harder to ignore the effects of health care costs on families and individuals. We’re seeing a push toward value-based insurance design and efforts to increase transparency on costs,” says Brendan Abel, legislative counsel for the MMS. At the local level, MMS specialists are seeing tensions between patients and providers. “When a practice attempts to collect, they often encounter frustrated patients who thought their insurer covered the cost,” says Jillian Pedrotty of the Physician Practice Resource Center.

The Implications of Higher Cost Sharing

To keep premiums at a reasonable price for employers and individuals, insurers are increasingly using tools like higher deductibles, coinsurance, and tiered co-payments. High deductibles are particularly burdensome for vulnerable populations, including low-wage workers and people with chronic conditions, studies show.

For physicians, the issue is about both their ethical responsibility toward patients and, increasingly, their own livelihood. High- deductible plans can create a double pain point for providers. They often deter patients from accessing needed care, and they require providers to collect a greater share of their fee directly from patients, a dynamic that is driving up bad debt for physicians and health care systems. “Doctors in hospitals providing care to underserved populations are getting hurt badly,” says Ron Dunlap, M.D., a cardiologist at South Shore Hospital and a past president of the MMS. “Lower-income patients are not coming in for screenings, which can lead to both worse outcomes and lower quality scores for physicians, resulting in lower reimbursements.”

A report by the MMS on the effects of high-deductible health plans on patient health and the financial impact on medical practices will be published this summer. The goal of the report is to help the Medical Society devise advocacy relating to relevant patient education and policies, health care delivery systems, cost transparency, and payment models that improve the ability to collect payments from patients and promote patients’ access to necessary medical care.

The Role of Physician Referrals

In the context of rising cost sharing, some of the health care decisions taken by patients seem counterintuitive. Why, for example, are they going to academic medical centers for treatment that could be provided at equivalent quality and lower cost in their own communities? This phenomenon is especially pronounced in Massachusetts, according to the Health Policy Commission (HPC). A 2016 study by the HPC and Tufts University School of Medicine (TUSM) evaluated the factors influencing patients’ decision making on where they seek care. “Physicians’ referrals are a key piece to the puzzle,” says Amy Lischko, DS.c, M.S.P.H., associate professor at TUSM, and co-PI on the project. “Patients reported that they would seek care in lower-cost settings if their physician referred them there.”

Next question: What influences physicians’ referrals? “This has not been well studied,” says Dr. Lischko. “What do physicians feel is their responsibility tied to patients’ affordability? What would motivate them to consider patients’ costs?” An effective solution would be “not cumbersome,” she says — for example, a tool incorporated into the EHR that merges the patient’s health insurance information with a physician’s referral considerations. Dr. Lischko is exploring the potential for a study that explores how doctors’ advice and actions can affect patient treatment decisions, leading to higher value care.

“There is increasing recognition in the medical profession of the need to consider cost sharing, that this is a relevant factor in patient care decision making,” says Paul Hattis, M.D., J.D., M.P.H., also an associate professor at Tufts. The Choosing Wisely campaign from the ABIM Foundation, for example, aims to help physicians talk with patients about avoiding wasteful or unnecessary medical tests, treatments, and procedures. “An extension of such a campaign could encourage patients to forego care in more expensive settings that offer no additional quality benefit,” says Dr. Hattis.

The Value of Talking about Cost

Typically, physicians may not have the time or the tools to consider patient costs during a visit. In a 2016 study that looked at three diseases associated with high out-of-pocket payments, 32 percent of patient visits involved a conversation about costs, sometimes including money-saving strategies, such as affordable prescriptions. The findings highlight the potential for physicians to help manage patients’ financial burden, the researchers wrote in BMC Health Services Research.

The Society is supporting a bill that would require insurers to make drug formularies available online for viewing by patients and physicians, potentially facilitating those conversations. Some barriers to cost-based decision making, however, are outside physicians’ control. Referrals may be influenced by a lack of access to electronic records at some practices, and network restrictions that place value-based community care beyond patients’ reach.

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