When the Doctor Is Forced to Decide Treatment Based on Cost, Not What’s Best for the Patient. . . .


Ten years ago this month I was new doctor, an intern doing primary care.  It was a joy that fall to begin at an outstanding clinic in a rural village where I would learn to see both adults and children over the next 3 years.

My first week at the clinic, an elderly patient, a farmer, presented to me with several days of a productive cough, perhaps a fever, some increased work of breathing.  A smoker, he’d had to quit for a few days due to his illness.  He had no contacts with ill people or with children (who might be likely to share their viruses.)

On exam he looked ill and had wet rales in one lung lobe.  I thought he had pneumonia, and listening to his symptoms I had become worried that he might need to be in the hospital.

We checked his vitals including pulse oximetry, asked him for a sputum sample for culture, did phlebotomy for a blood count and electrolytes.  Then we sent him up the hill to the community hospital for a chest x-ray and asked him to return with the x-ray so we could look at it.

It was an amazing experience to begin to find confidence as a physician, to be able to listen to the patient, perform a physical exam, then obtain additional data, and then bring it all together to share it — to make a deliberate and informed decision together with a patient about the diagnosis, prognosis, and treatment.

As it turned out, the patient’s tests were mostly reassuring.  He had acute bronchitis.  It could be viral.  More likely, I thought, he could be brewing a bacterial pneumonia.  After we looked at the x-ray together and discussed what worsening symptoms to watch for, I wrote a prescription for the drug I thought most likely to help his body expel the infection.  I asked to see him again in a week or so, sooner if necessary.

Medical school and my first two intern months had taught me about community-acquired pneumonia and the local patterns of infection.  To share this knowledge was liberating — we knew not only which organisms would be likely to be cause the patient’s illness but also which antibiotic might best treat the potential culprit.

The patient returned the next week to say he was feeling much better.  “That antibiotic worked great.”  He then gently explained to me that he could not afford the drug I had chosen.  It had cost more than his usual spending money for an entire month.  It had cut into his budget for food and gasoline and electricity.

With some anguish I discussed this with my preceptors.  How do we learn how much each drug costs?  Which antibiotics are both affordable and appropriate for the diagnosis?  How do we know how the patient will pay for their care?  Isn’t it immoral to ask?  Why does medical education stress state-of-the-art science if the ability to pay trumps our ability to practice the same medicine?

Thus I learned about the bottom line — the bottom line of the chart sticker.  It had a code that one could easily decipher.  It told who was paying the bill: which insurance company or HMO, or Medicare, or Medicaid, or “self-pay” . . . uninsured.  Soon I found myself checking that bottom line for every patient — and when I feared money would be a problem, I learned to raise the issue tactfully, respectfully.

My teachers soon taught me a few tricks.  For example many medications cost roughly the same amount per pill even though there might be several strengths to choose from.  If a pill could be cut in half we might prescribe a double dose and instruct the patient to take half a pill instead of a whole.  By cutting the pill in half, patients could cut the cost in half too.

Eventually I knew the actual costs of all kinds of tests and medications and could quote them.  I also knew what the local insurers were likely to cover — and not cover.  I kept a short list of generic drugs, each class listed by price, in my desk drawer.  And I learned that patients without health insurance often go without tests and treatments and specialists and even emergency care because of out-of-pocket costs.

None of us went to medical school to ask our patients to choose between an antibiotic and the electric bill.  But when I look back over ten years of my work, I am confronted by an appalling escalation of the insidious intrusion of the questions of “who will pay?” and “what is the cost?” — no matter how necessary the care, no matter how routine the test, no matter how clear the choice of treatment.

The Medical Society of the State of New York (MSSNY) recently reported that 93% of my New York colleagues complain that they have had to change their choice of prescription medications because of insurance carrier restrictions.  92% of New York physicians agree with the statement: “Insurance company financial incentives or disincentives to physicians regarding treatment protocols may not be in the best interest of their patients.”  And 87% say that insurance companies pressure them “to prescribe a course of treatment based on cost rather than on what may be best for the patient.”

The big picture of the costs of health care — $2.4 trillion, 16.6% of GDP for the nation in 2008 — rightly receives much attention.  But the relentless intrusion of costs into the doctor-patient relationship endangers nearly every interaction — a cruel fact which too many of us, patients and caregivers alike, are painfully, personally aware.

The MSSNY poll also showed that 95% of New York physicians believe that “Decisions on what medications are right for a patient should be made by the patient’s own doctor and not by the health plan or the insurance carrier.”  (And small wonder that Physicians for a National Health Program has so many new members here in New York.)

A single-payer program would provide a socially responsible way to cover the costs of all necessary medical care.  It is the first step toward a more humane physician-patient relationship.  By standing up for single-payer we will restore not only our profession, but our humanity.

Andrew D. Coates, MD, secretary of the Capital District (NY) chapter of Physicians for a National Health Program (at www.pnhp.org/), practices medicine in Albany, NY. 

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