Costs of Care...and Coercion?

The following anecdote is written by Dr. John Schumann, Associate Professor of Medicine at the University of Oklahoma. His story was a finalist in the 2011 Costs of Care Contest, and will be featured on American Public Media's Marketplace.

[All names and identifying features of characters in this story have been changed.]

Nora, a third year medical student, came to me in moral distress.

Ms. DiFazio, one of the hospitalized patients on her Internal Medicine rotation, was frightened to undergo an invasive (and expensive) medical procedure: cardiac catheterization.

The first year doctor [‘intern’] with whom Nora was paired, Dr. White, vented to her:

“These patients come to us seeking our help and then refuse what we have to offer them,” Dr. White steamed.

At the bedside, the intern demanded to know why Ms. DiFazio refused the procedure. When no reason beyond “I don’t want to” was offered, Dr. White told Ms. DiFazio that there was no longer cause for her to stay in the hospital.

By declining the procedure, Dr. White informed Ms. DiFazio that she would have to sign out ‘against medical advice’ (AMA). To signify this she would have to acknowledge that leaving AMA could result in serious harm or death. In addition, Ms. DiFazio would bear responsibility for any and all hospital charges incurred and not reimbursed by her insurance due to such a decision.

“The threat of a huge hospital bill got Ms. DiFazio to stay and take the test,” Nora related. “It just seems so wrong to bludgeon a patient this way. Can it possibly be true?”

I’d been out of medical school myself for eight years at that point; until then I’d never heard that patients who sign out against medical advice risk bearing the costs of their hospitalization. What about a patient’s freedom of choice, or as we like to call it in medicine, their autonomy?

I told Nora I didn’t know, but was determined to find out. Ethically, the notion that patients in the hospital must do our bidding or pay the price seemed dubious. Yet in a world of co-pays, deductibles, and ‘preexisting conditions,’ a mere grain of plausibility made this idea seem vaguely credible.

I asked around. To my surprise, many fellow attending physicians told me they had been taught the very same thing. My colleagues had trained at teaching institutions around the country, so I began to see this as a pervasive and widely-held belief.

I straw polled some of our residents, and like Dr. White, found that they almost unanimously believed that AMA discharges incurred financial penalties. Where did they learn this?

From their attendings.

From the nurses.

From the AMA form itself, with language stating that the patient, by signing, acknowledges financial risk.

We needed to find the truth.

Colleagues helped us sift through nearly ten years of AMA discharges from our teaching hospital. And though the results are in press at a medical journal, I can say that out of hundreds of cases of AMA discharges over a decade, in only a handful was the bill was not paid—and that was invariably due to ‘administrative issues,’ not because of the AMA discharge.

I also thought it important to go to the source: I called the insurance companies themselves. I talked with VPs and media relations people from several of the nation’s largest private insurance carriers.

Each of them told me that the idea of a patient leaving AMA and having to foot their bill is bunk: nothing more than a medical urban legend.

They were glad to tell me so, as this was a rare occasion of insurance companies looking magnanimous. One director went so far as to poll his company’s own medical directors—a half dozen of them--and found that several of them had been taught and believed the canard about AMA discharge and financial responsibility. He was happy to set the record straight.

So patients and doctors beware: The next time you or your loved one has decided that it’s time to leave the hospital, don’t let us doctors coerce you into staying by threatening you with the bill.

It simply isn’t true that leaving against medical advice makes it fall entirely upon your pocketbook.

Future Noras should feel empowered to set the record straight with their interns and residents. Most of all, the Ms. DiFazios of the world won’t have to submit to procedures that they don’t wish to undergo.

Cost Awareness in Health Care: An Idea Whose Time Has Come

Christopher Moriates, MD is a senior resident in Internal Medicine at the University of California San Francisco (UCSF). He is a co-creator of a cost awareness curriculum for residents at UCSF and is currently working with the American College of Physicians (ACP) on a national “High Value, Cost Conscious Care” curriculum. He will be starting a faculty position with the Division of Hospital Medicine at UCSF in July 2012.

“Nothing is as powerful as an idea whose time has come.” – Victor Hugo

It didn’t take that long during intern year to realize that something was wrong. As I signed so many orders that my signature, once proudly readable, began its gradual but clear progression towards more abstraction, I eventually started to wonder just how much all of these tests were actually costing my patients. After all, once you start checking boxes on an order sheet, the “calcium/phos/mag” just seems to roll off of the tongue. However, not just how much was this “costing” patients financially, but also in potential risks, harms and adverse effects.

I particularly remember being bothered when told by an Emergency Room attending physician that I had to get the Head CT on my 28-year-old male patient presenting with a benign-sounding headache and a normal physical examination, “unless you could go in there and tell him that you personally can guarantee him with 100% certainty that he does not have something bad like a brain tumor.” This did not seem like a fair bar to hop, particularly having put the M.D. after my name a mere few months prior. So I scribbled my name on another form and with the whisk of my pen subjected this patient to a normal CT head examination, saddling this young man with a significant amount of radiation and a hospital bill that now included an approximately $2,500 imaging charge. Nobody seemed to flinch, but it got me thinking.

I realized that considering cost was just not something that we were ever taught; “The reasons for this silence are historical, philosophical, structural, and cultural,” wrote Dr. Molly Cooke in the New England Journal of Medicine in 2010. And yet, it turns out that the ACGME officially states (under their Systems-Based Practice core competency) that “Residents are expected to… incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate.” This frankly was just not happening, and I know that my training program was not the outlier.

But this has all started to change.

It is hard not to feel, as I read impassioned articles about cost and/or value in health care in the most prominent medical journals (The New England Journal of Medicine, JAMA, The Annals of Internal Medicine, The Archives of Internal Medicine) and the popular press (The New York Times, The LA Times, Bloomberg), that the movement is starting to reach a critical mass. To see a patients’ hospital bill broken down and printed with a heart felt commentary by their daughter in a newspaper would have likely been unimaginable a short time ago. The call-to-arms seemed crystal clear during a recent speech by Don Berwick.

As for me, I am trying to do my part. During the past year, along with Dr. Krishan Soni and Dr. Andrew Lai at UCSF, I created and organized a multi-faceted longitudinal curriculum for residents to teach cost awareness.

In these blogs to follow, I will aim to discuss the implementation of this unique curriculum, along with many of the stories and lessons that we have collected along the way.

Script Writer Shares Story of Viral Hospital/Hotel Bill Video

By Dr. Vineet Arora (Twitter: @FutureDocs)

What Happens in Vegas Can Be Used to Teach Costs of Care

Funded with a grant from the American Board of Internal Medicine Foundation, Costs of Care has partnered with medical educators at Harvard Medical School and the University of Chicago (that would be us!) to start addressing this problem. We are developing a series of web-based medical education videos that use clinical vignettes to illustrate core principles of cost-consideration, including how to communicate with patients about avoiding unnecessary care and reducing overused or misused tests and procedures. As part of the project launch, we released a new teaser video today called “What if Your Hotel Bill Was Like a Hospital Bill?”. The video is a tongue-in-cheek depiction of the challenges patients face in deciphering medical expenses, and their additional confusion when they learn doctors are not trained to consider costs. - Excerpt from Costs of Care Press Release by Dr. Neel Shah

How does this relate to Vegas?

On a recent trip to Las Vegas with my family for the holidays, I was in the Bellagio lobby admiring the Chihuly glass ceiling. While that was impressive, I was also watching the clerks check in and out the long lines of visitors to the hotel. The staff explained any charges on the bill, confirmed that the bill agrees with the expectations of the patron and then finalized the transaction, printing a copy on the spot for the traveler before they got in the cab to the airport hailed by the bellman. What a far cry from hospitals where most of the hospital staff have no idea how much anything costs! After all, doctors are notoriously bad at considering costs in the doctor-patient relationship, as demonstrated by a great piece by Dr. Peter Ubel on his experience with the cost of his own prescription medications. As Paolo (or Paul Staisiunas who works as our research project manager in his day job) from Hotel Hospital highlights, "our hotel staff specifically focus on the highest quality of care...I doubt that they even know how much anything costs here." The rest of the script was easy to write. Shooting was a lot harder since we had to find a spot in the hospital that looked like a hotel but thanks to some creative camera angles and props from our MergeLab team, we were able to get it done.

Learning about costs of care is critical to taking care of patients. This was especially poignant as I recently completed inpatient service block at a nearby community hospital taking care of many uninsured patients who paid out of pocket for their medications (not to mention their hospital stay). Our residents were concerned about one patient who was uninsured and would have difficulty paying for Plavix, a critically important drug after his heart procedure. Review of his medications also revealed he was recently put on Lexapro, a nongeneric antidepressant (with a sordid history) that was costing him over 100 dollars a month when there is a generic alternative for 4 dollars a month, and help him afford his Plavix. When physicians do discuss costs, they also get it wrong and perpetuate a 'medical urban legend' like patients have to pay when they leave the hospital against medical advice. These are just a few of many examples of why teaching students and residents to bring up costs and arming them with tools to address the issue with their future patients is imperative. Without considering costs of care, we all take a 'gamble' that costs of care are not an issue for patients....Of course, the odds are against that.

Stay tuned for more work from our Teaching Value Project with Costs of Care funded by the ABIM Foundation.

--Vineet Arora, MD, MAPP

Special thanks to our production team and actors: Mark Saathoff , Andy Levy MS4, Kimberly Beiting, Paul Staisiunas, and Jeanne Farnan MD MHPE (and of course Neel Shah!)

Doctors, Not Financial Engineers

The following anecdote was written by Dr. Andrew Schutzbank, a physician in Boston who was among the winners of the 2011 Costs of Care Essay Contest.

Peggy was in her early 70s and suffered from a terrible lung disease known as pulmonary hypertension. So bad in fact, that she had a pump infusing a medicine under her skin 24 hours a day to keep the blood supply to her lungs open. Once started, this medicine, treprostinil, was known to improve life in those with pulmonary hypertension. Unfortunately, like all continuous infusion medicines of this type, it has the unfortunate side effect of sudden death if stopped for more than 4 hours. Starting it was a difficult choice for Peggy and her expert team of physicians, but her disease had progressed to a point where it was the right decision. As you can imagine, this drug was mighty expensive. We would only find out how expensive later.

On the day that I met Peggy, she was being admitted to the Intensive Care Unit (ICU) not for her pulmonary hypertension, but because she had a bleed in her stomach, which caused her to swallow blood/stomach contents into her already damaged lungs. Once stabilized, our first challenge was to ensure that she continued on the treprostinil. It took a little magic from pharmacy and the drug’s manufacturer, but we were able to get everything together and Peggy was no worse for the wear.

A few days later Peggy was improving, breathing tube out and awake and back to herself. Due to the special nursing needs with treprostinil, Peggy was required to be in the Cardiac Care Unit (CCU), a special type of (ICU), despite her progress. Even though Peggy managed this medicine at home by herself, hospital policy prevented her from transitioning out of the ICU to the general medical floor, at a fraction of the cost. Conceding that point, the decision was made to try and transition Peggy directly to Rehab. But her progress was stalled for one simple reason: treprostinil.

It turns out that if Peggy were to go to a rehab, they have to pay for her medications out of the money they receive to care for her. As it turns out, treprostinil costs $1400 per day. $1400. Now, Peggy does not pay that amount, she has a special arrangement worked out with the company and the state. But in order to make that arrangement work, the company charges full freight for the drug when the patient is institutionalized. Since the drug cost alone would wipe out payment for her stay, no rehab would accept her. So Peggy was stuck in the hospital, and stuck in one of the most specialized and expensive beds in the hospital in the CCU.

Think about that for a moment. A critical care bed was tied up for days for a patient that was well enough to leave the hospital, just not ready to go home. Arbitrage was suggested—would it not make more sense for our hospital to buy the drug for her at rehab, freeing up the CCU bed (which costs far more than daily dose of treprostinil). But we are doctors, not financial engineers. We work in the world of medicines and were unable to orchestrate such an unusual arrangement. So we did the only thing we know how to do. We stopped the expensive medicine.

This was not a financial decision. Peggy had been describing vague body pain, a known side effect of all prostaglandin medicines. Think of treprostinil as a 24-hour infusion of anti-Ibuprofen. Her breathing was actually quite good despite her recent trials in the hospital, so stopping the medicine made medical sense. We monitored her closely during the transition and she quickly improved! She was able to move around more and started on recovery. She was transitioned to a rehab shortly thereafter and continued to improve.

My colleagues’ decision to stop treprostinil was a medical one. But ironically, we would not have considered it if were not for the cost factor of the medicine. Peggy would have gone on for some time on an expensive medicine that was not helping her. At the same time, it was through one party’s insane attempt to “control costs” that simply caused costs to be shifted and multiplied. The entire health care system spent much more on Peggy’s care because no one had the vision or authority to deal with $1400 a day. Pennies compared to the amount wasted, and nothing compared to the risk undertaken by Peggy and her family during this trying time.

Questioning the Price

The following anecdote was written by Court Nederveld, a patient from Florida who was was among the winners of the 2011 Costs of Care Essay Contest.

Hypertension was the trigger that forced medical cost awareness to the forefront. My doctor decided that with my rise in blood pressure it would be prudent to prescribe a blood pressure medication and order a nuclear stress test. With only a catastrophic insurance policy and a $5000 deductible it was imperative for my financial health to know the cost of both the drugs and the procedure up front.

The prescription was the first thing we faced. The script for Lotrel was written and a trip to the pharmacy revealed an out of pocket cost of $200 for a thirty day supply. This was way beyond my means especially factoring in that this drug would most likely be required indefinitely. Relating this information to the doctor resulted in a prescription for the generic Norvasc and the pharmacy cost was to be $138 for 30 days. Still beyond household finances. I then began to research Lotrel and Norvasc and discovered that they are two old blood pressure medicines, amlodipine besylate and benazepril hydrochloride. I requested that my doctor write the script for these two separate drugs and I now take them daily at a cost of $7 for a thirty day supply of both drugs.

Having successfully challenged the cost of prescriptions my eyes were wide open as I began the quest for a nuclear stress test. My doctor, fully aware that I would be a self-pay referred me to a colleague in our area. A phone call began with introductions, but then I quickly explained I would be a self-pay patient and needed to know the cost of the procedure beforehand. The doctor was unable to immediately provide a cost and after checking with staff requested $2500. I reminded him that I was paying out of pocket. He replied that it could be done for $1900.

I told the doctor that I wanted to be sure I understood. I asked, “if I walked in with a check for that amount I would walk out with the test results?” The physician responded that I would need to come in for a consultation first. Cost $250. I asked again, “if I walked in with $2150 would I walk out with the test results?” Again the reply was that there would have to be a follow up visit to review the results. Cost $250. Hesitation must have been detected in my voice or the doctor detected a possible mark, because the doctor then said that perhaps I didn’t need a nuclear stress test and a regular stress test would suffice. Cost $800.

Consultation and follow up not included. I then asked what would occur if the regular stress test revealed nothing. His response was that we would do the nuclear stress test to be sure. The inverse was also true; if the regular stress test revealed any anomaly then a nuclear stress test would be ordered to provide further information. Total cost out of pocket would be $3450.

Feeling much like a cow on a milking machine I began to test the theory that medical procedures should be available as a commodity. Using the Internet to begin my search, the only specific criteria required was that the location of the facility performing the test be within a short drive from home. It took very little time to find and confirm a company that would provide a nuclear stress test sans consultation, and would willingly and promptly forward the results to my primary care physician. To verify that all was understood I informed them that I would have a check for the exact amount they quoted and no further remuneration would be forthcoming. All was as stated and the procedure was done. Total cost was $938.11.

While these two episodes have been the only challenges faced so far, having related these stories to friends and family, they also have begun to challenge costs and procedures with very similar savings.

It will be several years before Medicare is available to me and until that time I intend to challenge every prescription or procedure as to necessity and cost.