Full Disclosure — Out-of-Pocket Costs as Side Effects
Peter A. Ubel, M.D., Amy P. Abernethy, M.D., Ph.D., and S. Yousuf Zafar, M.D., M.H.S.
N Engl J Med 2013; 369:1484-1486 October 17, 2013 DOI: 10.1056/NEJMp1306826
Comments open through October 23, 2013
Few physicians would prescribe treatments to their patients without first discussing important side effects. When a chemotherapy regimen prolongs survival, for example, but also causes serious side effects such as immunosuppression or hair loss, physicians are typically thorough about informing patients about those effects, allowing them to decide whether the benefits outweigh the risks. Nevertheless, many patients in the United States experience substantial harm from medical interventions whose risks have not been fully discussed. The undisclosed toxicity? High cost, which can cause considerable financial strain.
Since health care providers don't often discuss potential costs before ordering diagnostic tests or making treatment decisions, patients may unknowingly face daunting and potentially avoidable health care bills. Because treatments can be “financially toxic,” imposing out-of-pocket costs that may impair patients' well-being, we contend that physicians need to disclose the financial consequences of treatment alternatives just as they inform patients about treatments' side effects. Health care costs have risen faster than the Consumer Price Index for most of the past 40 years. This growth in expenditures has increasingly placed a direct burden on patients, either because they are uninsured and must pay out of pocket for all their care or because insurance plans shift a portion of the costs back to patients through deductibles, copayments, and coinsurance. The current reality is that it is very difficult, and often impossible, for the clinician to know the actual out-of-pocket costs for each patient, since costs vary by intervention, insurer, location of care, choice of pharmacy or radiology service, and so on; nonetheless, some general information is known, and solutions that provide patient-level details are in development.
Consider a Medicare patient with metastatic colorectal cancer. Commonly, a component of first-line therapy for this disease is bevacizumab. The addition of bevacizumab to chemotherapy extends life by an average of approximately 5 months over chemotherapy alone. The drug is fairly well tolerated, but among other risks, patients receiving bevacizumab have a 2% increase in the risk of severe cardiovascular toxic effects. Over the course of a median of 10 months of therapy, bevacizumab costs
$44,000. A patient with Medicare coverage alone would be responsible for paying 20% of that cost, or $8,800, out of pocket, and that price tag doesn't include payments for other chemotherapy, doctor's fees, supportive medications, or diagnostic tests.
Most physicians insist on discussing the 2% risk of adverse cardiovascular effects associated with bevacizumab, but few would mention the drug's potential financial toxicity.
This example is not isolated, and the consequences for patients are grim. The problem is perhaps starkest in cancer care, but it applies to all complex illness. The Center for American Progress has estimated that in Massachusetts, out-of-pocket costs for breast-cancer treatment are as high as $55,250 for women with high-deductible insurance plans; the out-of-pocket costs of managing uncomplicated diabetes amount to more than $4,000 per year; and out-of-pocket costs can approach $40,000 per year for a patient with a myocardial infarction requiring hospitalization. The Centers for Disease Control and Prevention estimates that, owing in part to such high out-of-pocket costs, in 2011 about a third of U.S. families were either struggling to pay
Financial Burden of
Medical Care. medical bills or defaulting on their payments (see graphs).
This health care–related financial