By: Andrea N. Leep, MD, MHPE
Andrea N. Leep is an assistant professor of neurology at the Mayo Clinic. She works as a consultant in the Education Division of the Neurology Department at Mayo Clinic and is Associate Director of the Mayo Clinic Program in Professionalism and Values, Rochester, Minnesota.
In the rural community where I grew up, most folks didn’t have much in the way of health insurance. The saying was you had to be “pert near dead” in order to justify the expense of seeing a doctor. I felt privileged to have health insurance when I started medical school—but it only took one unexpectedly enormous bill (after what seemed like a rather minor issue) for me to realize that having insurance didn’t obviate the financial impact of medical care.
Upon starting clinical rotations, however, the issue of health care costs rarely came up. I would stay up late trying to generate (and test for) an extensive differential diagnosis for patients I helped admit. The more esoteric the diagnostic considerations, the more impressed the supervising physician seemed to be during my presentation the next day. I don’t recall ever being praised for a cost-effective diagnostic evaluation or encouraged to talk to patients about costs.
In this way, my perspective on health care costs was strangely dichotomous. When I was on the receiving end of health care, costs were a leading consideration in my decisions. When I was on the providing end of health care, costs were rarely a consideration at all. So much so that I still remember the first patient who brought the issue of costs crashing into my consciousness.
I met her during my continuity clinic as a first-year neurology resident. She presented with a many year history of slowly progressive leg weakness and spasticity with gait imbalance and urinary urge incontinence. On exam, she had very brisk reflexes and bilateral upgoing toes. After a big work-up, it was determined that the patient most likely had some form of hereditary spastic paraplegia (HSP). Without a second thought, I recommended genetic testing to try to confirm the diagnosis.
When the results came back, no causative mutations were identified—despite testing over 20 genes. I rehearsed strategies for sharing this news with the patient, anticipating that she would be disappointed. “Don’t worry,” I said. “These negative genetic tests don’t change anything. I still think you have HSP. We’ve got a plan for managing your spasticity. There’s a team available to address your bladder symptoms. The physical therapy you’ve started will help too. And I’ll see you back every year.”
The patient’s initial disappointment quickly changed to anger. “Why did we do genetic tests if they weren’t going to change anything?! Do you know how much it cost? $16,000!!! And my insurance didn’t pay a penny. I told my family, and they all offered to pitch in. Even my kids and cousins helped. Some gave me $1,000. Some gave $20. My husband borrowed against our home equity to pay for the rest. We’ll do whatever it takes to help me get better—but we aren’t a rich family. And you just said that the $16,000 we spent isn’t going to change anything?!”
As medical educators, we shouldn’t leave it up to patients to teach our trainees the importance of cost-conscious care. Encouragingly, many efforts are underway to promote cost-conscious care in medical education. Our recent survey in Academic Medicine demonstrates that medical students across all years of training generally have favorable attitudes toward cost-conscious care. However, students also endorse barriers to cost-conscious care and observe conflicting physician role-modeling behaviors in their learning environment. For students to successfully translate their favorable attitudes toward cost-conscious care into practice, the physicians they encounter in clinical settings must role model, reward, and reinforce cost-conscious behaviors. This will likely require both health care system reform (e.g., reimbursing for value rather than volume) and faculty development around the issue of costs.
Providing cost-conscious care may not be easy. Prices often aren’t transparent, and there are complex trade-offs between monetary costs and time, convenience, the satisfaction of making a definitive diagnosis, and the psychologic reassurance that negative test results can provide. But my patient with HSP taught me that it’s important to try.