In recent years, consumers have increasingly been encouraged to factor cost into their medical decisions — by, for example, avoiding unnecessary tests, buying generic drugs and reducing visits to the emergency room. The hope is that a patient better educated and more engaged in his or her health decisions will choose options that will both promote better health and decrease costs.
But a study published last month in the journal Health Affairs found that a majority of patients were reluctant to consider cost when making medical decisions, nor did they want their doctors to do so.
Researchers investigated the attitudes of 211 focus group participants in Washington and Santa Monica, Calif. Participants were asked to weigh their own out-of-pocket costs as well as the costs borne by their insurer. The participants, researchers said, did not generally understand how insurance works and felt little personal responsibility for helping to solve the problem of rising health care costs. They were unlikely to accept a less expensive treatment option, even if it was nearly as effective as a more expensive choice.
I talked about the findings with study co-author Susan Dorr Goold, a professor of internal medicine and health management and policy at the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. This is an edited transcript of that conversation.
Q. What, if anything, about the findings surprised you?
A. We were surprised at how firmly and frequently people talked about not wanting cost considerations to factor into decision-making at all. It surprised us that there weren’t some people speaking out and saying, “Wait, we’re all going to pay more if we don’t consider the costs.” We heard it, but not very often.
Q. You asked patients to consider how cost might influence their thinking. If, for example, someone had a headache for three months and the doctor explained that a CT scan would identify nearly all the problems for a fraction of the cost of an MRI, in general, people were unwilling to consider the cheaper test. How do you interpret that?
A. We talked about what might have happened if we had chosen a different example. When you talk about headache, you’re talking about your brain. What if we’d talked about toenail fungus instead? Is getting rid of it worth a treatment that’s nearly a thousand times more expensive?
Although we know from other research that patients certainly consider their out-of-pocket costs, they’re not very good at deciding what’s worth spending extra money on. Doctors have to be part of the discussion about the value of different options.
Q. You found that some participants seemed motivated to choose expensive care “out of spite,” because they were antagonistic toward their insurance company. What’s going on there?
A. There was an almost vengeful attitude toward insurance companies, the idea that “I’ve been paying in, and now I’m going to get what I’m owed,” or “I’m going to get them back for all the money I’ve paid in all these years.”
The motivation that “I’m sick and I don’t want to think about the money,” that’s understandable. But “I want to hurt the insurance company”? Why? Those health care payments come from money all of us have paid to insurers.