FINANCIAL CONSIDERATIONS

Understanding Your Patients' Financial Concerns

Tuning into the financial impact of treatment can result in more successful patient care.

By Leonard Joffe, M.D.

► Dedicating my career to helping people see has been enormously rewarding. I've learned, however, that the greatest rewards in my profession come from a determination to care about more than just my patients' eyesight.

During my 30 years of practice, I've seen an increasing number of patients who struggle not only with poor eye health but also with considerable anxiety surrounding the cost of necessary treatment. Financial concerns related to treatment can be heartwrenching, for both the patient and the physician. I recently listened as one patient wondered aloud if she should take a second job to pay for her medication. No physician wants to see a patient struggling with this kind of dilemma, but pressing financial concerns are common among patients today. Your ability to confront this reality openly and constructively can go a long way toward helping you build a successful practice that's rooted in thorough and compassionate patient care. Here are suggestions to guide your discussions with patients and your search for help.

Increase Your Awareness

Even patients who are privately insured or who otherwise appear to have adequate coverage can experience significant financial burdens when faced with an unexpected medical diagnosis. In fact, a study conducted by Harvard University in 2005 revealed that illnesses and related medical bills are a primary cause of approximately half of all personal bankruptcies, and that among those seeking relief from medical bills, roughly 75% had been insured at the time of diagnosis.¹ Out-of-pocket expenses, copayments, deductibles and other uninsured expenses can place enormous financial stress on even upper middle-income patients. No matter where your practice may be located, your awareness of these financial realities is critical.

Our community in Tucson, Ariz., isn't affluent, so a large number of my patients require assistance in covering the costs of their treatment. Many of my patients have Medicare replacement policies that leave them with high copayments of up to 30% for some medications. Patients who receive injections for AMD may be required to pay up to $600 for each treatment. I am acutely aware that very few of my patients can afford to make these payments on a regular basis.

The medications that pose the biggest concern in my practice are those used to treat AMD. However, both general ophthalmologists and retina specialists share concerns about the costs of treatment for patients with glaucoma, cataracts, diabetes and other conditions. Glaucoma medications and nonsteroidal drugs for cataracts, for example, aren't just expensive, they're often used for lengthy periods of time. Costs for these medications can add up, and when there's no generic alternative for a prescribed medication, patients often are billed at a higher rate [assigned to medications on a nongeneric formulary tier]. The manufacturers of many of these drugs can help to make them more affordable for patients, although in most cases patients must be uninsured to qualify. Regardless of the situation or available resources, however, it's essential for you to know if the treatments you prescribe create a financial hardship for your patients.

As you develop your practice, it's important to recognize that medical treatments can disrupt lives, not only financially but also in a host of other ways. Travel requirements, discomfort associated with injections and other procedures, interference with family obligations and related issues all have the potential to influence a patient's willingness or ability to comply with treatment plans. A patient's inability to afford a medication must be acknowledged along with other potential obstacles to treatment. Taking into account your patient's financial situation should become an inseparable part of recommending treatment.

Be Proactive

Because financial struggles can be a source of embarrassment, patients may have difficulty broaching the subject. Don't wait for your patient to initiate this conversation; your patient will be grateful for anything you can do to limit his anxiety regarding treatment costs. I personally want to know what type of insurance my patients carry and whether the cost of a medication is going to be an issue for them. Accordingly, my staff has adopted the habit of marking each patient's chart to ensure that I'm well informed.

The first time I encountered a patient with an inability to pay for treatment, I knew instinctively that dealing with the issue up front was the best approach. On that occasion, I intended to prescribe a medication that isn't used much any more, but that carried a hefty price tag at the time. My concern for my patient out-weighed my own wish to avoid awkwardness. I knew the drug was expensive, and I wanted to make sure the patient wasn't placed in a situation of financial hardship. That successful first encounter and subsequent others have taught me that it's essential to address financial issues prior to recommending treatment. Once you prescribe a certain treatment, it's too late to change your mind. Adjusting your treatment recommendations because of cost considerations can affect your credibility.

Cost Can't Guide Decisions

Your treatment decisions should be guided by your own experience and by scientific evidence rather than by cost. When two medications have demonstrated similar efficacy in the treatment of a particular condition, I know that many physicians opt for the less expensive option. Such decisions often are made with the intention of helping to lower medical costs system-wide, and sometimes with the intention of limiting financial risks to a practice.

My advice is to always treat to the best of your ability. If two drugs appear to have similar efficacy, make sure to review the potential drawbacks of choosing the less expensive drug. If, for example, a less expensive drug is prescribed off-label, its lack of approval may create barriers that ultimately will make the lower cost less attractive. In these situations, review all related issues with your patients before determining which drug to prescribe. Review the options, costs and the strategies for coping with costs.

I often follow up my review of options by allowing the patient to make a choice. In some cases, my patients feel more comfortable selecting an approved drug over one that's used off-label. In all cases, if I've addressed the situation correctly and ensured that my patient has the proper information and support, my patient is grateful for the opportunity to play a role in the decision-making process. When it comes to saving a patient's eyesight, cost should never be the focus. And when cost is an issue, there are ways to get help.

Look to Nonprofit Groups

An ever-growing number of nonprofit organizations are devoted to helping qualified patients cope with costs of medical treatment. These organizations typically use charitable donations from pharmaceutical companies and other corporations to safeguard access to care for insured or underinsured patients coping with one or more chronic or debilitating illnesses. Examples of such organizations include the Chronic Disease Fund, the Patient Access Network Foundation and the Healthwell Foundation. When patients have copays that interfere with their ability to afford necessities, such as groceries, housing and utility bills, they should be encouraged to apply for assistance from these programs. Patients usually complete an application and, if they're eligible, can receive up to $2,500 annually, which often is payable to the patient's provider. When patients exhaust the funds available from one organization, often they can reapply for assistance or apply to other organizations. Some drug companies will help patients access these financial resources and/or assist uninsured patients directly. (See "Lucentis Access Solutions" below.)

Learn from the Reps

Today, issues surrounding the cost of a particular drug often are addressed in the marketing of the product. When a drug representative approaches you to discuss a new product, it's common for the discussion to include information about how the drug can be accessed or paid for when patients are denied coverage. Pay close attention to what the drug representatives tell you; such information can be enormously valuable for your practice. Reps may supply you with written material that can provide patients and staff with strategies for making medication affordable. It's a good idea to ask the rep to review this material with your staff to ensure that everyone understands the programs and to give everyone a chance to ask him questions before he leaves.

Let Staff Educate Patients

Like most ophthalmologists, I have an extremely busy schedule. I don't have enough time to educate each patient in depth about covering medical costs, so it's important to know that I can confidently address most questions, but in order to respond adequately to my patients' needs for information, I rely on an immensely capable and well-informed staff.

During the early years of developing your practice, it's essential to focus on building a staff that's reliable, well trained and closely attuned to patient needs. You must feel confident that you can direct patients to staff who are willing and able to educate your patients and guide them through a reimbursement process that can be lengthy and often fraught with misunderstandings. I once had a patient who misread a large bill and incorrectly assumed that he was being billed for the entire amount. The patient had decided to discontinue treatment, but thankfully, my staff detected and resolved the problem.

One last note on patient education: Even though the Internet is the most popular source of information today, I don't recommend sending patients to the computer to resolve their insurance and reimbursement issues. Many patients in your practice are likely to be elderly and unfamiliar with the Internet. And, for obvious reasons, the Internet isn't practical for patients with significant visual impairment. In my practice, I must also keep in mind that many of my lower-income patients may not have a computer at home.

Limit Financial Risks

When I first began my practice, I was running a small business. During the past 30 years, the cash flow through my business has tripled, even though my profit hasn't increased commensurately. Sometimes it feels as though my practice is a conduit for money that ends up somewhere else, but I'm nevertheless responsible for the proper handling of all funds. Over the years, I've learned that the circulation of large sums of money through a business can pose a number of risks, and among these is the potential loss of revenue due to the mismanagement of paperwork.

On a typical day, I might perform as many as 10 to 15 injections, and each of these is typically quite expensive. My reimbursement for each procedure is contingent upon a proper sequence of administrative events taking place in a timely fashion. I've learned that if my staff isn't on top of related paperwork, the practice can easily fall behind financially.

The need to promptly submit error-free documents, carefully track all forms of reimbursement, and update patient records is one more reason to be sure you hire and train a highly qualified staff. And because large sums of money also pose a risk with regard to potential embezzlement, you want to make sure that you can place a high level of trust in all staff members.

Be a Patient Advocate

Healthcare costs require you to recognize potential financial hardships that may accompany recommended treatment. Your practice will thrive once you've developed a reputation for being aware of financial realities and helping your patients cope with treatment costs. Interacting with patients who require assistance in a caring manner also reflects your personal and professional values and is likely to encourage compliance with therapy. To ensure that your patients are provided with the assistance they need, make sure your staff members are patient advocates, too. nMD