Consumers Don't View Curbing Costs As Their Job in Treatment Choice

by Michelle Andrews, Kaiser Health News

In recent years, consumers have increasingly been encouraged by employers and insurers to help control rising health care costs. That may be by avoiding unnecessary tests, buying generic drugs and reducing visits to the emergency room, among other things. The hope is that a patient better educated and more engaged in health decisions will choose options that will promote better health and decrease costs.

Such "patient engagement" efforts assume that patients welcome the opportunity--or at least are willing--to get more involved in their own care. But as a study published last month in the journal Health Affairs found, a majority of patients didn’t want to factor costs into their medical decisions, nor did they want their doctors to do so.

The study investigated the attitudes of focus group participants in Washington, D.C. and Santa Monica, California. They were asked about weighing their own out-of-pocket costs and the costs borne by their insurer in medical decisions. 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.

Study co-author Susan Dorr Goold is 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. Dorr Goold says her team was surprised at how frequently people talked about not wanting cost considerations to factor into decision-making at all.

"It surprised us as we were analyzing the data 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,'" says Dorr Goold. "We heard it, but not very often and not very much. If patients think we shouldn't consider costs at all, doctors are put in a difficult position."

In the study, the researchers asked patients to consider how cost might influence their thinking if, for example, someone had a headache for three months and discussed getting an MRI versus a CT scan with his doctor. In this scenario, the doctor explained that a CT scan would identify nearly all the problems that were serious enough to need treatment for a fraction of the cost of an MRI. In general, people were unwilling to consider the cheaper test.

Dorr Goold says the team wonders if the response would have been different if they'd asked about a different health problem, say a toenail fungus.

"There’s a whole spectrum of medical problems, from life threatening to living with ugly toes," she says.

She says other research has shown while patients certainly consider their out of pocket costs, they're not very good at deciding what's worth spending extra money on. In fact, one of the beliefs people expressed was that you get what you pay for, that more expensive care is by definition better.

"The idea that you get what you pay for is a very American, market-oriented point of view," says Dorr Goold. "I often talk to patients about generic versus brand-name medications, for example, and how for the most part there’s no difference in value. If you're trying to get your blood pressure down or treat a rash, using a generic medication is fine. But you'd be surprised at how many people resist something just because it's cheaper, even if it is just as good."

Participants talked about being unwilling to make any tradeoffs between health and money, no matter how expensive the treatment. And people expressed concern that they don't want physicians to factor in patient resources when they make treatment decisions. Care should be the same, they said, whether someone is penniless or just flew in on a private jet.

Dorr Goold says patient resources do not influence care and treatment recommendation. BUT, that doesn't mean patients will be able to afford it.

"Lots of places have looked at what care we should pay for, and frankly the insurance companies are making those decisions now," says Dorr Goold. "They're deciding what’s covered and what’s not, what's medically necessary and what’s not. That's a judgment. No matter what kind of system you have, somebody has to decide what's going to be paid for."

One of the interesting findings was that some participants seemed motivated to choose expensive care "out of spite," because they were angry at their insurance company.

Dorr Goold says there was an almost vengeful attitude toward insurance companies, something like "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," says Dorr Goold. "But 'I want to hurt the insurance company?' Why? Those health care payments come from money all of us have paid to insurers. It's an interesting finding that requires more looking into."

This article was produced by Kaiser Health News with support from The SCAN Foundation.