Cost Lacking in Shared Decision-Making Discussions

Lack of awareness of the price of imaging keeps patients from making informed choices on care.

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Shared decision-making is a term applied to the communication process between a physician and patient. It balances information asymmetry: the physician knows the medical aspects and the patient knows values, lifestyle and treatment preferences. Discussions between physician and patient include available treatment options, potential outcomes, risks versus benefits, and patient values and preferences. 1-3

As important as these topics are, the one aspect of shared decision-making that is sorely lacking in these conversations is cost. Since every patient has different financial circumstances and levels of health insurance coverage, cost variation is a real concern. And with the increasing frequency of high-deductible health plans, many patients will pay out of pocket for their treatment costs. In no other industry does the customer make a purchasing decision without first knowing the purchase price. But in healthcare , the out-of-pocket cost to the patient is hard for either the physician or the patient to know.

One of the only measures of control a patient can exert on imaging cost is to abide by the low-cost recommendations of their insurance company. Ordering physicians request tests, but it’s often up to the patient to decide where to get the imaging done. Even with a recommendation in hand, however, how can the patient know what level of quality to expect from the read? Further, will the scan be diagnostic in the first place, or is there a chance it won’t be clear, requiring still more imaging to be done? And what about the level of professionalism displayed by staff members? Basing such a decision solely on price, even when the price is known, can present its own set of challenges.

Case in point: I recently had to get a back MRI. I scheduled my test for an imaging site that I have used for almost all my imaging tests. The staff are friendly, efficient, and they accommodate my special requests. The day before my MRI, my health insurance company recommended that I go to a different facility with a 50 percent lower cost. I have a high-deductible plan so this was all out-of-pocket for me. I initially agreed but after mulling it over, changed my mind and reinstated my original appointment. Why? Because I had no information about the lower-cost facility. I was not willing to gamble on possibly getting a sub-par scan, especially since the insurance agent could not tell me the price of the MRI at either site. I had my MRI done at my preferred site and paid $156.
The bottom line is that I lucked into making the right decision. I received a bill I could afford for a service with which I was pleased. But that won’t be the case for everyone until physicians work with payers to communicate both cost and quality information to patients. A person’s health is too important to trust to luck.

Radiologists can help influence the transition by advocating to publish screening site quality metrics that will enable patients to do site-to-site comparisons. Additionally, screening site billing services should consider developing a process to provide non-binding cost estimates to patients for their cost of imaging based on their insurance coverage.

 Andrea Borondy Kitts MS, MPH; Lung Cancer and Patient Advocate, Consultant Patient Outreach & Research Specialist, Lahey Hospital & Medical Center

1. Charles, C., Gafni, A., & Whelan, T. (1997). Shared decision-making in the medical encounter: what does it mean?(or it takes at least two to tango). Social science & medicine, 44(5), 681-692.
2. Alston, C. (2014). Shared decision-making strategies for best care: patient decision aids. Institute of Medicine of the National Academies.
3. Stacey, D., Légaré, F., Col, N. F., Bennett, C. L., Barry, M. J., Eden, K. B., ... & Trevena, L. (2014). Decision aids for people facing health treatment or screening decisions. The Cochrane Library.

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