Choosing (Words) Wisely: Talking with Patients About the Cost of Their Care (TH306)

Abstract

Objectives 1. Define what is already known about in-person discussion of medical care costs with patients and families. 2. Apply ethical principles and values to situations where options for treatment are limited by costs. 3. Discuss the adaptation of breaking bad news modules to the discussion of cost and integration of cost into a discussion of effectiveness. Learn practical models for negotiating the most difficult parts of the discussion, namely when the patient and family want resources and care that is not available within the healthcare program. The cost of medical care is rising at an unsustainable rate in the United States and will be reduced (Smith & Hillner, NEJM, 2011) with accountable care organizations, restrictions, and voluntary campaigns such as the American Board of Internal Medicine's "Choosing Wisely" campaign. About half of all bankruptcies are related to medical costs. Recent work (Sommers R, Danis M, Health Affairs, 2013) shows substantial barriers to patients' use of cost in decision making, including a desire for best care regardless of cost consequences for themselves and others, disinterest in societal costs, and inexperience with any discussion of costs. These tensions inevitably lead to conflicts between what people want and what can realistically be provided based on both medical effectiveness and cost. There are very few models about how to have these difficult conversations. How can healthcare professionals be trained in and feel comfortable with discussions about the limitation of resources? Presenters will discuss the very limited available data; models adapted from breaking bad news (for example "SPIKE," McFarlane, Riggins, Smith, J ClinOnc, 2008); current practices for crucial conversations we currently have with families that involve restrictions such as insisting on discharge when the family requests more days, and out of pocket costs for genetic tests and chemotherapy. We will explore the underlying ethical issues in professionalism and choices for the patient and/or society and resources to help healthcare professionals discuss the cost of care. Specific topics include: how and when to raise the issues, how to determine the cost of various medical care items, ways to explain to patients that some desired treatments simply are not available and why, and the ethical and social dimensions in which these decisions are made. The collaborative process will be illustrated through case studies of patients who need therapies that are not available within their payorsystem, or for whom the available treatment could bankrupt the family for years to come.