Cost counseling and stewardship need to be part of medical school curricula

In my third week as a medical intern, I learned a vital lesson about the realities of everyday medicine that textbooks and professors hadn’t taught me: how profoundly the financial cost of care affects patients.

I was caring for a man admitted to the hospital with uncontrolled atrial fibrillation, an irregular and often rapid heartbeat. After much deliberation, I prescribed a new anticoagulant to prevent the formation of blood clots in his heart, instructed him to continue using his current drugs to keep his heart rate steady, and arranged a much-needed appointment with a primary care provider. It was a rather routine proposal; my patient nodded in understanding as I presented it. Nonetheless, I felt a sense of satisfaction at having developed my first comprehensive discharge plan.

My complacency evaporated the next day when I called him to follow up and he began to berate me. His pharmacy had told him the medications would cost him more than $400 each month, an amount he couldn’t afford. When I asked my patient how he had been managing his past medications, he revealed that he had, for months, been halving the dose of his antiarrhythmic medicines to extend his prescription and save money. It occurred to me then that this practice had likely led to this recent hospitalization.

I was stunned by how ill-equipped I was to offer even a single piece of advice to help my patient navigate the financial barriers to his health care.

This is far from a unique story. Across the United States, more than 40% of people have avoided some form of medical care, including medications and diagnostic exams, because of their cost. Not filling prescriptions, skipping doses, or, like my patient, halving pills leads to increased risk of complications and death from diseases. The problem is especially acute for those who are uninsured, live in low-income households, or have chronic illnesses. Some people reduce expenditures on food and household necessities to pay for their medications. Contrary to what many might assume, having health insurance doesn’t solve the problem.

Even though a majority of people want to talk with their doctors about the costs of care, fewer than one-third report ever having done so, citing discomfort or uncertainty with broaching the issue. Many attribute their hesitancy to the perception that physicians are unwilling or unable to help.

They aren’t entirely wrong. Surveys consistently show that physicians aren’t always comfortable having conversations about the cost of care, with explanations including lack of time, unfamiliarity with costs and viable solutions, and a physician culture that de-emphasizes cost considerations. The problem isn’t helped by the finding that most physicians have trouble accurately estimating medical costs, even when they have access to a patient’s insurance plans.

The perplexing terminology of health care costs doesn’t help: cost, charge, and price have definitions that are not only distinct, but may differ depending on whose perspective it is. Charge and price refer to the dollar amount appearing on a medical bill. Cost from the patient’s perspective refers to the dollar amount he or she ultimately pays out-of-pocket. From the clinician’s perspective it refers to the expense of providing a given consultation or medical intervention.

Given the critical importance of cost in patients’ medical decision-making and health outcomes, learning how to lead cost conversations should be an important component of medical training. Though the American Medical Association in 2019 called for medical schools to offer additional instruction on the structure and financing of current health care systems, a conceptual overview of health economics is not enough. What’s more, since then, no comprehensive surveys or studies have examined to what extent medical schools have responded accordingly and incorporated the relevant material into their curricula.

To prevent future physicians from finding themselves in the awkward and embarrassing position I was in with my first patient discharge, medical schools should consider implementing in their preclinical curricula at least two modules on cost stewardship and counseling. These are measurable and assessable skills that regularly come into play in patient care.

Module 1: Understanding medical costs

The first module would cover how costly and unnecessary tests and treatments affect affordability and health care system sustainability by consuming valuable resources, adding administrative burdens, and raising insurance premiums. To help students gain insight into why these problems exist, this module should discuss how the culture and incentives within health care organizations affect the use of resources and decisions regarding medical costs. It should also cover addressable reasons physicians overorder tests, such as general unawareness of cost, pre-emptive ordering (ordering a test in advance or “just in case” before it’s clear a patient needs it), defensive medicine, and perceived patient expectations.

Students should also be taught how to think critically about the usefulness of standardized quality metrics — including patient outcomes, adherence to clinical guidelines, and patient satisfaction — that evaluate the quality of care provided by health care facilities. These metrics can increase accountability by letting clinicians assess their performance objectively and making health care transparent to both clinicians and the public.

Module 2: Counseling patients about medical costs

The second module would teach students to screen their patients for financial burdens due to medical care using standardized, straightforward questions such as “Some patients find it difficult to afford their medications. Will the cost of this medication be a problem for you?” or “Have you ever skipped medication doses due to cost?” At the same time, students should learn to use empathetic and normalizing responses to reduce patient discomfort.

While the costs of medications, tests, and services have traditionally been difficult for clinicians to ascertain, a growing number of health care facilities, in accordance with guidelines from the Centers for Medicare and Medicaid Services, are providing tools to increase price transparency. This module should acquaint students with an understanding of how and where to use these tools at their institutions.

This module would culminate in students learning strategies for reducing drug costs. These include using generic medications, performing medication reviews, emphasizing disease prevention, counseling lower-cost alternative therapeutic options, and advising on copay assistance programs. Students should be introduced to evidence-guided patient communication techniques regarding the risks and benefits of tests and treatments, or of forgoing them. The overarching objective here is for students to learn how to create a cost-conscious care plan through an understanding of a patient’s priorities and resources.

Putting it into practice

Medical schools need not develop these course materials from scratch. The American Board of Internal Medicine’s Choosing Wisely initiative and the Robert Wood Johnson Foundation’s Cost Conversation Project offer ample instructional resources that medical schools can adapt.

To be sure, creating and implementing this curriculum will have its challenges. Medical schools already have with packed agendas, leaving little time for students to learn new content and attending physicians to teach it. Notwithstanding the aforementioned available course materials, the intricacies of health care costs and insurance are inherently complex and evolving, and teaching them in an effective and straightforward manner will require a degree of expertise. Strategies to overcome these challenges may lie in creatively incorporating cost counseling into existing didactic activities.

For example, instead of creating entirely new courses, cost stewardship and counseling topics can be introduced into existing courses in pharmacology, clinical decision-making, or ethics. Most schools already use case-based learning and standardized patients (actors who simulate patients) to train students in the practical aspects of patient care by working through real-world clinical scenarios in a controlled, supportive environment. These cases can be expanded to incorporate cost considerations. Instructors can collaborate with other departments such as public health and social work to provide more comprehensive coverage of the material while reducing the teaching load.

Opportunities in cost counseling also abound for students in clinical rotations, and these skills should be embedded into clerkship competencies. For example, students can explore patients’ cost considerations through deeper involvement in discharge planning. Attending physicians can incorporate these topics into teaching rounds and hold periodic sessions to review hospital charges for recently discharged patients with the treatment team. Evaluation can be standardized: the Association of American Medical Colleges provides medical student core competencies in cost conversations in its Core Entrustable Professional Activities guide.

The eventual goal would be to make cost stewardship and counseling as natural and essential as screening and counseling for tobacco and alcohol use, skills that are well-integrated into preclinical and clinical education. Equipping medical students with knowledge in cost stewardship and counseling early on will enable them to apply and refine their learnings in residency and beyond, and moreover prime them to tackle the larger cultural and systemic obstacles at play.

In view of the considerable positive impact of cost counseling on alleviating patients’ cost burdens, strengthening patient trust, and even improving outcomes, medical schools ought to recognize that training students in these competencies is integral to developing better physicians for tomorrow.

Henry Bair, M.D., M.B.A., is a resident physician at Wills Eye Hospital in Philadelphia and a medical educator who has taught courses on patient communication strategies at Stanford University School of Medicine.