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Medical Schools Teach Students To Talk With Patients About Care Costs

Sep 11, 2015
Originally published on September 13, 2015 3:45 pm

Time for a pop quiz: When it comes to health care, what's the difference between cost, charge and payment?

"Does anyone want to take a stab at it?" Sara-Megumi Naylor asks a group of first-year residents at the David Geffen School of Medicine at UCLA.

Naylor answers her own question with a car metaphor. "Producing the car might be $10,000, but the price on the window might be $20,000, and then you might end up giving them [a deal for] $18,000, so that's cost versus charge versus payment," she explains.

It might seem natural for new doctors to learn about the cost of the care they're providing, but, in fact, doctors have been taught to provide the best care possible, leaving the cost considerations aside.

Now, in a stark departure from the past, the vast majority of the country's medical schools now integrate discussions of cost, value and effectiveness into their curricula.

It's "a dramatic change," says Dr. Janis Orlowski, chief medical officer with the Association of American Medical Colleges, which helps medical schools develop curricula.

A recent AAMC survey finds that 129 of 140 responding medical schools offered a required course on the cost of health care during the 2013-2014 school year. Nearly 40 percent of the schools said they also present the issue in elective courses.

Among the reasons for this change: the Affordable Care Act, which is moving towards rewarding doctors for providing high-value care, not for how many tests they order or surgeries they perform.

Another reason is that many more people now have high-deductible health plans. More patients now have to pay a lot for their care before insurance picks up the tab, and that's spurring some to become cost-conscious consumers.

In Southern California, medical schools and residency programs are developing their own ways to insert cost and value into their curricula.

For instance, University of California, Los Angeles started weaving these themes into daily lessons last year, and will be doing so on a much larger scale this school year, says Dr. Reshma Gupta, who is leading the effort there.

"In the everyday teaching they get about clinical medicine, what medications to prescribe, what's the name of this diagnosis, we're going to add a layer to every discussion about the value part of that as well," Gupta says.

She says it's also important to teach students and residents how to start these conversations with older mentors. Gupta gives them a rough script.

"I value your experience and why you're saying this, but I also read this journal article that tells me that maybe we should be using this antibiotic instead of this one, or doing this test instead of this more expensive test. What are your thoughts on it?"

But getting buy-in from students can be challenging, says Dr. Paul Lyons with the University of California, Riverside School of Medicine.

"They're so busy trying to master the basics of medicine, the science and the interpersonal skills, that I think it feels sometimes like this is one more issue they're being asked to master, when they have so much on their plate already," he says.

This information often resonates more deeply once students and residents see its direct impact on patients, Lyons says.

UC Riverside medical student Isaiah Roggow got a dose of all of this while volunteering at the school's free clinic in downtown Riverside.

He recalls one clinic patient with high levels of blood protein. He says much of the time that doesn't mean anything, but a doctor recommended testing for a type of cancer.

It turned out the clinic doesn't offer that test, because of its $400 price tag. Looking back, Roggow says that would be a lot to spend for a test that could prompt more questions but give few answers.

"Most of the time, when it's a positive test, it actually means we just have to do more tests," Roggow explains. "And does that actually serve the patient at all? Now they're just worried because they have this abnormal test that stresses them out, maybe for nothing."

Roggow says it's becoming second nature for students to consider whether a test is necessary, given its price tag. And that means that in the future, they'll be better prepared when their patients start quizzing them about costs.

This story is part of a partnership with NPR, KPCC and Kaiser Health News.

Copyright 2019 KPCC. To see more, visit KPCC.

AUDIE CORNISH, HOST:

When you go in for a doctor's visit, you don't usually talk to your physician about how much your care will cost. But there are pushes now for that conversation to happen because many people are on the hook for a larger portion of their medical bills. KPCC's Rebecca Plevin reports medical schools are evolving to meet this need.

REBECCA PLEVIN, BYLINE: Time for a pop quiz. When it comes to health care, what's the difference between cost charge and payment?

SARA-MEGUMI NAYLOR: Does anybody want to take a stab at it?

PLEVIN: Sara-Megumi Naylor is a chief resident at UCLA. She poses the question to a group of first-year residents. Naylor answers with a car metaphor.

NAYLOR: Producing the car might be 10,000, but the price on the window might be, like, 20,000. And then you might end up giving them, like, 18,000, right? So that's cost versus charge versus payment.

PLEVIN: It might seem natural for new doctors to learn about the cost of the care they're providing. But, in fact, doctors were typically taught to provide the best care possible, leaving the cost considerations aside. So, says Dr. Janis Orlowski with the Association of American Medical Colleges...

JANIS ORLOWSKI: It was not traditionally part of the medical school curriculum, but we have seen a dramatic change in the fact that now physicians are being trained to talk about cost.

PLEVIN: There are a couple reasons for this. One is the Affordable Care Act. It rewards doctors for providing high-value care, not for how many tests they order. And people now have high-deductible health plans. They have to pay a lot for their care before insurance picks up the tab. Orlowski says that's why doctors now have a responsibility to consider cost, even for something as common as antibiotics.

ORLOWSKI: Is this an antibiotic course that's going to cost $50 or is going to cost $5,000? We are recommending they take that into consideration when making their best recommendations.

PLEVIN: The University of California, Los Angeles, for example, has started weaving these themes into daily lessons. Dr. Reshma Gupta is leading that effort.

RESHMA GUPTA: In the everyday teaching they get about clinical medicine, you know, what medications to prescribe, what's the name of this diagnosis, we're going to add a layer to every discussion about the value part of that as well.

PLEVIN: She says it's important to teach students and residents how to start these conversations with older mentors. Gupta gives them a rough script.

GUPTA: I value your experience, but I also read this journal article that tells me that, you know, maybe we should be using this antibiotic instead of this one. What are your thoughts on it?

PLEVIN: But getting buy-in from students can be challenging. Dr. Paul Lyons is with the UC, Riverside medical school.

PAUL LYONS: They're so busy trying to master the basics of medicine that I think it feels like this is one more issue they're being asked to master when they have so much on their plate already.

ISAIAH ROGGOW: I'm just going to do some head-to-toe questions real quick.

PLEVIN: These lessons came alive while UC, Riverside medical student Isaiah Roggow was volunteering at a free clinic. He tried to order a $400 blood test. But he learned the clinic doesn't offer it. It's expensive and usually not that helpful.

ROGGOW: Most of the time when it's a positive test, it actually means we just have to do more tests. And does that actually serve the patient at all? Now they're just worried 'cause they have this abnormal test that stresses them out maybe for nothing.

PLEVIN: Roggow says it's becoming second-nature for students to ask whether a test is necessary given the price tag. And that means that in the future, they'll be better prepared when their patients start quizzing them about costs. For NPR News, I'm Rebecca Plevin in Los Angeles.

CORNISH: This story is part of reporting partnership of NPR, KPCC and Kaiser Health News. Transcript provided by NPR, Copyright NPR.