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First, Do No (Financial) Harm

First, do no harm is a well-established mantra of the

medical profession, but it mayneed to be reconceptu-

alized in an era of unsustainable health care spending.

Medical bills are now a leading cause of financialharm1

and physicians decide what goes on the bill. The pos-

sible consequentialharmis substantial, often leadingto

lost homes and depleted savings.1 While the Afford-

able Care Actwillensure expandedcoverage, newly in-

sured Americanswill notnecessarilybe immunefromin-

creased costs of their care. More Americans than ever

before are enrolled in high-deductibleinsurance plans,

meaning that seemingly simple decisions that physi-

cians make about testing could directly lead to thou-

sands of dollars in out-of-pocket costs.1 This strain on

household budgets can cause further erosion of per-

sonalhealth.Lackof money topay for medical bills and

medications has consistently topped the list of finan-

cial concerns for Americans on the monthly Consumer

Reports Indexsurvey, in manycases leading patientsto

postpone or forgo needed care.2

Some physicians may be resigned to a reality that

financial adverse effects are a known and unavoidable

harmofmedicalcare.However,thesameargumenthad

beenmade previously about central lineinfections, yet

central line infections are almost universally avoidable

through specific actions of physicians.3 Just as physi-

cians playan importantrole in preventing serious infec-

tions,physicianscanalso helppatientsavoidexperienc-

ingfinancial harm as a resultof medical care (Box).

ScreenforFinancial Harm

First, physicians can help patients avoid financial harmbyscreeningeachpatientto determine financialrisk and

preferences. Forinstance, patientscan be asked if they

haveany concernsabouthowtheirmedicalcarewillbe

paid for and howmuchthey personally may owe. Simi-

lar to advance directives, making such screening rou-

tine could help alleviate patient or physician discom-

fort broaching this delicate topic. The consideration of

severe financialstrain directly resultingfrom care must

also be balanced with the need for care. Such an ap-

proach does raise the important concern that patients

will be stratified and treated differently based on their

insurance and financial status. To avoid the legitimate

concernof exacerbatinginequities,a universal precau-tionsapproachtoprovidingfiscallyresponsiblecarecan

be adopted.

Adopta Universal Approach

In 2007, themajority of medical debtors hadhealth in-

surance at the beginning of their illness, and an esti-

mated25 million Americans were underinsured.1Hence,

itis increasinglydifficult toknow which patients will be

faced with insurmountable medical bills in thenear fu-

ture. Since physicianscannotbe surewhichpatientswill

ultimately have unaffordable medical bills, theyshould

treat allpatientsas if they could be.

Thisapproach applies to bothinpatient andoutpa-

tient encounters because patients often face signifi-

cantfinancialobligationsin bothsettings.Althoughphy-

sicians may assume that hospitalizations for insured

patients are automatically covered by healthplans,in re-

ality these patients may still face large co-payments.

Thus, in someinstances whether hospitalization canbeavoidedshould be discussed. Inaddition,the payer may

refute theappropriateness ofadmission or leave cover-

age gaps due to high deductibles, caps, or other cost-

sharingmechanisms.In theambulatorycaresetting,pa-

tients may pay a percentage of the fees for services.

However, patients can be understandably confused

whether they are being treated as inpatients or outpa-

tientsbecauseemergency department careand obser-

vation status in the hospital are often considered am-

bulatory care sites.4

VIEWPOINT

Christopher Moriates,

MD

Universityof California,

San Francisco.

Neel T. Shah,MD, MPPHarvardMedical

School, Boston,

Massachusetts.

VineetM. Arora,MD,

MAPP

Universityof Chicago,

Chicago, Illinois.

Corresponding

Author: Christopher

Moriates, MD,

Universityof California,

San Francisco,505

Parnassus Ave,M1287,

San Francisco,CA

94143-0131 (cmoriates

@medicine.ucsf.edu).

Box. Example Scenario: Assessing PossibleFinancial

Harm fora Patient With Low Back Pain for3 Weeks

Without RedFlag Symptoms

Screen forfinancialharmAreyouworriedabout how your medical care will be

paid for?

Areyouhavingtrouble payingfor your medicationsat

home?

Adopta universal approach

Eventhoughyour insurancewillcoverit, I dont think

thatbackimagingwill helpus. Most backpainlikeyours

gets better on its own within 4 to 6 weeks. The risks

of radiation and the high cost outweigh any possible

benefits. What were you hoping to find out with a

scan?

Understandfinancialramificationsand valueofrecom-

mendations

Physical therapy has been shown to be beneficial insome back pain cases like yoursif thepain lasts more

than 4 weeks. I could refer you to physical therapy if

you areinterested, butit maynot becoveredby your

insuranceandwouldlikelycostyouuptoacouplehun-

dreddollarsout-of-pocket.WouldthatbeOKwithyou?

If you would prefer to not spend the time and the

money, I couldinsteadgive yousome examplesof ex-

ercises that you can do on your own for now and we

canreevaluate theneedforphysical therapynexttime

if your pain is notgettingbetter. What do you think?

Optimize careplans for individual patients

Your insurancewill notcoverphysical therapy, butyou

couldgo toyourlocalyogaclassif you want formuch

cheaper.Yogahasalsobeenshowntobehelpfulforlow

back pain. Do you think that you would want to try

that?

Opinion

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Understand Financial Ramifications

and Value of Recommendations

Manystudies demonstrate thatphysicians are unaware of the cost

of routinelyordered tests,let alone the potentialfinancial risks for

patients seeking care.5 To explain potential options and their fiscal

implications to patients, physicianswill need to take responsibility

forknowing the financialramifications of thecare they areprovid-

ing. This does not always require knowing the exact dollars-and-cents costs:one of thebest ways to deflate medical bills would be

to avoid interventionsthat do notmake patientshealthier.With up

to one-third of total health care costs currently estimated to be

wasteful,6 physicians should concentrate on providing appropri-

ate care. Several tools and resources can assist physicians in iden-

tifying these areas of likely overuse, including the widely publi-

cized Choosing Wisely campaign.7

Optimize Care Plans for IndividualPatients

Physicians alsoshouldlearnhow tooptimizepersonalizedhealthcare

decisionsfor patients financialhealth. Toooften physicians choose

less than ideal options fortheir particular patients not dueto a lack

of caring, but rather a lack of knowing. This includes not prescrib-

inggenericorotherinsurance-covereddrugswhenappropriate.Lack

of awareness about the opportunities to provide higher-valuecare

should no longer be an allowable excuse. Physicians, as well as of-

fice andhospital staff, canaid patients by directingthemto readily

available high-qualityresources aboutmedicationcosts andtheir in-

surance plans. Providing true patient-centered care should not re-place physical ailments with distressing fiscal harms.

Conclusions

Financial concernsare important topatients andphysiciansneed to

be prepared to address this aspectof their care. Although these fi-

nancial discussions may present some challenges, physicians al-

readyparticipate in difficult discussions withpatientsabout opiate

abuse,domestic violence, andend-of-life decisions. Toprovidetruly

patient-centeredcare,physicianscan liveup tothe mantra ofFirst,

dono harmby not onlycaring for theirpatients health, butalso for

their financial well-being.

ARTICLE INFORMATION

Published Online: July 8,2013.

doi:10.1001/jama.2013.7516.

Conflict of Interest Disclosures: Theauthors have

completedand submitted theICMJE Form for

Disclosure of PotentialConflicts of Interest.Dr

Moriates reported serving as a consultant to

McGraw-Hill, receiving grants from the ABIM

Foundationand UCSF Center for HealthcareValue,

and receiving payment for lectures from Kaiser

Permanente and Highland Hospital. Dr Shah

reported board membershipwith eMPR,serving as

a consultantto McGraw-Hill, receiving grants from

the ABIMFoundationand Ariadne Labs,receiving

payment forlectures from Women& Infants

Hospital and theAmerican Academy of Physician

Assistants,and receiving travel/accommodations

reimbursement from theRobert WoodJohnson

Foundation. Dr Arora reported receiving grant

funding from the ABIMFoundation.

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Opinion Viewpoint

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