Professional Obligations When Patients Pay Out of Pocket

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Here’s what the ethics literature—and real-world experience—teaches us about helping patients make better cost-conscious choices.

During a long-overdue routine check-up with a 65-year-old Caucasian patient we’ll call Dan, you discover his blood pressure is 150/90—this, despite the prescription you wrote for him nearly a year ago. When you recommend that he increase the daily dose and suggest he may want to try a newer drug, he tells you he never filled the original prescription. Soon it’s apparent that he and his wife, who has diabetes, hypercholesterolemia, and severe arthritis, have been deciding which medicines to take and how often to schedule visits based on their monthly budget.

This is one of countless common scenarios playing out as a result of consumer-directed health care (CDHC), the latest movement in the constant struggle to control the costs and improve the quality of health care. CDHC uses mechanisms like steeply tiered co-payments, high deductibles coupled with health savings accounts, and reduced coverage (such as the infamous “donut hole” in Medicare Part D) to compel patients to spend their own money, not insurance money. This approach is intended to give patients more “skin in the game” so that they look harder for thriftier options and accept only treatments they really think are worth the money.


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