Patient-Centered Communication: Every Doctor's Moral Imperative

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Repeated active discussions with patients about distress, treatment options, and goals can both reduce costs and help to identify when aggressive treatment is no longer appropriate.
Repeated active discussions with patients about distress, treatment options, and goals can both reduce costs and help to identify when aggressive treatment is no longer appropriate.

“There is a lot of waste in medicine,” said hematologist/oncologist Stuart Goldberg, MD, of the John Theurer Cancer Center at Hackensack University Medical Center in New Jersey and chief scientific officer at Cota, a health care data and analytics company that bridges precision medicine to population health.

By some estimates, up to one-third of health care spending is unnecessary, he noted.

Waste contributes importantly to financial distress for patients, sometimes called “financial toxicity” — a problem that is getting worse as the costs of medications and diagnostics escalate.

“The shift from intravenous medications to pills may improve quality issues for our patients but also affects their pocketbook. The cost for pills is borne much more by the patient than hospital-based infusions,” Dr Goldberg explained. “Patients are paying more out of pocket…if chemo pills cost $10,000 a month retail, then a 10% copay is $12,000 a year. That can quickly drain a patient's nest-egg.”

Overly aggressive or futile care at the end of a patient's life is particularly costly, both in dollars and in terms of patients' quality of life.

“There's a huge ramp-up in costs as death approaches,” Dr Goldberg said. “In cancer and some other diseases, we can do more, but should we?”

Poor information-sharing among different health care systems is another big problem, in part because it leads to duplicate lab tests.

“Everybody thought computers were going to allow us to follow patient care wherever a patient goes. But from a business perspective, we don't want a competing hospital to access our records,” Dr Goldberg said. “I get a lot of patients for second or third opinions for whom we have no labs. We can wait weeks to get them, but it's easier to repeat a test that's already been done.”

Without proper biomarker and genetic testing in the first place, before treatment plans are devised, expensive treatments are also likely to be misused.

“Prescribing an expensive targeted agent to a patient whose tumor doesn't harbor the relevant gene mutation makes little clinical sense. And not offering the targeted agent to a patient who has the mutation because you didn't know deprives the patient of a better chance at success. But many diagnostic biomarker tests are not covered by insurance.

“Genomic tests often cost $3000 to $4000 and may not be covered by private insurers or Medicare,” Dr Goldberg added. “You wind up giving patients therapies that don't work because you didn't know there's a better therapy available to your patient. It hurts the patient and wastes money.”

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