ACR Bulletin

Covering topics relevant to the practice of radiology

Paying the Price

A growing number of patients are avoiding critical care because they cannot afford it. Can radiologists help find the answer?
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Financial toxicity’s avoidance of care aggravates existing health inequities in a society.

—Yoshimi Anzai, MD, MPH
March 25, 2021

In a national survey conducted by the University of Utah, patients were asked the one thing they valued most from a healthcare provider. The answer — overwhelmingly — was “affordable out-of-pocket costs.”1 Unfortunately for many patients, affordable out-of-pocket costs aren’t always in reach. A survey by the West Health Institute and the National Opinion Research Center at the University of Chicago found that 40% of patients skipped a recommended test, treatment, or follow-up appointment within the last year because they could not afford it and were more concerned about the cost of treatment than getting sick. Many of these individuals are also having difficulty paying for necessities such as food, heat, and housing already, and cannot keep up with rising healthcare costs.2 These patients and their families are suffering from financial toxicity of care.

“Financial toxicity is the financial burden imposed on patients and their caregivers and it greatly affects access to care,” says Ruth C. Carlos, MD, MS, FACR, professor and assistant chair of clinical research in the department of radiology at the University of Michigan and editor-in-chief of the JACR®. “There are data that show that even a $5 increase in out-of-pocket costs can lead to patients not filling their necessary prescriptions.”3 She adds that even services fully covered by insurance, such as screening mammography, may be avoided because of the worry that the test will be positive, leading to additional screening or care patients cannot afford. “As a result, financial toxicity’s avoidance of care aggravates existing health inequities in a society,” says Yoshimi Anzai, MD, MPH, associate chief medical quality officer at University of Utah Health.

And that’s not the only burden it leaves on patients, says Anzai. Financial concerns can also cause a great deal of stress for patients. “Imagine having to decide whether to put food on the table or pay for your son’s chemotherapy,” she says. “The stress of these out-of-pocket costs can impact a patient’s health as well.”

Although the work in addressing financial toxicity has just begun, radiologists may be able to help find some of the answers. As radiologists integrate themselves more fully into patient care, they need to be aware of the broader consequences to patients and the multifactorial causes — not just the things that radiologists perceive as directly under their control. “Patient care is not only understanding a patient’s condition, but also the factors affecting a patient’s health and overall well-being — and that includes outside factors, such as their financial situation,” says Carlos.

Financial toxicity and its burdens also directly affect radiology services, says Anzai. “Imaging is perceived as a very expensive service, not only by patients but by referring physicians,” she notes. “Our specialty is an area where patients may ignore care or may shop around to find significantly cheaper imaging, even if it means going to lower quality clinics.”

There are data that show that even a $5 increase in out-of-pocket costs can lead to patients not filling their necessary prescriptions.

—Ruth C. Carlos, MD, MS, FACR

One way to help address financial toxicity among patients is to screen patients for medically induced financial distress, Carlos suggests.3 “It could be as simple a question as, ‘Are you worried about your out-of-pocket costs for your test today?’” she notes. From there, a practice or department can develop referral programs where patients who are identified as financially stressed can be referred to financial counselors or navigators to case manage these situations, Carlos says. “Places such as these can help patients optimize insurance plans and navigate financially induced burden,” adds Anzai. “Finding a way to help patients by using an imaging encounter to screen for financial burden increases the value of care even before we image the patient. Reducing financial burden can also potentially increase the amount of cost share that patients are able to pay, which is a system benefit,” says Carlos.

Price transparency — making the prices of procedures available to the public — continued to gain ground as a tactic against financial toxicity. Proponents argue that more informed consumers will make smarter consumers, allowing patients to shop around and make choices that will put less strain on their finances.3 However, some work has to be done before price transparency tools are effective for radiology, according to Carlos and Anzai. “Price transparency tools need to become more actionable for the patient,” says Carlos. Most public health costs are chargemaster costs, and therefore don’t reflect the actual prices that patients would be
paying for procedures. These prices are often overinflated and serve as the starting point of negotiation between hospitals and private payers.1 “If a patient just looks at that, they’re likely to get sticker shock,” says Anzai. “The patient will see a huge number and look for other places or continue to avoid care altogether. This is why the University of Utah Hospital has developed online, interactive, out-of-pocket estimate tools for our patients.”1

Current price transparency lists don’t always accurately present the care being given either, because while it reflects the dollar cost of the procedure, it doesn’t take into account the quality of the care being delivered — whether it’s patient-centered care, an ACR Diagnostic Imaging Center of Excellence™, or other factors that affect care, both Carlos and Anzai say. “Price is quantifiable — it’s easy to describe. Quality, however, is multifactorial and may be difficult to convey. When you tell patients you’re giving them higher quality care than other facilities, what does that mean to them? It’s potentially something different to everyone,” says Carlos. “More patient education, research, and outreach has to be done for quality to be effectively communicated. Quality practices, such as being enrolled in the ACR Dose Index Registry®, are incredibly important — but your average patient may not understand why, especially if they’re just looking at a price transparency tool.”

Regardless, the push for price transparency and against financial toxicity is here to stay, says Anzai. “We need to take the lead on this. Not only is it the ethical thing to do, but we should be proactive rather than reactive in understanding patient finances and their effects,” she says. “Fewer patients are accepting care just because a physician says so, and more are demanding affordable prices. Healthcare is moving forward with it, whether we like it or not.”