Discussing Out-of-Pocket Expenses With Patients

Talking about out-of-pocket medical expenses can be an uncomfortable experience for both the doctor and the patient. As doctors, we are trained to educate our patients on the best treatment options available for their condition. Patients who carry medical insurance are conditioned to expect that these options will be covered by their insurance, at least in part. But with the ever-changing medical insurance landscape, coupled with constant advances in ocular treatment options, more and more often, the most desirable therapies may not be covered by any medical or vision insurance carriers.

CARE OVER COST

If we aim to provide the highest level of care, premium services and out-of-pocket expenses are a reality that we must not only face, but also embrace. All patients have a right to be given the full range of options, both covered and out-of-pocket, that are available to treat their condition. It is wrong to assume which services a patient can afford and to attempt to practice medicine on a budget on their behalf without first giving them all of their options. Doing so only sets you up for subpar results, patient dissatisfaction, tough questions to answer, and sometimes even additional complications that could have been avoided or mitigated with the more expensive treatment. Furthermore, if a patient finds out that other options were available but not offered to them, they may rightfully become upset and lose trust in you as their provider. Even if they would not have chosen the most expensive option, they may feel slighted that they were not given the option to choose for themselves.

COMMON AREAS FOR OUT-OF-POCKET EXPENSES

In medical eye care, one area where the discussion of out-of-pocket expenses often comes up is name brand versus generic medication. In our practice, we strive to always recommend the appropriate name brand medication as first-line therapy to provide the highest level of care for each patient case.

We typically only consider generic medications after first attempting to obtain prior authorization, changing to alternative name brand medications, and/or educating the patient on the difference in efficacy and possible higher rates in side effects. Only then will we change to a generic medication, with proper documentation in the medical record that the change is the patient’s choice. This process of not going to generic first-line may take a little more education and time spent with the patient and certainly can result in more work for your staff, considering the paperwork and authorizations. However, these steps are important to us and to our patients, and they usually appreciate our efforts when we thoroughly explain why we feel the name brand option is best for them. Patients have to realize that not all medications are created equal and that we are making choices to give them the best end results.

Refractive surgery is another area that often involves the need to discuss out-of-pocket expenses, especially when it comes to refractive cataract surgery. Most patients are aware that an elective refractive surgery, such as LASIK, is one they have to pay for, but they don’t always know the cost in advance. Many patients are conditioned to expect cataract surgery to be covered by their medical insurance, and it is—in its most basic form. But with the enhanced results from advances such as femtosecond laser, the intraoperative Optiwave Refractive Analysis (ORA) System (Alcon), and premium IOLs, patients often desire more than the standard surgical cataract outcomes. Discussing these options prior to surgery is mandatory so that every patient can choose for themselves what option best fits their personal needs, desires, and price point.

A major emerging area for frequent discussion about out-of-pocket services is dry eye disease (DED). In our practice, nearly every patient presents with dry eye risk factors, if not full-blown DED. The understanding of DED and the technology and treatments used to treat it are currently in a golden age, and it seems that every time we turn around, something new crops up in this space. For some guidance on how to navigate discussions about cost with patients, see Talking Money to Your Patients With Dry Eye.

MAKE IT EASIER ON YOURSELF

Keep Thorough Patient Records

Document your discussions about out-of-pocket medications, procedures, and your ultimate decisions.

Prepare Your Staff to Discuss Options

In our practice, we expect every physician to consistently educate patients about surgical options and recommendations for best outcomes throughout the entire surgical process. We also rely on our technicians and surgical counselors to be highly educated in these areas in order to reinforce the doctor’s recommendations and to help field patient questions. If we carefully discuss these options and are upfront about the associated costs, we typically find that patients are accepting of what the higher cost options provide and view the cost as money well spent.

Call in Reinforcements

I recommend using your pharmaceutical representatives as resources from which to learn about the nuances that can be included in documentation to help with better coverage and to ease the prior authorization process. The reps are knowledgeable about certain plans that work for certain medications and can make recommendations about prior authorization websites or specialty pharmacies that work better for their product. When applicable, take the time to give the patient the coupons that the reps provide and to educate them on how to activate and use them. The reps want you and your patients to have greater access to their medications. Working with them can really help to facilitate this process in ways that are more successful than you might think.

HOLD YOURSELF to A HIGH STANDARD

Patient education is the key, but this is nothing new. Whether we are recommending spectacle lens upgrades, advising on the need for multiple pairs of glasses, recommending myopia control or specialty contact lenses, discussing ocular disease or surgical options, or offering out-of-pocket services, it is always imperative to educate and confirm that the patient understands.

As you read this, you are probably thinking that you don’t have time to discuss every option with every patient. I know this because I was just like you once. Then one day, I decided to give it my best shot for my patients, and I haven’t looked back since. You may change some of your processes and enlist the help of your team. You will have to train them a little more in the beginning, but once you have established this culture of education among your staff and patients, discussions about the cost of services, brand name medications, etc, will become easier, more exciting, and more profitable.