Full Disclosure — Out-of-Pocket Costs as Side Effects
Peter A. Ubel, M.D., Amy P. Abernethy, M.D., Ph.D., and S. Yousuf Zafar, M.D., M.H.S.
N Engl J Med 2013; 369:1484-1486 October 17, 2013 DOI: 10.1056/NEJMp1306826
Comments open through October 23, 2013
Few physicians would prescribe treatments to their patients without first discussing important side effects. When a chemotherapy
regimen prolongs survival, for example, but also causes serious side effects such as immunosuppression or hair loss, physicians
are typically thorough about informing patients about those effects, allowing them to decide whether the benefits outweigh the
risks. Nevertheless, many ...view middle of the document...
Consider a Medicare patient with metastatic colorectal cancer. Commonly, a component of first-line therapy for this disease is
bevacizumab. The addition of bevacizumab to chemotherapy extends life by an average of approximately 5 months over
chemotherapy alone. The drug is fairly well tolerated, but among other risks, patients receiving bevacizumab have a 2% increase
in the risk of severe cardiovascular toxic effects. Over the course of a median of 10 months of therapy, bevacizumab costs
$44,000. A patient with Medicare coverage alone would be responsible for paying 20% of that cost, or $8,800, out of pocket,
and that price tag doesn't include payments for other chemotherapy, doctor's fees, supportive medications, or diagnostic tests.
Most physicians insist on discussing the 2% risk of adverse cardiovascular effects associated with bevacizumab, but few would
mention the drug's potential financial toxicity.
This example is not isolated, and the consequences for patients are grim. The problem is perhaps starkest in cancer care, but it
applies to all complex illness. The Center for American Progress has estimated that in Massachusetts, out-of-pocket costs for
breast-cancer treatment are as high as $55,250 for women with high-deductible insurance plans; the out-of-pocket costs of
managing uncomplicated diabetes amount to more than $4,000 per year; and out-of-pocket costs can approach $40,000 per
year for a patient with a myocardial infarction requiring hospitalization. The Centers for Disease Control and Prevention
estimates that, owing in part to such high out-of-pocket costs, in 2011 about a third of U.S. families were either struggling to pay
Financial Burden of
medical bills or defaulting on their payments (see graphs).
This health care–related financial burden can cause substantial distress, forcing people to cut corners in
ways that may affect their health and well-being. In our research, we discovered that many insured
patients burdened by high out-of-pocket costs from cancer treatment reduce their spending on food and
clothing to make ends meet or reduce the frequency with which they take prescribed medications.
Whether because of insufficient training or time, many physicians don't include information about the cost
of care in the decision-making process. But discussing costs is a crucial component of clinical decision
making. First, discussing out-of-pocket costs enables patients to choose lower-cost treatments when
there are viable alternatives. Patients experience unnecessary financial distress when physicians do not inform them of
alternative treatments that are less expensive but equally or nearly as effective. We discovered this phenomenon when
interviewing a convenience sample of breast-cancer survivors who had participated in a national study of financial burden. Many
women reported discussing treatment-related costs with their physicians only after they had begun to...