Gary McClain, PhD, is a licensed counselor, research consultant, speaker, and author who specializes in helping individuals cope with the emotional impact of chronic and catastrophic illnesses. In this series, he provides guides for how to tackle communication challenges with your doctor.
Marco left his doctor’s office feeling pretty optimistic. He had a handful of prescriptions, two he had been taking regularly for his chronic condition, and two his doctor was adding to his regimen. He also had a referral for a couple of tests, one he had been undergoing regularly to monitor his condition, and another one his doctor had recommended as a precaution.
However, it didn’t take long for Marco to feel like the wind had been knocked out of his sails. When he stopped by the lab to schedule the tests, he was informed one test was only covered quarterly, so it was too soon to schedule it. He would need to pay for it himself. The other test could be scheduled, but his out-of-pocket would be high. Too high.
Marco was even more frustrated when he stopped by the pharmacy. The two new medications that had been prescribed were not included in his health insurance company’s list of covered medications – and so he would have to pay the full amount.
What Marco was feeling can best be described as “sticker shock.” The simple truth was he had run into a financial roadblock. He felt embarrassed, as well as concerned that his financial limitations would impact the quality of his care.
How to avoid breaking the bank
So, what do you do when you can’t afford tests or medications your physician has recommended?
If you are like Marco, your first reaction may be to feel like you are caught between a rock and a hard place. On one hand, you trust your doctor and want to adhere to his or her recommendations. After all, you have been doing well so far. But on the other hand, your insurance company says you don’t need a test as often as your doctor has been prescribing it. And won’t even cover the new medications.
This doesn’t have to be about who is right and who is wrong. Instead, concerns about tests, medications, and your budget can open the door to working more closely with your physician.
Here are some ideas to get you started:
Get informed. The Web offers all kinds of information on your condition and how it can be treated. Most likely you’ve been there, done that. But you might want to look more specifically for best practices in terms of the tests and medications your doctor has recommended. Search for your condition and the latest research studies. You can also see which treatments have the most recent research. One trustworthy site to consider is Mayo Clinic's website, which has great information on conditions, as well as specific treatments, tests, and medications.
Get informed about your coverage. Your insurance company or managed care provider most likely has a website with information that might include the formularies (covered medications). It might help to peruse the formulary to see what is and isn’t covered, not with the purpose of choosing your own regimen but to get a sense of the options available to your physician. Some insurance companies also offer consultation with a health coach who is usually a registered nurse. The health coach can discuss your condition with you and may be able to provide you with information on best practices for treating your condition.
Don’t be afraid to be honest about your financial limitations. The best way to start a conversation about money is to be straightforward. Something like, “I have to be honest with you, doctor. I just can’t afford the tests/medications you recommended. Can we talk about alternatives that won’t affect the quality of my care?” Sure, nobody likes to admit they can’t afford something. And if you are concerned your doctor may feel you are questioning his or her competence, start out by reassuring your doctor this is not a matter of what you won’t do, but what you can’t afford.
When a medical test is too expensive
Ask about alternative tests. New research is frequently finding evidence that some of the most widely use medical tests may not always be useful, and showing how testing can be done with less costly and invasive alternatives, if testing is needed at all. Ask your physician if he or she can consider other testing options. If you pick up new information on testing when you are on the Web, print out what you learned and bring it with you.
Ask if the frequency of testing can be modified. Medical research is also showing some tests are being administered too frequently. This is another question to ask your doctor.
It comes down to what is "enough." Physicians want to be proactive and thorough in their approach to treating their patients. Frequent and extensive testing has resulted. You might need to have a conversation with your doctor about how the two of you can work toward a compromise.
When you can't afford prescribed medications
Ask if you can review your insurance company’s formulary with your doctor. While your physician most likely has a “go-to” medication he or she prefers to use to treat your condition, in many cases there are other medications available that are also effective and covered at a lower copay. While your doctor may not be as familiar with the alternatives, or have some reservations about them, if it is easier on your budget, then he or she may agree this is the best route to go, at least on a trial basis.
Ask if there is a generic—or even an over-the-counter—product available. Often, though not always, generic versions of your doctor's “go-to” medicines are available. Some of these may be sold over the counter at your drugstore. Keep in mind your doctor may feel the newest medication is more effective, or has a lower side effect profile, than the generic option. Your doctor may write your prescription for the generic, or let you try the over-the-counter product, with the understanding that the two of you will be watching to see if it is effective enough.
Check out patient assistance programs. Many pharmaceutical companies offer patient assistance programs which provide their medications at a low cost or free to patients who are qualified based on finances. You can find more information by visiting the pharmaceutical company’s website, or the website dedicated to the specific medication. Your physician might also have a patient assistance program application for your drug that he or she can give you. Another website you could check out is www.needymeds.org, which has information on paying for medications. And, if you are near a medical center, you might check into volunteering for studies that may include free treatment and testing
Also keep in mind …
Your doctor is your healthcare partner. Finances are a major piece of the healthcare puzzle, if not the glue that makes the pieces all fit together. Partnering with your physician means talking about some of the non-medical aspects of your treatment, like how you are going to pay for it. Physicians are accustomed to having these conversations, so don’t hesitate to talk about your budget.
Sometimes all you have to do is ask. Physicians are sensitive to the need for low-cost alternatives. Physicians are also being asked by managed care providers to do more with less. Formularies are one example of the constraints they are working under, as are new regulations around testing. Consequently, your physician is most likely going to have worked with other patients who have concerns and financial limitations similar to yours.
Still, be ready to negotiate. If your doctor has a my-way-or-the-highway approach, you might want to consider obtaining a second opinion. While this will require another copay, having an additional perspective can help you better understand your options. After all, you are paying the bills and you are in control of your healthcare.
Marco, our friend with the financial concerns, made a follow-up appointment with his doctor to talk about his concerns. In preparation for this appointment, Marco had done his own research on his insurance company’s medication formulary as well as the tests his doctor had recommended. Marco was honest about what he felt he could and couldn’t afford. His physician offered alternatives, including generic medications, and a revised testing schedule for his regular test. Followed by a big sigh of relief from Marco … and his wallet.
If your healthcare is straining your budget, it might be time to have a talk with your physician. After all, you’re a team!