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“On a scale of 0 to 10, how painful is the cost of your health care?”

That’s a question all physicians should ask their patients, and one that has become increasingly more relevant in everyday patient care due to the relentlessly rising costs of health care and prescription drugs. These are now compounded by the economic devastation of the Covid-19 pandemic.

When government assistance tapers, the dust settles, and the fundamental economy reemerges, more and more Americans will find themselves suffering financially and unable to withstand more assaults on their pocketbooks.


Today more than ever, it’s important for physicians to know the actual cost of the care they provide. Doing so makes it possible to offer more holistic care, care that factors in not only the customary considerations, such as drug risk and benefit, but also financial suffering and sacrifice. It isn’t something physicians are trained to do, or were ever expected to do, but now should be called upon to do.

The financial consequences of health care can include damaging sacrifices in savings or spending, which may also affect other family members; mental health problems, such as anxiety and depression; serious stress on a marriage or other relationship; job immobility due to employer-based health insurance; lower wages caused by higher employer health insurance costs; otherwise avoidable borrowing, including from predatory lenders; and sometimes personal bankruptcy. Growing health care costs also negatively affect government-funded health insurance (Medicare and Medicaid) and safety net programs such as unemployment and welfare programs, as well as the Veterans Health Administration, potentially resulting in higher taxes.


High costs can also directly compromise health, such as splitting pills or skipping doses, abandoning prescriptions, missing clinic visits, and making more trips to the emergency department. These can prevent optimal care and make future health complications — and expenses — more likely. They can also require hospitalization and sometimes lead to premature death, for which the literal and figurative price tags are impossible to gauge.

Concerned about the cost of the care we provide to our patients, the three of us have changed how we work. We now ask our patients about financial side effects at every encounter, after first explaining why we are doing this. We ask because it is rare for patients to tell us unprompted what financial challenges they are facing, what sacrifices they have made to adhere to their care, and when and where they haven’t been able to get the care they feel they need.

We ask about out-of-pocket expenses, including out-of-pocket costs at the pharmacy; copays or bills for any tests, such as imaging studies; copays for clinic visits; and how and when they spend their annual deductible. We pay attention to our patient’s insurance coverage, knowing this might affect which drug we decide to prescribe, or which tests we recommend.

We ask if they sometimes leave prescriptions unfilled or split or skip doses. We ask what sacrifices they make to pay for their care. If we have time during the visit, we ask if out-of-pocket costs for health care prevent them from spending their money on something else important to them or their family. We sometimes also ask our insured patients about their annual premiums, including whether they’ve gone up over the past few years and how that has affected them. When we ask, we learn. And when the answers worry us, we search for solutions. After all, one of our mandates is to first do no harm.

We may not be the first physicians to be asking our patients these questions. But we are very much still in the minority.

An understanding of the financial pain imposed by the care we deliver is vital, at times as vital as understanding heart rate, respiratory rate, and body temperature. For us there is no more turning a blind eye, no more passivity, no more guessing, and no more room for implicit bias. Instead, we ask and we learn and we improve the way care for our patients.

Ted M. Burns is a neurologist and professor of neurology at the University of Virginia. A. Gordon Smith is a neurologist and professor and chair of the department of neurology at Virginia Commonwealth University. He has received funding from the National Institutes of Health and is a consultant for Alexion, Argenx, Eidos, Disarm Therapeutics, and Regenesis. Jason L. Crowell is a neurologist at Beth Israel Deaconess Medical Center in Boston and a graduate fellow at the Harvard Kennedy School.

  • If we replaced our money driven broken health care system with a single payer improved Medicare for all health care finance system, these doctors would not have to be concerned about how their patients would be forced to pay for their care. The financing would shift to an efficient single payer, the government, funded by taxes based on ability to pay. This would eliminate the profiteering on the backs of sick people and mind numbing bureaucracy of the insurance industry.

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