Informed Consent 2.0

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Is healthcare going to the dogs?  In at least one way, it probably should.

While not often spoken of together, physicians and veterinarians share an otherwise unique position of helping people make healthcare decisions in the awkward and charged space between risk, benefit and cost.  Both share an ethical requirement to provide the information necessary for informed decision making. Before starting a treatment or procedure, patients (and pet owners) need to understand the potential risks and benefits of their care, as well as the reasonable alternatives.

But veterinarians often share some other important information, information that physicians seldom share, or even know – that being: exactly what will it cost.

When our family dog recently became very sick, my veterinarian shared not only about the diagnosis, her recommended treatment, its risks, benefits and the plausible alternatives, but she also provided a detailed estimate of what Cosmo’s care was going to cost me.

Isn’t it crazy that when it comes to our own healthcare, we don’t get the same information?

In age when medical debt is responsible for more than 60 percent of bankruptcies, when healthcare costs for a typical family of four are up $1100 this year alone and when patients are being asked to bear a greater percentage of their healthcare bills, informed consent should include a discussion of the cost of care – for people as well as pets.

For physicians, gaining informed consent can be a time-consuming process, as patients have varying capacities for understanding nuanced medical information. As a result, physicians often omit details in favor of a general discussion – a practical reality that may compromise the patient’s complete understanding of the procedure or treatment they are about to receive.

The American Medical Association points out that “the physician has an ethical obligation to help the patient make choices from among the therapeutic alternatives consistent with good medical practice. Informed consent is a basic policy in both ethics and law that physicians must honor.” The discussion between the treating physician and the patient should include diagnosis, planned treatment, risks and benefits, known alternatives and their risks and benefits, and what happens if the patient receives no treatment.

While the list may seem comprehensive at first, what’s missing is a discussion of the cost to the patient and/or patient’s family. Amazingly, the FDA’s recent proposed guidance on informed consent for research subjects does see added costs as an important disclosure for enrollees, yet many physicians in day-to-day care quickly point to the simple fact that they don’t know what ‘stuff’ costs, what insurance they accept or how much the patient might be expected to pay.

And yet, according to the American College of Physicians Ethics Manual, physicians have an obligation to practice ‘parsimonious care’ – to diagnose medical conditions efficiently, to respect the need to use resources wisely when treating patients and to ensure resources are equitably available.

So, with patients and families shouldering more of the cost of care, and physicians ethically bound to be efficient, both parties in the informed consent conversation have a direct interest in understanding the costs associated with the available options to enable truly informed decision-making.

Isn’t it time for specific information on cost be part of the physician-patient discussion?

The American Veterinary Medical Association’s definition of informed consent clearly takes costs into mind, saying vets “should provide the client or authorized agent with an estimate of the charges for veterinary services to be rendered.” Would it be rational for the AMA to follow suit, and ask that patients and families be given detailed estimates of out-of-pocket expenses prior to asking for their consent to treat?

Pricing transparency in healthcare can be the rule in treating people, not just how we care for our pets. And when it comes to cutting costs, recent analysis has shown the potential for estimated savings of $100 billion over the next decade with new policies that ensure prices are available and accessible to key decision-makers — namely insurers, employers and healthcare professionals.

So – if we can provide upfront, prospective, detailed healthcare pricing information for our animals, shouldn’t we do the same when the patients are our parents, our children and ourselves?

Joseph Smith (@JoeSmithMD), a former practicing cardiologist, is chief medical and science officer of the Gary and Mary West Health Institute (@WestHealth), an independent, nonprofit medical research organization that works with healthcare providers and research institutions to create new, more effective ways of delivering care.

7 replies »

  1. Hello Dr. Joe. I read an article a while back about your bluetooth (wireless) fetal heart rate monitor. Is the device complete? How can I get a hold of one?
    Thank you!

  2. Thanks for the interest. Over 270 years ago, Thomas Gray famously wrote “Where ignorance is bliss, ’tis folly to be wise.” Its difficult to argue that physician and patient “ignorance” of healthcare prices has yielded a blissful result. Believe it is similarly hard to argue that truly informed consent can exist without understanding the financial implications of the course of action – in healthcare as in everywhere else. While no one should imagine that price transparency is a simple fix to our healthcare cost crisis, Gandhi may have been onto something when he said “Truth never damages a cause that is just”

  3. I hate to say it, but I’m probably more likely to spend on care for my dogs than myself.

    That being said, I totally agree with Dr. Smith, we need to get the patient’s involvement and interest in what testing and treatments cost.
    The patient has been too removed from the costs for too long.

  4. I also don’t find all that cost knowledge keeps vet prices down. Seems to me they’re about the same as people care – except you get to end it early with a needle.

  5. “Isn’t it crazy that when it comes to our own healthcare, we don’t get the same information?”

    Yes, but we also don’t get to say that’s too much money for Aunt Sally so please euthanize her.

    In fact I wish I had your vet. All my vets have been far removed from knowing costs, and don’t want to for fear the cost knowledge will interfere with treatment.