In a recent post, I asked whether you think doctors should routinely discuss the costs of medical interventions with their patients before exposing these patients to large out-of-pocket expenses. (See "Should Your Doctor Talk With You About the Cost of Your Pills?") According to the responses I have gotten on websites and by email, most of you think the answer is "yes." As one respondent put it: "I thought this was a given."

But sadly, it is not a given. Nor is it obvious that financial discussions can ever be easily integrated into clinical encounters.

For starters, the cost of most healthcare interventions is hidden to doctors. When physicians order MRIs or rheumatology referrals or non-generic blood pressure pills, for example, they rarely know how much money these interventions will cost these patients, each of whom seem to have different insurance plans from different third-party payers. That same MRI might be free for one patient and $500 for the next.

To make matters worse, when patients are acutely ill, doctors often prescribe multiple interventions to them over short periods of time. A swollen leg may require an ultrasound to look for a clot, an MRI to assess for ruptured cartilage, a blood test to rule out infection, and an echocardiogram to test for congestive heart failure. A skilled clinician won't order all these tests at once. But she might order one or two, based on her clinical judgment, and cue up additional tests should the initial results fail to yield an answer. Figuring out which tests to order at what time is already a complicated set of judgments for physicians to make. For physicians to then take the time to determine how much a particular patient would pay out of pocket for each of these tests would take this job from complicated to heroic.

Despite these challenges, physicians have a duty to figure out how to weave finances into their clinical conversations. In the United States, most insurance companies are increasingly asking patients to pay more out of pocket for their healthcare, putting more "skin in the game" in an effort to make patients more sensitive to the costs of their healthcare. Deductibles are getting larger. Co-pays are becoming steeper. While the goal of all of this "skin" is to make patients and doctors more price-sensitive, it is impossible for people to be sensitive to prices they are unaware of.

I would like to hear your stories about how to make such conversations happen. Are you a physician who routinely discusses out-of-pocket costs with your patients? How do you manage to do this?

Are you a patient who has found ways to talk about money with your doctor? How did you pull that off? Any advice you have for the rest of us?

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