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Join us as we welcome Neill Slater, an emergency physician, to discuss the critical issue of patient compliance and the hidden costs of health care. We will explore why patients often don’t take their prescribed medications, the challenges physicians face when discussing treatment costs, and practical steps to bridge this communication gap. Neill will share insights on how medical education, routine practices, and systemic changes can improve patient outcomes and trust.

Neill Slater is an emergency physician.

He discusses the KevinMD article, “Talk to your patients about money.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome Neill Slater. He’s an emergency physician. Today’s KevinMD article is “Talk to your patients about money.” Neill, welcome to the show.

Neill Slater: Thank you, Kevin. I appreciate you having me on the podcast and allowing me the time to speak to your audience. It’s a real honor to be here.

Kevin Pho: All right. So let’s start by briefly sharing your story and journey.

Neill Slater: OK. I’m a board-certified emergency medicine physician. I graduated from my residency now 18 years ago, and I’ve worked clinically the whole time. But my passion has always been in the business interest of medicine.

So 15 years ago I started a small democratic ER group with some partners, and we still run that to this day, staffing ERs in West Texas. 10 years ago I started an urgent care with some friends, and we’ve, over the last decade, brought that into nine locations of urgent care and family practice offices in Texas. And I also co-own a billing and coding company that we started to service our clinics and then ended up developing that into taking on other clients.

So that background has given me a kind of 360 degree view of different aspects of the business of medicine. And a funny thing is, with business, if you set it up correctly, after a while there’s not as much for you to do, if you hire the right people and bring on the right staff, there’s not as much to do.

So that’s given me a lot of time in the last few years where I’ve been more interested in teaching, teaching our new attendings that join our group about personal finance and the business of medicine, and then teaching residents, students, fellows in the hospitals that I work at. And then that’s what caused me to start my blog, Business Is the Best Medicine.

Kevin Pho: All right. So for those new physicians who come to you, and medical students and residents who rotate through your emergency department, what are the most common money questions that you feel that you need to educate on?

Neill Slater: Well, to be honest, they don’t know very much generally, just like I didn’t when I came out of residency, because we’re just not taught in medical school or residency much of anything.

And so really I start with the basics of debt, of how to handle your income. In emergency medicine a lot of us are independent contractors, and so learning how to deal with your taxes and save, without having to get into trouble. You always know it’s tax time, and people are asking to work extra shifts because they haven’t saved for the taxes that they owe. So really I just try to stick with the basics when it comes to teaching physicians and residents.

But I think that it goes deeper than that, and what I like to portray to them is that not paying attention to your finances can really affect your career and the choices that you can make. It affects your autonomy as a physician, because if you come out of school with hundreds of thousands of dollars of debt, and then you go immediately and buy a big house and a new car and take on a bunch more debt, it limits the choices you can make.

If you work in a small town without a lot of options for employment, you can’t speak out on the things that you care about, you can’t push back on anything that you feel like is encroaching upon your autonomy, because you don’t have any other options. You’ve sort of backed yourself into a corner. And so I try to portray that message to new attendings as well.

Kevin Pho: Now, over the last 5, 10 years I talked to a lot of physicians who are also in that business, personal finance space. Now, you said that you’ve been doing this for a while now. Have you seen the needle move? Do you feel that these new physicians are getting a little bit of a better business sense when they come to you, or is it pretty much the same as always?

Neill Slater: There seems to be a little more awareness. I’m not sure if they really understand, but it does seem like there is some more awareness on the topic, that people at least are interested in the topic and want to have the conversation. So yeah, I think maybe with all the people in the space over the years, maybe the needle is starting to move a little bit.

Kevin Pho: All right. So let’s talk about your KevinMD article, titled “Talk to your patients about money.” Tell us what it’s about.

Neill Slater: Well, I think the topic of money is very important in medicine. When I was a kid there was a saying that in polite company you never talk about politics, religion, or money. Well, these days you can’t get people not to talk about politics, right? And religion is not really a taboo subject anymore. So it leaves money as being the one subject that people seem to really be uncomfortable talking about.

And so the point of my article was to encourage physicians to be comfortable talking to patients about money, because it matters. And the way this came up to me as an emergency physician is, I see all the time, virtually every shift that I work, some patient will come in with uncontrolled hypertension or uncontrolled diabetes, and I talk to them, I say, are you taking your medications? And they say, no, I can’t afford them.

And I ask them then, well, have you talked to your doctor about this, that you can’t afford them, because there are cheaper options out there? And invariably they say no, they haven’t brought the subject up with their physician. And whether that’s because they don’t feel comfortable talking about money themselves, or they don’t feel comfortable in that relationship, they just say, OK, give me the prescription, and then they leave and never fill it, or they fill it once and can’t do it again. And then they end up in the ER, which damages their finances by getting a large bill for something that they didn’t particularly need.

So that was really the impetus for me, for starting to think about, why don’t we, because I talk about money all the time anyway, why don’t we bring that into the patient relationship in a respectful way, in a way that is really helping that relationship and getting them care that they can actually afford? So that’s where it came from.

But when you broach the subject with physicians, it’s a difficult ask. It’s difficult for physicians to talk about money. There’s the societal taboo that I’ve already mentioned, but there’s also sort of a philosophy that permeates medicine that money shouldn’t matter. And I get it, right? In a perfect world money wouldn’t matter, because we’d be able to do whatever we wanted to for any patient and it would be paid for. But we don’t live in a perfect society, unfortunately, and so we have to accept reality, that it really does matter to a lot of patients.

And most physicians, as we kind of already touched on, are just ignorant about this. We’re not taught about it in school, we aren’t taught about it in residency, and in fact, at least in my residency, we were actively taught not to think about money. The adage was, we treat everybody the same, we don’t pay attention to insurance, we don’t care whether they’re insured or not, and that ensures that we are not playing favorites or doing the wallet biopsy or anything like that.

And it’s a noble idea, and I think for true emergencies, absolutely, I still subscribe to that. But most people that come to the emergency department don’t have life or death emergencies. They’re there for other things, and so I think that we end up playing the role of a primary care physician a lot of times, for better or worse, and so we have to be able to bring that into our conversation to help them.

Other reasons, it’s just, the monetary aspects of health care are very opaque. It’s not clear how money works in medicine. If you go to the ER you’re going to get a bill from four, five, six different people. You’re going to get the physician group, a facility fee, a charge for your labs, your X-rays, the doctor reading the X-rays, maybe a consultant. And even with some of the laws that have passed around providing fair estimates, that’s really for cash payer patients.

And then you add the aspect of insurance on top of that. What kind of insurance does the patient have? What contracts do they have with the physician group or the hospital? Have they met their deductible or not? All these things really matter, and I think physicians are just somewhat ignorant of that, because we’re not taught it.

And then a point I like to make is that in trying to do the right thing, we sometimes don’t, and this I call the pernicious idea of the best. So doctors want the best for their patients always, right? It’s natural. We want the best medicine, the best treatment, the best scan, or whatever we’re looking at. But if a patient can’t afford the best, are you really doing them a favor by prescribing it? Would it not be better to prescribe the third or the fourth best blood pressure medicine that they can actually afford and take, than to prescribe the best that they can’t?

And so I just want physicians to know that they have to have those conversations, because in their mind they’re doing the right thing, but in reality, to the patient, they may not be. And the idea of the best always changes and is somewhat nebulous anyway. Sometimes it’s marketing more than reality. Is there a marginal difference between new PPIs, or an anti-nausea medicine or something? It may be more marketing than it is reality, what’s the best.

So those are the keys there. And then, doctors have a difficult time because of how busy we are. We are busy, we see lots of patients, we’re pressured to see more patients, and so we form habits that may be to the exclusion of good monetary habits.

So order sets. In the ER we’re notorious for chest pain workups, psych workups, that have a ton of different tests on there to try to encompass everybody, when in reality a lot of times you don’t need to add that D-dimer or that amylase to every patient with chest pain. The D-dimer was not meant to be a screening test, but it ends up on a lot of these order sets that we do, and we do it to save time, but maybe those could be add-ons.

And we do this with medicines. We have the same 25, 50 medicines that we prescribe all the time, because we’re comfortable with them, we know how to prescribe them. But those may not be the cheapest medicines, and so again, maybe we should look at it from that aspect.

Kevin Pho: Now, when you say physicians are uncomfortable talking about money with their patients, give us an example of what exactly that means. Do you actually get pushback when you educate physicians about this? Do you just get a sense of general unease? What does it look like when a physician is just simply uncomfortable talking about money with their patient?

Neill Slater: It’s more of a general sense of unease, I think. Everybody conceptually can get it, and there’s a lot of things that we get conceptually but that doesn’t make it any easier to talk about.

We’re trained over time how to speak to our patients about sexual encounters, we’re trained how to speak to people about intimate details of their lives, bathroom habits and abuse and drug and alcohol abuse, things like this. It takes time over your career to get really comfortable and nuanced about how to present this to a young lady versus an older man, on how you talk about these. And so I think there’s just a general unease because we’re not used to it and we’re just not comfortable with it.

So I don’t think anybody pushes back on the concept. It makes sense. It’s just more of having to make it a part of your routine with the patient.

And one thing that I do get is, we don’t think of ourselves as being wealthy, right? But patients look at us in a very different way. And people are struggling out there in society to pay their bills, there’s obviously been inflation going on. And so in the medical community we talk about our salaries and decreased reimbursement and so on. Patients don’t want to hear that. They look at us and see people who have a lot of money.

And so I think you have to understand that relationship, you have to approach it in a very respectful way so that you don’t come across as out of touch, so to speak, with the population that you’re serving who don’t have as much money as you do. And I do think some physicians are wary about that, and rightfully so. It’s something that we have to practice.

Kevin Pho: So tell us your approach about introducing economics and money in the exam room. What does that look like, and what are some tips that you could share with other physicians who have that general unease?

Neill Slater: For me it’s easy, because I’ve been doing it for a long time. And so I think of it like talking about sex, which can be an uncomfortable topic, but I just have standard questions, like, do you have sex with men, women, or both? No judgment. And I ask it of every single patient that I see, so that I don’t feel like I’m looking at one patient differently than another.

And I do the same with money. I just say, I’m going to prescribe you this medication, can you afford it? I think it’s going to cost about x amount of dollars. And you have to educate yourself on that, to know about how much it might cost. I’ll ask them directly, do you have insurance, what kind of insurance, have you met your deductible yet, do you know what your prescription plan is?

Because, and the truth is, sometimes the patients don’t know either, and so I’m not going to say this is perfect. Patients don’t know what medicines they’re on, they don’t know about their insurance sometimes as well, if they have it. But I just make it a part of my routine, when I’m going back in the room and explaining things to the patients, this is what I found, this is our plan. And I like to end with, do you have any financial concerns about the treatment plan that we’ve constructed for you today? Is there anything you’d like to ask?

And then also, when I am leaving, I let them know, if you have any issues, and this is more for the urgent care than the ER, just because follow-up policies are a little difficult in the ER, but in the urgent cares, what I instruct my providers to say is, let us know if you have any problems affording your medications when you get to the pharmacy. Because things change, right? I used to prescribe colchicine all the time for gout, and then one day people started saying, hey, this costs $400 and my insurance company won’t pay for it.

And so policies change, drug manufacturers change. So that catch all question, if you have any questions or you’re concerned about being able to afford this, just give us a call. And for primary care offices, I think that’s a good approach.

Kevin Pho: So let’s say you asked these economic questions with your patients, and now, knowing that information, does that affect your diagnostic approach in terms of what type of tests that you order?

Neill Slater: I’m not sure that it affects it in the emergency department as much, because we have a mandate to rule out emergencies, and I’m not sure that that affects certainly diagnostic testing.

But in a situation like the urgent care, if you’re looking at somebody’s throat and they meet Centor criteria, do you really need to order a strep swab? If everybody in their family has been tested for COVID and they have the symptoms, do you really need to test them for COVID at this point? And you can have that conversation with the patients.

And it certainly comes to treatment, where again, going back to the strep throat reference, you can give somebody a shot of Bicillin L-A, but that costs about $200 from the manufacturer, and by the time you’re in a clinic and you add a markup and you add an injection fee, that may be $300 to a patient. Where you could prescribe Pen VK and it’s $20, and that’s if you don’t have insurance, for a treatment course.

And if that patient, even if they have insurance, if they haven’t met their deductible, that’s $300 out of pocket plus a couple of hundred for the visit in an urgent care. So now you’re looking at a $500 visit for something that you could treat less expensively and equally as good.

And there’s a lot of examples like that. And so I think it’s just a matter of having the conversation with the patient. The patient might still want the shot, and if they do, that’s OK, right? I think the two treatment modalities are equivalent. But it allows you to have that conversation with the patient, and they make informed decisions, as opposed to getting a bill in the mail in a couple of months that says, hey, you owe an additional $300 for this medication that your insurance company didn’t cover because you hadn’t met your deductible. That makes patients unhappy and may put them in a bad financial position.

Kevin Pho: We’re talking to Neill Slater. He’s an emergency physician. Today’s KevinMD article is “Talk to your patients about money.” Neill, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Neill Slater: Thank you, Kevin. So I would recommend three things for your audience.

What can you as a provider do? You can educate yourself. Learn about health insurance, deductibles, co-pays, coinsurance, the prescription medication plans. We just aren’t taught this stuff and I think we all need to learn it. Learn how much the medications that you’re prescribing on a regular basis cost. Learn how much the tests cost.

Number two is, assess your own practice. So stop practicing just based on habit. Really look at the medication costs, look at your order sets. Is everything necessary for every patient, or can some of these be opt in? Look out for unnecessary tests, things like viral panels for somebody with a viral illness. Does it really matter if it’s adenovirus, or if you just tell the patient they’ve got a viral illness and it’ll be better in a week? Those tests can cost $700 or more, and that cost often goes directly back to the patient because of these high deductible plans.

And finally, just get comfortable talking about money. We talk about all these uncomfortable topics with our patients already, we’re in a position to be able to do that. And so you have to train yourself to have these conversations, because it’s important. We don’t want to put additional financial stress on our patients. Health care is expensive already, and it’s just one more thing that we can add to our practice that may make a difference in the lives of our patients.

Kevin Pho: Neill, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Neill Slater: Thank you, Kevin. I appreciate that.