Cheryl Bettigole, MD, MPH
August 2014—In the days after my “Perspective” piece on the thousand-dollar Pap smear was published,1 I was profoundly moved by the number of physicians from diverse specialties and practice settings who reached out to tell me how important they believe issues of cost and cost transparency are to our ability to practice in the best interest of our patients. Barbara Crothers, DO, of the CAP Cytopathology Committee, was among those who reached out. I learned from Dr. Crothers and her colleagues that pathologists share the sense of frustration and loss of control that I often have as a primary care provider confronted by opaque ordering systems and skyrocketing costs for a simple, potentially life-saving test. Avoiding use of health care services that are not evidence-based and that may even do harm is core to medical professionalism. We are now seeing among American physicians a growing movement to honor this obligation, beginning with the National Physicians Alliance’s Good Stewardship Project and flourishing through the American Board of Internal Medicine Foundation’s Choosing Wisely initiative. As physicians, we are now choosing to take responsibility for making sure that health care services truly benefit patients, rather than ceding that responsibility to insurers or Medicare/Medicaid policymakers.
However, the Food and Drug Administration’s recent approval of Roche’s HPV test has the potential to create more confusion for clinicians who are trying to choose the best test for their patients for all the reasons Dr. Crothers and Dr. Tambouret articulate in their article (see article at left). To select the test most likely to reduce cervical cancer morbidity and mortality, we need to know the impact of each test not only on diagnosis but also on health outcomes. For uninsured patients and those with significant co-insurance, the price of screening remains an important factor. If clinicians do not have access to cost information at the time of ordering, including the costs of reflex tests that may be added on, we are putting our patients at risk for what has been called “financial toxicity.”2 One unaffordable bill for a Pap test (or other medical test) can be enough to convince a patient that he or she cannot afford medical care unless the need is dire, and word of these costs can spread quickly among vulnerable populations. If we hope to continue our gains against cervical cancer, we must regain control of these costs.
I am grateful for the interest of the pathology community in these issues. Despite my father having been a laboratory director and hematologist, I have to admit it never occurred to me to reach out to a laboratory’s pathologist for assistance in navigating the complex ordering systems I was facing. There is much that pathologists can do to help. I agree with the suggestions Dr. Crothers and Dr. Tambouret offer: 1) that pathologists be included in laboratory marketing programs to ensure that information is presented appropriately, 2) that pathologists be available as consultants on test selection, and 3) that information about cost and indications appear on lab order forms. More broadly, we need easy channels of communication between primary care physicians and pathologists. These should include passive systems (information about indications and cost available at the point of care) and active systems (information about how to contact the pathologist with questions). Opening such channels will help build a learning health system in which evidence-based care becomes the norm and financial burdens of care are responsibly limited to those situations in which they are clinically necessary.
- Bettigole C. The thousand-dollar Pap smear. N Engl J Med. 2013;369(16): 1486–1487.
- Ubel PA, Abernethy AP, Zafar SY. N Engl J Med. 2013;369(16):1484–1486.
Dr. Bettigole is a family physician and chief medical officer of Complete Care Health Network, a group of community health centers serving southern New Jersey. She is immediate past president of the National Physicians Alliance.