Financial Anxiety Makes Medical Procedures More Painful

By Pat Anson

The high cost of healthcare is a big problem for many Americans. A KFF survey recently found that about one in four U.S. adults are “very worried” about paying for healthcare, and have skipped or postponed seeing a doctor in the last 12 months because of the cost. 

But rising medical costs do more than damage a patient’s bank account. New research shows that financial anxiety about the cost of healthcare may cause more physical pain during medical procedures, driving many patients to skip appointments altogether.

The study, “Paying for Pain: How Healthcare Costs Influence Physical Pain Predictions,” found that financial distress spills over into sensory expectations. That discomfort leads the brain to anticipate significantly more physical pain from procedures ranging from simple blood draws to complex endoscopies.

"We found that the psychological pain of paying money doesn't stay separate from our physical expectations," said lead author Helen Colby, Assistant Professor of Marketing at The Tepper School of Business, Carnegie Mellon University.

"When a medical test costs more out of pocket, people mentally brace for a more painful physical experience. Financial anxiety changes how we construct the prospect of healthcare in our minds before we ever set foot in a doctor's office.”

Colby and her colleagues conducted three experiments to see if the anticipation of an out-of-pocket expense for a routine medical procedure would heighten pain.

Three hundred adult volunteers were recruited for an imaginary blood draw. About half were told that their insurance would fully pay for the procedure, while the other half were told there would be an out-of-pocket cost of $53.  

Those who were told they’d have to pay reported significantly greater financial anxiety and anticipated physical pain than those who had zero out-of-pocket expenses.

In another experiment, 350 volunteers were told to imagine getting an endoscopy, a procedure that involves a thin flexible tube with a light and camera being inserted into the body to diagnose or treat a health issue. Half were told that insurance would pay for the endoscopy, while the other half were told there would be $787 in out-of-pocket costs.

The group that would have to pay for the procedure had significantly more financial anxiety. They were also less likely to schedule the endoscopy.     

For the third experiment, 400 people were recruited to be evaluated for a nerve condition. Half would pay nothing for the procedure, while the other half were told they’d have to pay $1,120 in out-of-pocket expenses.

Once again, those who anticipated paying a high cost had significantly more financial anxiety and were less likely to schedule the procedure.  

Since these were all “imaginary” procedures, we don’t know with certainty how physically painful they might have been in real life. But researchers say their experiments demonstrate that the cost of a procedure consistently predicts when patients have more financial anxiety, anticipate more pain, and are less likely to schedule appointments.

"Healthcare providers and marketers need to realize that price tags carry heavy emotional weight," Colby said. "Communicating lower-cost options, offering clear payment plans, or framing preventive care as low-cost can lower financial anxiety. By reducing the pain of payment, we can decrease expected physical discomfort and encourage patients to get the medical care they need.

Researchers say their findings suggest that pharmacies, vaccine makers, insurance companies, and public policymakers should market preventive care procedures like flu shots as being free or low cost. Consumers are less likely to seek treatment when procedures are more expensive, not only due to financial concerns, but also due to anticipated physical pain. 

Doctors Feel Helpless When It Comes to Patient Medical Debt

By Crystal Lindell

A new study looked at medical debt from the point of view of doctors and other medical professionals. What researchers found offers insights into how burdensome medical debt has become on the healthcare system as a whole in the United States – and how helpless doctors feel in the face of it. 

According to the Census Bureau, about 14 million Americans owe over $1,000 in medical debt and about 3 million owe more than $10,000.  

The new report – released by Undue Medical Debt, a nonprofit funded by the Robert Wood Johnson Foundation – found that medical debt is a serious problem for clinicians and their patients, and that it’s impacting how, when and if patients receive care.  

In short, doctors feel they are forced to weigh bad financial health versus bad physical health in their treatment decisions. 

For the study, Undue Medical Debt, held four focus groups in early 2024. Each group consisted of a diverse group of participants, including family doctors, internists, hospitalists, nurse practitioners and community health workers, who shared their experiences with patients struggling with medical debt. 

They found that cost-of-care conversations with patients were relatively common and that patients were less afraid to talk about their medical debt than anticipated. However, clinicians feel they have very limited training and few resources to offer patients 

Most focus group participants reported having regular conversations with patients about medical debt and that patients were concerned about paying for their care. But the healthcare system is so replete with confusing and often disparate policies that it is difficult to be a fully informed consumer. 

One clinician said that when patients take on medical debt, they end up deferring their healthcare, which is bad for them, their families and for the healthcare system as a whole. 

“Because you have someone that, if they could have come in a year and a half before, you’re treating elevated cholesterol and blood pressure, but they push off their care and a year and a half after that, they’re showing up in your emergency room with a stroke,” the clinician said. 

“That costs them more money, that costs the system more money, and so it’s a very negative perpetuation of bad value; when you put debt upon debt people stay away from healthcare.” 

Clinicians said that they hope the importance of physical health will win out, but those decisions are often out of their control. They worry about the patient who disappears from care, particularly those who show up months, years or even decades later with advanced disease that could have been successfully treated earlier. 

Several clinicians thought the healthcare system as a whole was on the verge of collapse. 

“I’m not sure how much power I have. I’m sure there’s something that I can do more of, maybe from a top level. I guess sit on a board, talk to some of our administrators,” one clinician lamented. “But in general, healthcare has just unfortunately become such a machine. You know, it’s just such a machine.”

They added that they’re trying to give people the best care they can, but time constraints hold them back. Many felt helpless. 

“We’re trying to address unbelievable amounts of problems, five and six different comorbid problems that are really, really serious and trying to prioritize, and we do that for probably, some of us, myself, 14 to 19 people a day, in some cases sometimes more,” one provider said.  

Undue Medical Debt said that the business of medicine has pulled clinicians away from practicing medicine, forcing them to become financial counselors on top of their other duties. While many note this is outside their purview, they also understand they have “no choice” but to play this role. 

Doctors and nurses in the focus groups blamed multiple actors for the state of the healthcare industry, such as insurers, pharmaceutical companies and health system bureaucracy.  

When testing policy fixes with clinicians, the most popular ones included: presumptive financial aid screening; hiring people to help patients access resources and financial aid in multiple languages; capping interest rates, and making home foreclosures due to medical debt illegal. 

The Consumer Financial Protection Bureau recently adopted a rule that bans all medical debt from credit reports and prohibits lenders from using medical information in their lending decisions. That will remove an estimated $49 billion in medical bills from the credit reports of about 15 million Americans. 

Veterinarians Know. Why Can’t Doctors?

As a patient, I have long bemoaned the fact that the cost of medical services is so far removed from providers. There aren’t many other businesses that operate in such a way. Usually the person selling a service has to be aware of the cost of that service. And make no mistake, in a for-profit healthcare system, doctors are selling you healthcare.  

There’s one example that highlights how absurd the situation has gotten – veterinarians. When I take my cat to the vet – a medical office where most customers pay out of pocket – the veterinarians and their staff are always acutely aware of the cost of each procedure, and they always provide an estimate up front. 

It’s a system that makes me believe such care is possible for human patients, too. However, anytime I’ve seen a doctor and brought up pricing before agreeing to a test or procedure, the doctor has looked at me like I was speaking in an alien language. They can’t fathom that they would ever be asked to provide a cost estimate for their own services, much less factor it into treatment options. 

I don’t currently have health insurance, so cost is an enormous factor for me now. However, even when I did have what people would consider “good” health insurance, co-pays and out of pocket expenses ruined my credit. 

Yet anytime I tried to get cost estimates in advance of treatments or procedures, they would imply that I must not value my body if I am concerned with such petty things as money. 

To be honest, even that was somewhat understandable a few years ago. But recently, many hospitals and doctors have resorted to what Undue Medical Debt calls “Extreme Collection Actions.” That’s when hospitals and doctors used collection methods such as suing people, taking their homes, or garnishing wages. 

For many patients in the United States, the system is set up so that when you see a doctor, they order tests and treatments without telling you any sort of price range at all. Then they send you an opaque bill that lacks any sort of price breakdown. And then they’ll report you to a credit collector if you don’t pay them. 

The fact that any of this is legal shows how broken healthcare has gotten. 

While many doctors quoted in the Undue Medical Debt study said they don't want to be bothered with talk about money, that’s a luxury their patients don’t have. 

Undue Medical Debt has a free downloadable toolkit designed to help healthcare workers have conversations about cost and medical debt with their patients.

“Our toolkit lays the groundwork to not only help clinicians assist their patients in avoiding the unjust burden of medical debt, but it also encourages clinicians to leverage their expertise and lived experience to champion upstream solutions to stymie the creation of unpayable medical debts to begin with,” said Eva Stahl, Undue Medical Debt’s Vice President of Public Policy and Program Management.

Here’s hoping doctors actually use it. 

Physical Therapy Reduces Healthcare Costs for Low Back Pain

By Pat Anson, PNN Editor

Almost everyone suffers from low back pain at some point in their lives. Most recover in a few days, but for some the pain lingers and become chronic, making low back pain the world’s leading cause of disability.  

Why are some people able to recover quickly from low back pain?

For many, the answer may be early treatment with physical therapy (PT), according to a new study by researchers at Johns Hopkins Medicine.   

“Our goal was to determine if early PT for patients with lower back pain had an impact on their overall health care resource utilization,” says senior author Richard Skolasky Jr., ScD, director of the Johns Hopkins Spine Outcomes Research Center. “We were especially curious about the 30 days after initial symptom onset, as this is when patients are most likely to seek care.” 

Skolasky and his colleagues analyzed healthcare data from 2010 to 2014 for nearly a million U.S. adults with acute low back pain, excluding those suffering from serious disorders such as arthritis or spinal cord injuries. About 10% of the patients received early treatment with physical therapy.

The study findings, recently published by BMC Health Services Research, showed that patients getting early PT were significantly less likely to see a chiropractor, orthopedic surgeon or pain specialist after 30 days than those who did not get physical therapy. They were also less likely to get advanced imaging, epidural steroid injections or to visit an emergency room.

Researchers estimate that healthcare costs for a typical patient getting early PT was about $500 less over 30 days than those not receiving physical therapy.

Another key finding from the study was significant geographical differences in the use of physical therapy. Patients in the West (16%) and Northeast (15%) were nearly twice as likely to get early PT than those in the Midwest (9.4%) and South (8.6%). The authors offered no explanation for why treatment patterns varied so much by region.

The study did not specifically examine whether physical therapy benefits patients with low back pain more than other forms of treatment, but the findings suggest that they did. Researchers say health outcomes should be examined more closely in future studies.

“As the U.S. population ages, the prevalence of lower back pain is expected to increase, along with the associated costs of treating it,” says Skolasky. “Furthermore, with advances in imaging and treatments, the cost of managing lower back pain has increased substantially. Our findings have important implications that may guide health care policy when examining downstream health care costs and resource utilization.” 

Previous studies have found that physical therapy and regular exercise significantly reduces low back pain. Other studies also found little evidence to support the use of opioids, spinal injections and acetaminophen for low back pain.