Study Will Examine Legal, Ethical Implications of Patients Paying for More of Their Medical Costs

September 13, 2005

WINSTON-SALEM, N.C. – With patients being required to pay more of their medical costs, a new study will look at how this added responsibility affects the care that patients receive and what the implications are for health care law and medical ethics.

Patients are becoming the primary decision-makers on spending for medical care, according to Mark A. Hall, J.D. at Wake Forest University School of Medicine.

“This change fundamentally alters the doctor-patient relationship,” said Hall, professor of law and public health sciences. “These developments require patients and doctors to confront the costs of different treatment options much more explicitly than when insurance covered virtually everything.”

Doctors and patients used to assume that insurance would pay, so their conversations focused on the medical risks and benefits of treatment options and not on what they cost. Not any more.

With a $275,000 grant from the Robert Wood Johnson Foundation (RWJF) under its Investigator Awards in Health Policy Research program, Hall and Carl Schneider, J.D. of the University of Michigan School of Law, will study the impact of the shift in financial responsibility on health care law and medical ethics.

“This project will provide better understanding of how consumer-directed initiatives are actually working at the bedside and of how law and ethics can and should respond to these developments,” he said.

Hall will study four core areas of health care law and ethics – physicians’ bedside ethics, informed consent, medical malpractice law, and insurance law and policy – from the perspective of patients shouldering much greater responsibility for paying the costs of care.

The 30-month project will include face-to-face interviews with both patients and physicians in North Carolina and in Michigan.

Hall noted that many health plans have long had tiered pharmacy benefits where the patient share depends on which drugs the doctor prescribes. For instance, patients pay more for brand name drugs than generics, and a lot more for drugs that aren’t on an approved list. “The same techniques applied to prescription drugs in the 1990s are being applied now to all insured health care benefits,” such as choice of hospitals and doctors, he said.

But, Hall said, there has been little research that addresses how to resolve the new set of conflicts that potentially arise when patients bear the financial consequences of treatment decisions.

“Now, while the medical interests of doctors and patients remain aligned, their financial interests are often opposed,” he said. “Physicians must become both medical advisors and purchasing agents for their patients, but as such they become agents for the purchase of their own services, paid for by the patients they advise and treat.”

Hall said the advent of health savings accounts also helped shift the balance to the patients. When traditional insurance coverage is denied, patients may decide to go ahead with treatment anyway, and pay for it out of health savings accounts. “These aspects of patient cost-sharing substantially alter the nature of employers’ responsibilities to individual workers and the overall workforce.”

RWJF’s Investigator Awards in Health Policy Research program supports highly qualified individuals undertaking broad studies of the most challenging health, health care and health policy issues facing America.


Media Contacts: Robert Conn, or Karen Richardson,, at (336) 716-4587.

About Wake Forest University Baptist Medical Center: Wake Forest Baptist is an academic health system comprised of North Carolina Baptist Hospital and Wake Forest University Health Sciences, which operates the university’s School of Medicine. U.S. News & World Report ranks Wake Forest University School of Medicine 30th in primary care, 41st in research and 14th in geriatrics training among the nation's medical schools. It ranks 36th in research funding by the National Institutes of Health. More than 100 medical school faculty are listed in Best Doctors in America.

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