Because hospitalization accounts for 80 percent of the health care bill and because hospitalization costs are so high, the medical profession has developed a series of alternatives to hospital care. The alternatives include expanded outpatient clinics, chronic care facilities, home care programs, and hospice programs. Although the motivation for these changes has been economic, the result has been humane: most people prefer almost any health care setting to a hospital. Expanded Outpatient Facilities-Outpatient facilities—physicians’ offices, clinics, or specialized facilities—now offer many of the procedures and treatments that previously required hospitalization. Examples of these procedures and treatments include blood transfusions, some intravenous treatments, specialized diagnostic examinations like CAT scans or MRI scans, endoscopy, induced sputum tests to diagnose Pneumocystis pneumonia, and most minor surgical procedures. The biggest reason that outpatient facilities have expanded their services is cost: treatments done on an outpatient basis are substantially less expensive than those done in a hospital. Another reason that outpatient facilities have expanded is that insurers will not reimburse people who are only admitted to the hospital to get some types of treatments and procedures. And to make things more confusing, some insurers now reimburse only those treatments done in a hospital. The contradiction in reimbursement rules is difficult to understand but important to know about. Talk to your insurance company, your social worker, and your physician. It may be that the test you need will cost more to do in the hospital, but the final bill to you will still be less.*171\191\2*
Several factors might dissuade a person from participating. The most frequent concerns are:1. Inconvenience: Many trials require extensive testing and frequent visits to the clinic. These requirements should be clearly stated in the informed consent papers. These tests and visits can be an enormous inconvenience to the participant.2. Risk: Clinical trials are scientific experiments. They exist because medical scientists need information about the effectiveness and safety of a new drug, or about the safety and effectiveness of an old drug used in a new way. Some of these drugs are potentially toxic, and although trials never test drugs on humans that have not been first tested extensively in the laboratory and in animals, unanticipated side effects are always possible. The degree of risk obviously varies with different drugs and different conditions.3. Assignment to the “wrong group”: For all controlled and double-blinded trials, there is always the risk that the participant will receive the placebo, the less effective drug, the more toxic drug, or the less effective dose. Some participants attempt to break the blind and find out what drug or dose they are taking, through a variety of mechanisms. The investigators understand participants’ reasons for doing this, but breaking the blind destroys the scientific credibility of the trials. If enough people break the blind, the trial might as well not be done.4. Costs: Usually drugs and costs for monitoring are provided at no expense to the participant. Some drug trials, however, expect reimbursement from the participants for the cost of medical care. You will need to establish what costs, if any, are involved before you agree to participate. In addition, if the drug is toxic, you will need to establish who pays the cost of care for any side effects.5. Restrictions on other options for treatment: Most trials require that someone who is participating in one trial not participate at the same time in other trials. Some trials exclude people who have received other experimental drugs. Other trials prohibit the participant from using certain drugs or from receiving certain treatments. You should carefully review any such restrictions before agreeing to participate in clinical trials. A reassurance: any participant in a trial can withdraw from participation at any time.*187\191\2*