Cost-of-Care Conversations with Patients

As healthcare costs in the U.S. grow, cost-of-care conversations have become increasingly important. Between 2006 and 2019, the percentage of privately insured people with high-deductible plans rose from 4% to 29%. Indeed, over a quarter of Americans have reported having trouble paying their medical bills [1]. These barriers can harm patient well-being overall, as well as the effectiveness of their care. One survey of 506 U.S. adults found that 29.6% of respondents postponed care or went without treatment for financial reasons [2]. 

Nevertheless, while research offers varying statistics regarding the frequency with which cost-of-care conversations take place, they appear fairly infrequent. In one survey of cancer patients, only 14% reported having a discussion of cost with their clinician [3]. Another study, which examined transcripts from 677 outpatient breast cancer treatment appointments, found that 22% included a cost-of-care conversation. However, these conversations were brief, with a median length of 33 seconds [4]. 

However, patients tend to value these conversations when they do occur. In one study, 94% of patients said they believed that doctors should discuss cost of care with patients [3]. These numbers tend to be higher for patients in a more precarious financial position, suggesting that potential distress about cost of care motivates, rather than discourages, patients from discussing those costs. For instance, a survey of 17 patients who had recently undergone surgery found that the Medicaid-insured patients and those without insurance were more likely to desire thorough discussions of finances earlier in their treatment. However, not all patients feel that doctors should participate in such conversations. Some patients name insurance representatives or hospital-employed financial advisors as their preferred intermediaries [5]. Moreover, an analysis of interviews with 28 cancer survivors found that most preferred to discuss finances with their care team rather than their doctor [6]. 

For their part, doctors must balance patients’ preferences when deciding whether, how, and when to engage in cost-of-care conversations. In a survey of over 600 internists, 75% reported taking out-of-pocket care costs into account when making judgments, though only 50% reported regularly engaging in cost-of-care conversations. However, those who regularly engaged in these discussions were somewhat more likely to be highly aware of patients’ financial burdens. For instance, 94% of the frequent-conversation group reported having been aware of patients reducing consumption of prescribed medication for financial reasons, while only 84% of the remaining respondents reported awareness of these situations [7]. However, it appears that training can increase the number of physicians who initiate cost-of-care conversations. A survey found a reported rise in cost-of-care conversations from 17% to 32% following a training session on the topic for clinicians and staff [8]. 

In summary, most patients prefer to receive thorough information about the cost of medical care, particularly if they are uninsured or financially vulnerable. However, they may opt to receive this information from a financial advisor rather than a medical professional. Most doctors, meanwhile, do not initiate cost of care discussions, and those who do tend to be more aware of patients’ financial situations. Even brief trainings can prompt doctors to initiate these conversations with greater frequency, suggesting that uncertainty or discomfort may be major barriers to effective cost-of-care communication. 

References 

[1] Sloan, Caroline E, and Peter A Ubel. “The 7 Habits of Highly Effective Cost-of-Care Conversations.” Annals of Internal Medicine, U.S. National Library of Medicine, 7 May 2019, www.ncbi.nlm.nih.gov/pubmed/31060062.  

[2] Tipirneni, Renuka, et al. “Association Between Health Insurance Literacy and Avoidance of Health Care Services Owing to Cost.” JAMA Network Open, vol. 1, no. 7, 2018, doi:10.1001/jamanetworkopen.2018.4796.  

[3] Irwin, Blair et al. “Patient experience and attitudes toward addressing the cost of breast cancer care.” The Oncologist vol. 19,11 (2014): 1135-40. doi:10.1634/theoncologist.2014-0117  

[4] Hunter, Wynn G., et al. “Discussing Health Care Expenses in the Oncology Clinic: Analysis of Cost Conversations in Outpatient Encounters.” Journal of Oncology Practice, vol. 13, no. 11, 2017, doi:10.1200/jop.2017.022855.  

[5] Day, Roger T., et al. “Patient Perspectives about Surgical Cost of Care Conversations.” Journal of the American College of Surgeons, vol. 231, no. 4, 2020, doi:10.1016/j.jamcollsurg.2020.07.156.  

[6] Pisu, Maria, et al. “How, When, and With Whom Should Cost of Care Conversations Occur? Preferences of Two Distinct Cancer Survivor Groups.” JCO Oncology Practice, vol. 16, no. 9, 2020, doi:10.1200/jop.19.00726.  

[7] Perez, Susan L, et al. “U.S. Internists’ Perspectives on Discussing Cost of Care With Patients: Structured Interviews and a Survey.” Annals of Internal Medicine, U.S. National Library of Medicine, 7 May 2019, www.ncbi.nlm.nih.gov/pubmed/31060057.  

[8] Carroll, Jennifer K., et al. “Addressing Medication Costs During Primary Care Visits: A Before–After Study of Team-Based Training.” Annals of Internal Medicine, vol. 170, no. 9_Supplement, 2019, doi:10.7326/m18-2011.