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Scott AM, Harrington NG, Herman AA. Oncologists' Perceptions of Strategies for Discussing the Cost of Care with Cancer Patients and the Meaning of Those Conversations. HEALTH COMMUNICATION 2024; 39:1343-1357. [PMID: 37190672 DOI: 10.1080/10410236.2023.2212419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
To better understand what makes cost-of-care communication between oncologists and cancer patients more or less successful, we conducted in-depth interviews with 32 oncologists (22 male, 10 female) who were board-certified in medical, surgical, or radiation oncology. Through qualitative descriptive analysis by four coders, we found that oncologists used six broad strategies to discuss cost with patients: open discussion, avoidance, reassurance, warning, outsourcing, and educating. We also found that oncologists invoked certain meanings of cost conversations: cost conversations as holistic care, coercion, a matter of timing, risking patient suspicions, advocacy, unwanted distraction, transparency, bad news delivery, problem-solving, pointless, informed decision making, or irrelevant. These meanings appeared to be linked to oncologists enacting certain strategies (e.g., oncologists who invoked cost conversations as holistic care tended to enact open discussion, those who saw cost conversations as risky tended to use avoidance). Theoretically, our results suggest that the invoked meaning of a difficult conversation may be a key explanatory mechanism for differentiating high-quality from low-quality communication in cost conversations. Practically, our findings suggest that oncologists should consider how well the invoked meaning of the cost conversation is serving their own and their patients' goals.
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Aguirre A, DeQuattro K, Shiboski S, Katz P, Greenlund KJ, Barbour KE, Gordon C, Lanata C, Criswell LA, Dall'Era M, Yazdany J. Medication Cost Concerns and Disparities in Patient-Reported Outcomes Among a Multiethnic Cohort of Patients With Systemic Lupus Erythematosus. J Rheumatol 2023; 50:1302-1309. [PMID: 37321640 PMCID: PMC10543599 DOI: 10.3899/jrheum.2023-0060] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Concerns about the affordability of medications are common in systemic lupus erythematosus (SLE), but the relationship between medication cost concerns and health outcomes is poorly understood. We assessed the association of self-reported medication cost concerns and patient-reported outcomes (PROs) in a multiethnic SLE cohort. METHODS The California Lupus Epidemiology Study is a cohort of individuals with physician-confirmed SLE. Medication cost concerns were defined as having difficulties affording SLE medications, skipping doses, delaying refills, requesting lower-cost alternatives, purchasing medications outside the United States, or applying for patient assistance programs. Linear regression and mixed effects models assessed the cross-sectional and longitudinal association of medication cost concerns and PROs, respectively, adjusting for age, sex, race and ethnicity, income, principal insurance, immunomodulatory medications, and organ damage. RESULTS Of 334 participants, medication cost concerns were reported by 91 (27%). Medication cost concerns were associated with worse Systemic Lupus Activity Questionnaire (SLAQ; beta coefficient [β] 5.9, 95% CI 4.3-7.6; P < 0.001), 8-item Patient Health Questionnaire depression scale (PHQ-8; β 2.7, 95% CI 1.4-4.0; P < 0.001), and Patient-Reported Outcomes Measurement Information System (PROMIS; β for physical function -4.6, 95% CI -6.7 to -2.4; P < 0.001) scores after adjusting for covariates. Medication cost concerns were not associated with significant changes in PROs over 2-year follow-up. CONCLUSION More than a quarter of participants reported at least 1 medication cost concern, which was associated with worse PROs. Our results reveal a potentially modifiable risk factor for poor outcomes rooted in the unaffordability of SLE care.
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Affiliation(s)
- Alfredo Aguirre
- A. Aguirre, MD, M. Dall'Era, MD, J. Yazdany, MD, MPH, Division of Rheumatology, University of California, San Francisco, California;
| | - Kimberly DeQuattro
- K. DeQuattro, MD, Division of Rheumatology, University of Pennsylvania, Pennsylvania
| | - Stephen Shiboski
- S. Shiboski, PhD, Department of Epidemiology & Biostatistics, University of California, San Francisco, California
| | - Patricia Katz
- P. Katz, PhD, Department of Medicine, University of California, San Francisco, California
| | - Kurt J Greenlund
- K.J. Greenlund, PhD, Epidemiology and Surveillance Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kamil E Barbour
- K.E. Barbour, PhD, MPH, Lupus and Interstitial Cystitis Programs, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Caroline Gordon
- C. Gordon, MD, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, Alabama
| | - Cristina Lanata
- C. Lanata, MD, Genomics of Autoimmune Rheumatic Disease Section, National Human Genome Research Section, National Institutes of Health, Bethesda, Maryland
| | - Lindsey A Criswell
- L.A. Criswell, MD, MPH, DSc, Genomics of Autoimmune Rheumatic Disease Section, National Human Genome Research Section, National Institutes of Health, Bethesda, Maryland USA
| | - Maria Dall'Era
- A. Aguirre, MD, M. Dall'Era, MD, J. Yazdany, MD, MPH, Division of Rheumatology, University of California, San Francisco, California
| | - Jinoos Yazdany
- A. Aguirre, MD, M. Dall'Era, MD, J. Yazdany, MD, MPH, Division of Rheumatology, University of California, San Francisco, California
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Everson J, Henderson SC, Cheng A, Senft N, Whitmore C, Dusetzina SB. Demand for and Occurrence of Medication Cost Conversations: A Narrative Review. Med Care Res Rev 2023; 80:16-29. [PMID: 35808853 DOI: 10.1177/10775587221108042] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
High medication prices can create a financial burden for patients and reduce medication initiation. To improve decision making, public policy is supporting development of tools to provide real-time prescription drug prices. We reviewed the literature on medication cost conversations to characterize the context in which these tools may be used. Our review included 42 articles: a median of 84% of patients across four clinical specialties reported a desire for cost conversations (n = 7 articles) but only 23% reported having held a cost conversation across six specialties (n = 16 articles). Non-White and older patients were less likely to report having held a cost conversation than White and younger patients in 9 of 13 and 5 of 9 articles, respectively, examining these associations. Our review indicates that tools providing price information may not result in improved decision making without complementary interventions that increase the frequency of cost conversations with a focus on protected groups.
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Affiliation(s)
- Jordan Everson
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Audrey Cheng
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | | | - Stacie B Dusetzina
- Vanderbilt University School of Medicine, Nashville, TN, USA.,Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
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Espinoza Suarez NR, LaVecchia CM, Morrow AS, Fischer KM, Kamath C, Boehmer KR, Brito JP. ABLE to support patient financial capacity: A qualitative analysis of cost conversations in clinical encounters. PATIENT EDUCATION AND COUNSELING 2022; 105:3249-3258. [PMID: 35918230 DOI: 10.1016/j.pec.2022.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To explore how costs of care are discussed in real clinical encounters and what humanistic elements support them. METHODS A qualitative thematic analysis of 41 purposively selected transcripts of video-recorded clinical encounters from trials run between 2007 and 2015. Videos were obtained from a corpus of 220 randomly selected videos from 8 practice-based randomized trials and 1 pre-post prospective study comparing care with and without shared decision making (SDM) tools. RESULTS Our qualitative analysis identified two major themes: the first, Space Needed for Cost Conversations, describes patients' needs regarding their financial capacity. The second, Caring Responses, describes humanistic elements that patients and clinicians can bring to clinical encounters to include good quality cost conversations. CONCLUSION Our findings suggest that strengthening patient-clinician human connections, focusing on imbalances between patient resources and burdens, and providing space to allow potentially unexpected cost discussions to emerge may best support high quality cost conversations and tailored care plans. PRACTICE IMPLICATIONS We recommend clinicians consider 4 aspects of communication, represented by the mnemonic ABLE: Ask questions, Be kind and acknowledge emotions, Listen for indirect signals and (discuss with) Every patient. Future research should evaluate the practicality of these recommendations, along with system-level improvements to support implementation of our recommendations.
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Affiliation(s)
- Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; VITAM - Centre for Sustainable Health Research, Laval University, Quebec, QC, Canada
| | | | - Allison S Morrow
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; Milken Institute School of Public Health, The George Washington University, Washington DC, USA
| | - Karen M Fischer
- Division of Biomedical Statistics and Informatics, Mayo Clinic, MN, USA
| | - Celia Kamath
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, MN, USA.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
- Associate Editor, JAMA Network Open
| | - Nitya Thakore
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
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Scott AM, Harrington NG, Spencer E. Primary Care Physicians' Strategic Pursuit of Multiple Goals in Cost-of-Care Conversations with Patients. HEALTH COMMUNICATION 2021; 36:927-939. [PMID: 32019346 DOI: 10.1080/10410236.2020.1723051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Despite the importance of cost-of-care conversations between physicians and patients, such discussions are not well understood. We used multiple goals theory to examine the specific goals that are salient in these discussions and how physicians pursue these goals. We used qualitative descriptive coding to analyze the verbatim transcripts from in-depth interviews with 36 primary care physicians. Our analysis identified a number of goals that are commonly salient in cost conversations, including task goals (reducing the cost of care, making treatment decisions, and promoting patient adherence), identity goals (reinforcing their professional identity as a "good doctor," acting as a steward of medical resources, being an advocate for patients, and preventing patient embarrassment), and relational goals (strengthening the physician-patient relationship and mitigating damage to the physician-patient relationship). In addition, participants articulated a number of ways in which these goals compete with each other, making cost conversations challenging. We found that physicians use a common repertoire of rhetorical strategies to manage these goals, including directly addressing cost, avoiding discussion of cost, and falsely reassuring patients about cost concerns. Our analysis revealed that the meaning of the cost conversation explains the connection between physicians' goals and strategies. Specifically, we found that physicians invoke polysemic meanings of cost conversations to achieve their multiple goals using seemingly contradictory strategies. The results of our analysis have implications for building theory and improving practice.
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Harrington NG, Scott AM, Spencer EA. Working toward evidence-based guidelines for cost-of-care conversations between patients and physicians: A systematic review of the literature. Soc Sci Med 2020; 258:113084. [DOI: 10.1016/j.socscimed.2020.113084] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/14/2020] [Accepted: 05/22/2020] [Indexed: 01/29/2023]
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Abstract
SIGNIFICANCE This article is the first to investigate the nature of medication cost discussions between ophthalmologists and glaucoma patients. Only 87 of the 275 office visits analyzed had a discussion of medication cost. Providers should consider discussing medication cost with patients to identify potential cost-related barriers to medication use. PURPOSE Glaucoma is an incurable chronic eye disease affecting a growing portion of the aging population. Some of the most commonly utilized treatments require lifelong use, requiring high patient adherence to ensure effectiveness. There are numerous barriers to glaucoma treatment adherence in the literature, including cost. The aim of this secondary analysis was to describe the frequency and nature of patient-physician communication regarding medication cost during glaucoma office visits. METHODS This was a mixed-methods secondary analysis of video-recorded participant office visits (n = 275) from a larger observational study of glaucoma communication. We analyzed medical information, demographic characteristics, and interviewer-administrated questionnaires, as well as verbatim transcripts of interviews. RESULTS Only 87 participants discussed medication cost during their glaucoma office visit. The majority of the subjects who discussed cost had mild disease severity (51%), took one glaucoma medication (63%), and had Medicare (49%) as well as a form of prescription insurance (78%). The majority of glaucoma office visits did not discuss medication cost, and providers often did not ask about cost problems. Of the few conversations related to cost, most focused on providers offering potential solutions (n = 50), medical and prescription service coverage (n = 41), and brand or generic medication choices (n = 41). CONCLUSIONS Our findings are similar to previous studies showing few patients have conversations with providers about the cost of glaucoma medications. Providers should consider bringing up medication cost during glaucoma office visits to prompt a discussion of potential cost-related barriers to medication use.
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Hunter WG, Zafar SY, Hesson A, Davis JK, Kirby C, Barnett JA, Ubel PA. Discussing Health Care Expenses in the Oncology Clinic: Analysis of Cost Conversations in Outpatient Encounters. J Oncol Pract 2017; 13:e944-e956. [PMID: 28834684 DOI: 10.1200/jop.2017.022855] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE ASCO identified oncologist-patient conversations about cancer costs as an important component of high-quality care. However, limited data exist characterizing the content of these conversations. We sought to provide novel insight into oncologist-patient cost conversations by determining the content of cost conversations in breast cancer clinic visits. METHODS We performed content analysis of transcribed dialogue from 677 outpatient appointments for breast cancer management. Encounters featured 677 patients with breast cancer visiting 56 oncologists nationwide from 2010 to 2013. RESULTS Cost conversations were identified in 22% of visits (95% CI, 19 to 25) and had a median duration of 33 seconds (interquartile range, 19 to 62). Fifty-nine percent of cost conversations were initiated by oncologists (95% CI, 51 to 67), who most commonly brought up costs for antineoplastic agents. By contrast, patients most frequently brought up costs for diagnostic tests. Thirty-eight percent of cost conversations mentioned cost-reducing strategies (95% CI, 30 to 46), which most commonly sought to lower patient costs for endocrine therapies and symptom-alleviating treatments. The three most commonly discussed cost-reducing strategies were: switching to a lower-cost therapy/diagnostic, changing logistics of the intervention, and facilitating copay assistance. CONCLUSION We identified cost conversations in approximately one in five breast cancer visits. Cost conversations were mostly oncologist initiated, lasted < 1 minute, and dealt with a wide range of health care expenses. Cost-reducing strategies were mentioned in more than one third of cost conversations and often involved switching antineoplastic agents for lower-cost alternatives or altering logistics of diagnostic tests.
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Affiliation(s)
- Wynn G Hunter
- Duke University, Durham, NC; Michigan State University, East Lansing, MI; and Verilogue, Horsham, PA
| | - S Yousuf Zafar
- Duke University, Durham, NC; Michigan State University, East Lansing, MI; and Verilogue, Horsham, PA
| | - Ashley Hesson
- Duke University, Durham, NC; Michigan State University, East Lansing, MI; and Verilogue, Horsham, PA
| | - J Kelly Davis
- Duke University, Durham, NC; Michigan State University, East Lansing, MI; and Verilogue, Horsham, PA
| | - Christine Kirby
- Duke University, Durham, NC; Michigan State University, East Lansing, MI; and Verilogue, Horsham, PA
| | - Jamison A Barnett
- Duke University, Durham, NC; Michigan State University, East Lansing, MI; and Verilogue, Horsham, PA
| | - Peter A Ubel
- Duke University, Durham, NC; Michigan State University, East Lansing, MI; and Verilogue, Horsham, PA
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Ubel PA, Zhang CJ, Hesson A, Davis JK, Kirby C, Barnett J, Hunter WG. Study Of Physician And Patient Communication Identifies Missed Opportunities To Help Reduce Patients' Out-Of-Pocket Spending. Health Aff (Millwood) 2017; 35:654-61. [PMID: 27044966 DOI: 10.1377/hlthaff.2015.1280] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Some experts contend that requiring patients to pay out of pocket for a portion of their care will bring consumer discipline to health care markets. But are physicians prepared to help patients factor out-of-pocket expenses into medical decisions? In this qualitative study of audiorecorded clinical encounters, we identified physician behaviors that stand in the way of helping patients navigate out-of-pocket spending. Some behaviors reflected a failure to fully engage with patients' financial concerns, from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending. Many of these failures resulted from systemic barriers to health care spending conversations, such as a lack of price transparency. For consumer health care markets to work as intended, physicians need to be prepared to help patients navigate out-of-pocket expenses when financial concerns arise during clinical encounters.
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Affiliation(s)
- Peter A Ubel
- Peter A. Ubel is a professor in the Sanford School of Public Policy, Fuqua School of Business, and School of Medicine, and faculty in the Duke-Margolis Center for Healthcare Policy, all at Duke University, in Durham, North Carolina
| | - Cecilia J Zhang
- Cecilia J. Zhang is a medical student in the School of Medicine, Duke University
| | - Ashley Hesson
- Ashley Hesson is a student in the College of Human Medicine at Michigan State University, in Grand Rapids
| | - J Kelly Davis
- J. Kelly Davis is a research associate in the Fuqua School of Business, Duke University
| | - Christine Kirby
- Christine Kirby is a research associate in the Fuqua School of Business, Duke University
| | - Jamison Barnett
- Jamison Barnett is chief technology officer and vice president of Verilogue Sound Insight, in Horsham, Pennsylvania
| | - Wynn G Hunter
- Wynn G. Hunter is a medical student in the School of Medicine, Duke University
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Pain Predicts Function One Year Later: A Comparison across Pain Measures in a Rheumatoid Arthritis Sample. PAIN RESEARCH AND TREATMENT 2016; 2016:7478509. [PMID: 27119021 PMCID: PMC4826936 DOI: 10.1155/2016/7478509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/06/2016] [Indexed: 11/22/2022]
Abstract
Background. Guidance is limited on best measures and time periods to reference when measuring pain in order to predict future function. Objective. To examine how different measures of pain predict functional limitations a year later in a sample of rheumatoid arthritis patients. Methods. Logistic regression analyses were conducted using baseline and one-year data (n = 262). Pain intensity in the last 24 hours was measured on a 0–10 numerical rating scale and in the last month using an item from the Arthritis Impact Measurement Scale 2 (AIMS2). AIMS2 also provided frequency of severe pain, pain composite scores, and patient-reported limitations. Physician-rated function was also examined. Results. Composite AIMS2 pain scale performed best, predicting every functional outcome with the greatest magnitude, a one-point increase in pain score predicting 21% increased odds of limitations (combined patient and physician report). However, its constituent item—frequency of severe pain in the last month—performed nearly as well (19% increased odds). Pain intensity measures in last month and last 24 hours yielded inconsistent findings. Conclusion. Although all measures of pain predicted some functional limitations, predictive consistency varied by measure. Frequency of severe pain in the last month provided a good balance of brevity and predictive power.
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Hunter WG, Hesson A, Davis JK, Kirby C, Williamson LD, Barnett JA, Ubel PA. Patient-physician discussions about costs: definitions and impact on cost conversation incidence estimates. BMC Health Serv Res 2016; 16:108. [PMID: 27036177 PMCID: PMC4815215 DOI: 10.1186/s12913-016-1353-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/17/2016] [Indexed: 02/08/2023] Open
Abstract
Background Nearly one in three Americans are financially burdened by their medical expenses. To mitigate financial distress, experts recommend routine physician-patient cost conversations. However, the content and incidence of these conversations are unclear, and rigorous definitions are lacking. We sought to develop a novel set of cost conversation definitions, and determine the impact of definitional variation on cost conversation incidence in three clinical settings. Methods Retrospective, mixed-methods analysis of transcribed dialogue from 1,755 outpatient encounters for routine clinical management of breast cancer, rheumatoid arthritis, and depression, occurring between 2010–2014. We developed cost conversation definitions using summative content analysis. Transcripts were evaluated independently by at least two members of our multi-disciplinary team to determine cost conversation incidence using each definition. Incidence estimates were compared using Pearson’s Chi-Square Tests. Results Three cost conversation definitions emerged from our analysis: (a) Out-of-Pocket (OoP) Cost -- discussion of the patient’s OoP costs for a healthcare service; (b) Cost/Coverage -- discussion of the patient’s OoP costs or insurance coverage; (c) Cost of Illness-- discussion of financial costs or insurance coverage related to health or healthcare. These definitions were hierarchical; OoP Cost was a subset of Cost/Coverage, which was a subset of Cost of Illness. In each clinical setting, we observed significant variation in the incidence of cost conversations when using different definitions; breast oncology: 16, 22, 24 % of clinic visits contained cost conversation (OOP Cost, Cost/Coverage, Cost of Illness, respectively; P < 0.001); depression: 30, 38, 43 %, (P < 0.001); and rheumatoid arthritis, 26, 33, 35 %, (P < 0.001). Conclusions The estimated incidence of physician-patient cost conversation varied significantly depending on the definition used. Our findings and proposed definitions may assist in retrospective interpretation and prospective design of investigations on this topic. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1353-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wynn G Hunter
- Duke University, School of Medicine, 4906 Glendarion Drive, Durham, NC, 27713, USA.
| | - Ashley Hesson
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - J Kelly Davis
- Duke University, Fuqua School of Business, Durham, NC, USA
| | | | | | | | - Peter A Ubel
- Duke University, School of Medicine, 4906 Glendarion Drive, Durham, NC, 27713, USA.,Duke University, Fuqua School of Business, Durham, NC, USA.,Duke University, Sanford School of Public Policy, Durham, NC, USA
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Hunter WG, Zhang CZ, Hesson A, Davis JK, Kirby C, Williamson LD, Barnett JA, Ubel PA. What Strategies Do Physicians and Patients Discuss to Reduce Out-of-Pocket Costs? Analysis of Cost-Saving Strategies in 1,755 Outpatient Clinic Visits. Med Decis Making 2016; 36:900-10. [PMID: 26785714 DOI: 10.1177/0272989x15626384] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/04/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND More than 1 in 4 Americans report difficulty paying medical bills. Cost-reducing strategies discussed during outpatient physician visits remain poorly characterized. OBJECTIVE We sought to determine how often patients and physicians discuss health care costs during outpatient visits and what strategies, if any, they discussed to lower patient out-of-pocket costs. DESIGN Retrospective analysis of dialogue from 1,755 outpatient visits in community-based practices nationwide from 2010 to 2014. The study population included 677 patients with breast cancer, 422 with depression, and 656 with rheumatoid arthritis visiting 56 oncologists, 36 psychiatrists, and 26 rheumatologists, respectively. RESULTS Thirty percent of visits contained cost conversations (95% confidence interval [CI], 28 to 32). Forty-four percent of cost conversations involved discussion of cost-saving strategies (95% CI, 40 to 48; median duration, 68 s). We identified 4 strategies to lower costs without changing the care plan. They were, in order of overall frequency: 1) changing logistics of care, 2) facilitating co-pay assistance, 3) providing free samples, and 4) changing/adding insurance plans. We also identified 4 strategies to reduce costs by changing the care plan: 1) switching to lower-cost alternative therapy/diagnostic, 2) switching from brand name to generic, 3) changing dosage/frequency, and 4) stopping/withholding interventions. Strategies were relatively consistent across health conditions, except for switching to a lower-cost alternative (more common in breast oncology) and providing free samples (more common in depression). LIMITATION Focus on 3 conditions with potentially high out-of-pocket costs. CONCLUSIONS Despite price opacity, physicians and patients discuss a variety of out-of-pocket cost reduction strategies during clinic visits. Almost half of cost discussions mention 1 or more cost-saving strategies, with more frequent mention of those not requiring care-plan changes.
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Affiliation(s)
- Wynn G Hunter
- Duke University, School of Medicine, Durham, NC, USA (WGH, CZZ, PAU)
| | - Cecilia Z Zhang
- Duke University, School of Medicine, Durham, NC, USA (WGH, CZZ, PAU)
| | - Ashley Hesson
- Michigan State University, College of Human Medicine, East Lansing, MI, USA (AH)
| | - J Kelly Davis
- Duke University, Fuqua School of Business, Durham, NC, USA (JKD, CK, LDW, PAU)
| | - Christine Kirby
- Duke University, Fuqua School of Business, Durham, NC, USA (JKD, CK, LDW, PAU)
| | - Lillie D Williamson
- Duke University, Fuqua School of Business, Durham, NC, USA (JKD, CK, LDW, PAU)
- University of Illinois, Department of Communication, Champaign, IL, USA (LDW)
| | | | - Peter A Ubel
- Duke University, School of Medicine, Durham, NC, USA (WGH, CZZ, PAU)
- Duke University, Fuqua School of Business, Durham, NC, USA (JKD, CK, LDW, PAU)
- Duke University, Sanford School of Public Policy, Durham, NC, USA (PAU)
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Physician-patient communication on cost and affordability in asthma care. Who wants to talk about it and who is actually doing it. Ann Am Thorac Soc 2015; 11:1538-44. [PMID: 25375395 DOI: 10.1513/annalsats.201408-363oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
RATIONALE Patient perceptions of financial burden and rates of cost-related nonadherence are high among individuals with asthma across the socioeconomic spectrum. Little is known about preferences and frequency of physician-patient discussions about cost/affordability among individuals managing respiratory conditions. OBJECTIVES To examine who has a preference to discuss the cost of their asthma care with their physician, how often physician-patient communication about cost/affordability actually is occurring, and what clinical and demographic characteristics of patients are predictive of communication. METHODS Data came from 422 African American adult women with asthma who were asked about communication preferences and practices around cost and affordability with their physician. Data were analyzed using descriptive statistics and multiple variable logistic regression models. MEASUREMENTS AND MAIN RESULTS Fifty-two percent (n = 219) of this sample perceived financial burden. Seventy-two percent (n = 300) reported a preference to discuss cost with their health-care provider. Thirty-nine percent (n = 163) reported actually having a conversation with their physician about cost. Among the 61% who reported no discussion, 40% (n = 103) reported financial burden, and 55% (n = 140) reported a preference for discussion. Lower household income (P < 0.001), perception of financial burden (P < 0.001), and higher out-of-pocket expenses for medicines (P < 0.05) were significantly predictive of greater preference to communicate about cost/affordability with the doctor when adjusted for clinical and demographic characteristics. Perception of financial burden (P < 0.001), preference to discuss affordability (P < 0.001), and greater number of chronic conditions (P < 0.001) were significantly predictive of greater likelihood of communication about cost/affordability with the doctor when adjusted for clinical and demographic characteristics. Bivariate analyses revealed that patients who reported a discussion of cost were more likely to report worse asthma control and lower asthma-related quality of life. CONCLUSIONS An imbalance is evident between patients who would like to discuss cost with their doctor and those who actually do. Patients are interested in low-cost options and a venue for addressing their concerns with a care provider; therefore, a greater understanding is needed in how to effectively and efficiently integrate these conversations and viable solutions into the delivery of health care. Additional research is necessary to determine whether communication about the cost of therapy is associated with health outcomes.
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Yazdany J, Dudley RA, Chen R, Lin GA, Tseng CW. Coverage for high-cost specialty drugs for rheumatoid arthritis in Medicare Part D. Arthritis Rheumatol 2015; 67:1474-80. [PMID: 25900105 DOI: 10.1002/art.39079] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 02/12/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE More than 1 in 4 Medicare beneficiaries with rheumatoid arthritis use high-cost biologic disease-modifying antirheumatic drugs (DMARDs), and spending for these drugs has risen sharply for Medicare Part D. Our aim was to conduct the first systematic, national investigation of how Part D plans cover biologic DMARDs and to determine patients' financial burden under current cost-sharing structures. METHODS We performed a cross-sectional analysis of Part D plan formularies (n = 2,737) in 50 states and Washington, DC using the January 2013 Centers for Medicare and Medicaid Services Prescription Drug Plan Formulary and Pharmacy Network Files. We calculated the percentage of plans covering each DMARD as well as the percentage requiring prior authorization and/or coinsurance. We also compared biologic drug coverage in Medicare Advantage prescription drug plans to that in Medicare Part D stand-alone plans. RESULTS All plans covered at least 1 biologic DMARD, but the vast majority required prior authorizations (95%). Nearly all plans (81-100%) required patients to pay a coinsurance percentage (averaging 29.6% of drug costs) rather than a fixed dollar copayment. This translated into mean out-of-pocket costs of $2,712-$2,774 before reaching the catastrophic phase of coverage, during which beneficiaries pay 5% of drug costs. Medicare Advantage prescription drug plans covered more individual biologic DMARDs (55-100%) than did Medicare Part D stand-alone plans (22-100%), but Medicare Advantage prescription drug plans required higher average coinsurance (31.1% versus 29.0%). In contrast, 6 of 9 nonbiologic DMARDs were covered by nearly all plans without prior authorizations at fixed copayments averaging $5-$10/month. CONCLUSION Nationally, nearly all Part D plans cover at least 1 biologic DMARD, but the vast majority require cost sharing sufficiently high to risk significant financial burden to patients.
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Affiliation(s)
| | - R Adams Dudley
- University of California, San Francisco, and Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Randi Chen
- Pacific Health Research and Education Institute, Honolulu, Hawaii
| | - Grace A Lin
- University of California, San Francisco, and Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Chien-Wen Tseng
- Pacific Health Research and Education Institute, Honolulu, Hawaii, and University of Hawaii John A. Burns School of Medicine, Mililani
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Meluch AL, Oglesby WH. Physician–patient communication regarding patients’ healthcare costs in the US: A systematic review of the literature. ACTA ACUST UNITED AC 2015. [DOI: 10.1179/1753807615y.0000000010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Lauffenburger JC, Farley JF, Gehi AK, Rhoney DH, Brookhart MA, Fang G. Factors driving anticoagulant selection in patients with atrial fibrillation in the United States. Am J Cardiol 2015; 115:1095-101. [PMID: 25724781 DOI: 10.1016/j.amjcard.2015.01.539] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 01/18/2015] [Accepted: 01/18/2015] [Indexed: 12/16/2022]
Abstract
With the introduction of novel oral anticoagulants (NOACs), the factors driving anticoagulant selection in atrial fibrillation (AF) in real-world practice are unclear. The goal was to examine whether and to what extent utilization has been driven by predictions of stroke risk (treatment benefit), bleeding risk (treatment harm), or prescription benefits' coverage. We extracted a cohort of patients with nonvalvular AF initiating anticoagulation from October 2010 to December 2012 from a large US database of commercial and Medicare supplement claims. Multivariable regression examined associations between ischemic stroke (CHA2DS2-VASc) and bleeding (Anticoagulation and Risk Factors in Atrial Fibrillation [ATRIA]) risk scores and benefits' generosity (proportion of costs covered by patients relative to total) with warfarin and novel oral anticoagulant (NOAC) selection and also between dabigatran and rivaroxaban. C-statistics and partial chi-square statistics were used to assess the variation explained. Of 70,498 patients initiating anticoagulation, 29.9% and 7.9% used dabigatran and rivaroxaban, respectively. Compared with warfarin, patients were less likely to receive an NOAC with high ischemic stroke risk (CHA2DS2-VASc ≥2; adjusted relative risk [aRR] 0.75, 95% confidence interval [CI] 0.72 to 0.77) and high bleeding risk (ATRIA ≥5; aRR 0.66, 95% CI 0.64 to 0.69) but more likely with good benefits' generosity (≤20% of costs borne by patient; aRR 2.03, 95% CI 1.92 to 2.16). Prescription generosity explained almost twice the model variation as either risk score. Compared with dabigatran, patients were more likely to fill rivaroxaban with high bleeding risk (aRR 1.16, 95% CI 1.09 to 1.24). In conclusion, patients with greater bleeding and ischemic stroke risk were more likely to initiate warfarin, but generous benefits more strongly predicted NOAC usage and drove more selection.
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Abstract
Racial and ethnic health disparities are a national health issue. They are well described in other chronic diseases, but in rheumatoid arthritis (RA), research into their causes, outcomes, and elimination is in its early stages. Health disparities occur in a complex milieu, with system-level, provider-level, and individual-level factors playing roles. Dissecting the overlapping aspects of race/ethnicity, socioeconomic variables, and how their individual components combine to explain the magnitude of disparities in RA can be challenging. Recent research has focused on the extent to which treatment preferences, adherence, trust in physicians, patient-physician communication, health literacy, and depression have contributed to observed disparities in RA. Practicing evidence-based medicine, improving patient-physician communication skills, reducing language and literacy barriers, improving adherence to therapies, raising awareness of racial/ethnic disparities, and recognizing comorbidities such as depression are steps clinicians may take to help eliminate racial/ethnic disparities in RA.
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Affiliation(s)
- Christine A McBurney
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace St., S720A BST, Pittsburgh, PA 15261, USA.
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Harrold LR, Briesacher BA, Peterson D, Beard A, Madden J, Zhang F, Gurwitz JH, Soumerai SB. Cost-related medication nonadherence in older patients with rheumatoid arthritis. J Rheumatol 2013; 40:137-43. [PMID: 23322458 DOI: 10.3899/jrheum.120441] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Economic access to costly medications including biologic agents can be challenging. Our objective was to examine whether patients with rheumatoid arthritis (RA) are at particular risk for cost-related medication nonadherence (CRN) and spending less on basic needs. METHODS We identified a nationally representative sample of older adults with RA (n = 1100) in the Medicare Current Beneficiary Survey (2004-2008) and compared them to older adults with other morbidities categorized by chronic disease count: 0 (n = 5898), 1-2 (n = 30,538), and ≥ 3 (n = 34,837). We compared annual rates of self-reported CRN (skipping or reducing medication doses or not obtaining prescriptions because of cost) as well as spending less on basic needs to afford medications and tested for differences using survey-weighted logistic regression analyses adjusted for demographic characteristics, health status, and prescription drug coverage. RESULTS In the RA sample, the unadjusted weighted prevalence of CRN ranged from 20.7% in 2004 to 18.4% in 2008 as compared to 18.5% and 11.9%, respectively, in patients with 3 or more non-RA conditions. In adjusted analyses, having RA was associated with a 3.5-fold increase in the risk of CRN (OR 3.52, 95% CI 2.63-4.71) and almost a 2.5-fold risk of spending less on basic needs (OR 2.41, 95% CI 1.78-3.25) as compared to those without a chronic condition. CONCLUSION Patients with RA experience a high prevalence of CRN and forgoing of basic needs, more than do older adults with multiple other chronic conditions. The situation did not improve during a period of policy change aimed at alleviating high drug costs.
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Affiliation(s)
- Leslie R Harrold
- Meyers Primary Care Institute, and the University of Massachusetts Medical School, Department of Medicine, Worcester, MA 01605, USA.
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