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Kamath CC, Espinoza Suarez NR, Vallejo S, Montori VM, Brito JP, Boehmer KR. Not all cost conversations are the same: An exploration of potential value in cost conversations during Atrial fibrillation treatment decision making. PATIENT EDUCATION AND COUNSELING 2024; 128:108366. [PMID: 39032442 DOI: 10.1016/j.pec.2024.108366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES To explore the cost conversations taking place when patients with atrial fibrillation and their clinicians decide on whether and how to use anticoagulation to prevent strokes. METHODS Secondary qualitative thematic analysis of conversations from 476 clinical encounters in three sites of a multicenter randomized trial comparing usual care with and without a shared decision-making tool. RESULTS We identified three themes with subthemes: (1) What was discussed: conversation content (2) How content was transmitted: communication patterns and (3) Implicit conversation drivers. Due to each patient's unique circumstances, bi-directional conversations focused on relationship- and solution-based content enabled better cost burden discovery. Conversation drivers included affordability, comorbidities, preferences, and uncertainty about future costs. CONCLUSIONS Cost conversations were often initiated by clinicians, and if they did not invite a response, patients passively received information without understanding or weighing cost burden. When clinicians discussed cost information using relational or solution-focused content and bi-directional communication patients were more likely to engage in discussion including their unique situation. PRACTICE IMPLICATIONS Solution-focused cost conversations can reduce financial treatment burden, but require estimates of out-of-pocket costs, insurance coverage, and long-term financial effects of various options. Conversation tools and information on financial resources are valuable to patients and clinicians.
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Affiliation(s)
- Celia C Kamath
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA; Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Nataly R Espinoza Suarez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; VITAM - Center for Sustainable Health Research, Integrated University Health and Social Services Center of Capitale-Nationale, Quebec City, QC, Canada; Faculty of Nursing, Laval University, Quebec City, QC, Canada
| | | | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.
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Hesson AM, Davuluri K, Corbin CK, Rujan AM, Berman DR. There's no place like home: optimizing the antepartum inpatient experience. Matern Health Neonatol Perinatol 2024; 10:15. [PMID: 39085946 PMCID: PMC11293146 DOI: 10.1186/s40748-024-00185-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/18/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND To characterize the demographics of a modern hospitalized antepartum population, compare the morbidities of this subset to national morbidity trends, and identify predictors of satisfaction during hospitalization to inform opportunities to enhance equitable antepartum care. METHODS Pregnant people admitted to the antepartum service of a large university hospital between 2011 and 2019 were surveyed about their hospitalization, pregnancy outcomes, provider interactions, perceived needs, and resource use. Multiple correspondence analysis was used to group patient responses based on latent relationships among demographic, medical, and psychosocial variables. Multivariate analyses were conducted to identify predictors of patient experience rating. Patient free text responses were qualitatively analyzed for common themes. RESULTS Of 740 pregnant people invited to participate, 298 surveys met criteria for analysis. 25.2% of these pregnant people identified as non-white and 20.8% were admitted for the management of a chronic medical condition. Patient responses clustered into three representative groups: (1) working pregnant people facing resource limitations, (2) first-time pregnant people with college educations, and (3) pregnant people with medical problems and limited partner support. The mean overall patient admission experience rating was 8.4 ± 1.7 out of 10. Variables represented in Cluster 1 (working and resource limitations) were associated with lower patient experience rating (p < 0.01). There was no significant variation in experience rating with indication for admission (P = 0.14) or outcome of the pregnancy (P = 0.32). Conversely, feeling supported by partners (P < 0.01) and providers (P < 0.01) directly correlated with a better experience. CONCLUSION Black pregnant people and those with chronic medical conditions are overrepresented in this antepartum population when compared to the demographics of those not requiring hospitalization in pregnancy, where these groups also have higher rates of maternal morbidity and mortality at the national level. The most important contributors to patients' satisfaction with their antepartum experience are feeling listened to by providers and supported by partners. Improving patient-provider communication and partner engagement during antepartum admissions should be a focus of inpatient high-risk obstetric care.
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Affiliation(s)
- Ashley M Hesson
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Michigan, 1500 East Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Kavya Davuluri
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Michigan, 1500 East Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - C Kenzie Corbin
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Michigan, 1500 East Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Anna M Rujan
- Department of Obstetrics & Gynecology, Northwestern University, Chicago, IL, USA
| | - Deborah R Berman
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Michigan, 1500 East Medical Center Dr, Ann Arbor, MI, 48109, USA
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Amin K, Bethel G, Jackson LR, Essien UR, Sloan CE. Eliminating Health Disparities in Atrial Fibrillation, Heart Failure, and Dyslipidemia: A Path Toward Achieving Pharmacoequity. Curr Atheroscler Rep 2023; 25:1113-1127. [PMID: 38108997 PMCID: PMC11044811 DOI: 10.1007/s11883-023-01180-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE OF REVIEW Pharmacoequity refers to the goal of ensuring that all patients have access to high-quality medications, regardless of their race, ethnicity, gender, or other characteristics. The goal of this article is to review current evidence on disparities in access to cardiovascular drug therapies across sociodemographic subgroups, with a focus on heart failure, atrial fibrillation, and dyslipidemia. RECENT FINDINGS Considerable and consistent disparities to life-prolonging heart failure, atrial fibrillation, and dyslipidemia medications exist in clinical trial representation, access to specialist care, prescription of guideline-based therapy, drug affordability, and pharmacy accessibility across racial, ethnic, gender, and other sociodemographic subgroups. Researchers, health systems, and policy makers can take steps to improve pharmacoequity by diversifying clinical trial enrollment, increasing access to inpatient and outpatient cardiology care, nudging clinicians to increase prescription of guideline-directed medical therapy, and pursuing system-level reforms to improve drug access and affordability.
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Affiliation(s)
- Krunal Amin
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Garrett Bethel
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Larry R Jackson
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Utibe R Essien
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | - Caroline E Sloan
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
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Fitzpatrick V, Erwin K, Rivelli A, Shields M, Delfinado L, Cabiya M, Wennerberg K. The potential impact of introducing a cost tool to facilitate cost-of-care conversations in routine OB care: Lessons from the CONTINUE pilot study. PEC INNOVATION 2023; 2:100136. [PMID: 37214536 PMCID: PMC10194338 DOI: 10.1016/j.pecinn.2023.100136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 05/24/2023]
Abstract
Objective The objective of the CONTINUE study is to gather preliminary data on the potential impact of implementing a "Cost Tool" in routine obstetrics (OB) care. It is hypothesized that by providing prenatal patients with an ability to forecast their care plan, they would be better able to anticipate and plan for the costs associated with their prenatal care. Methods Pilot data from interviews and surveys were collected from 71 prenatal patients across three clinics throughout Chicago, IL. Results As compared to privately insured prenatal patients, prenatal patients with public insurance reported the most benefit in Cost Tool use. Specifically, that the Cost Tool helped to navigate insurance more effectively (OR 4.49, p=0.0254), see the "Big Picture" and link it to the family budget (OR 4.25, p=0.0099), and make the financial tradeoffs needed to get through pregnancy (OR 5.50, p=0.0305). Conclusion The CONTINUE study provides preliminary signals of the Cost Tool's potential to help publicly insured prenatal patients better navigate the costs associated with their care plan. Innovations The CONTINUE study contributes valuable preliminary data about the utility of a cost tool in routine OB care, especially as it may benefit low-income prenatal patients navigate prenatal care better.
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Affiliation(s)
- Veronica Fitzpatrick
- Advocate Aurora Research Institute, Downers Grove, IL, USA
- Advocate Aurora Health; Downers Grove, IL, Milwaukee, WI, USA
| | - Kim Erwin
- Illinois Institute of Technology Institute of Design, Chicago, IL, USA
| | - Anne Rivelli
- Advocate Aurora Research Institute, Downers Grove, IL, USA
- Advocate Aurora Health; Downers Grove, IL, Milwaukee, WI, USA
| | - Maureen Shields
- Advocate Aurora Research Institute, Downers Grove, IL, USA
- Advocate Aurora Health; Downers Grove, IL, Milwaukee, WI, USA
| | - Leah Delfinado
- Advocate Aurora Health; Downers Grove, IL, Milwaukee, WI, USA
| | - Marie Cabiya
- Advocate Aurora Health; Downers Grove, IL, Milwaukee, WI, USA
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McLoone J, Chan RJ, Varlow M, Whittaker K, Lindsay D, Thamm C, Leigh L, Muir L, Mackay G, Karikios DJ, Hunt L, Hobbs K, Goldsbury DE, Nabukalu D, Gordon LG. Challenges and solutions to cancer-related financial toxicity according to Australian health professionals: qualitative results from a national survey. Support Care Cancer 2023; 31:441. [PMID: 37402039 DOI: 10.1007/s00520-023-07875-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/09/2023] [Indexed: 07/05/2023]
Abstract
PURPOSE To qualitatively explore Australian healthcare professionals' perspectives on how to improve the care and management of cancer-related financial toxicity, including relevant practices, services, and unmet needs. METHODS We invited healthcare professionals (HCP) who currently provide care to people with cancer within their role to complete an online survey, which was distributed via the networks of Australian clinical oncology professional associations/organisations. The survey was developed by the Clinical Oncology Society of Australia's Financial Toxicity Working Group and contained 12 open-ended items which we analysed using descriptive content analysis and NVivo software. RESULTS HCPs (n = 277) believed that identifying and addressing financial concerns within routine cancer care was important and most believed this to be the responsibility of all HCP involved in the patient's care. However, financial toxicity was viewed as a "blind spot" within a medical model of healthcare, with a lack of services, resources, and training identified as barriers to care. Social workers reported assessment and advocacy were part of their role, but many reported lacking formal training and understanding of financial complexities/laws. HCPs reported positive attitudes towards transparent discussions of costs and actioning cost-reduction strategies within their control, but feelings of helplessness when they perceived no solution was available. CONCLUSION Identifying financial needs and providing transparent information about cancer-related costs was viewed as a cross-disciplinary responsibility, however, a lack of training and services limited the provision of support. Increased cancer-specific financial counselling and advocacy, via dedicated roles or developing HCPs' skills, is urgently needed within the healthcare system.
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Affiliation(s)
- Jordana McLoone
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital NSW, Sydney, New South Wales, Australia.
- Discipline of Paediatrics & Child Health, UNSW Medicine & Health, Randwick Clinical Campus, University of NSW, Sydney, New South Wales, Australia.
| | - Raymond J Chan
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
| | - Megan Varlow
- Cancer Council Australia, Sydney, New South Wales, Australia
| | - Kate Whittaker
- Cancer Council Australia, Sydney, New South Wales, Australia
| | - Daniel Lindsay
- Faculty of Medicine, University of Queensland, Brisbane, Herston, Australia
- QIMR Berghofer Medical Research Institute, Population Health Department, Brisbane, Herston, Australia
| | - Carla Thamm
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
| | - Lillian Leigh
- Rare Cancers Australia, Bowral, New South Wales, Australia
| | - Laura Muir
- Cancer Council NSW, Sydney, New South Wales, Australia
| | - Gillian Mackay
- Clinical Oncology Society of Australia, Sydney, New South Wales, Australia
| | - Deme J Karikios
- Department of Medical Oncology, Nepean Hospital, Kingswood, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Lee Hunt
- Cancer Voices NSW, Sydney NSW, Australia
| | - Kim Hobbs
- Oncology Social Work Australia & New Zealand/Westmead Hospital NSW, Westmead, New South Wales, Australia
| | - David E Goldsbury
- The Daffodil Centre, University of Sydney, Cancer Council NSW, Sydney, New South Wales, Australia
| | - Doreen Nabukalu
- QIMR Berghofer Medical Research Institute, Population Health Department, Brisbane, Herston, Australia
| | - Louisa G Gordon
- Faculty of Medicine, University of Queensland, Brisbane, Herston, Australia
- QIMR Berghofer Medical Research Institute, Population Health Department, Brisbane, Herston, Australia
- Queensland University of Technology (QUT), School of Nursing and Cancer and Palliative Care Outcomes Centre, Brisbane, Kelvin Grove, Australia
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Sloan CE, Ubel PA. Patients want to talk about their out-of-pocket costs-Can real-time benefit tools help? J Am Geriatr Soc 2023; 71:1365-1368. [PMID: 36941733 PMCID: PMC10175166 DOI: 10.1111/jgs.18342] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/23/2023] [Indexed: 03/23/2023]
Abstract
This editorial comments on the article by Mattingly et al.
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Affiliation(s)
- Caroline E Sloan
- Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Peter A Ubel
- Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
- Fuqua School of Business, Duke University, Durham, NC, USA
- Sanford School of Public Policy, Duke University, Durham, NC, USA
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Politi MC, Housten AJ, Forcino RC, Jansen J, Elwyn G. Discussing Cost and Value in Patient Decision Aids and Shared Decision Making: A Call to Action. MDM Policy Pract 2023; 8:23814683221148651. [PMID: 36643615 PMCID: PMC9834940 DOI: 10.1177/23814683221148651] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/05/2022] [Indexed: 01/12/2023] Open
Abstract
Direct and indirect costs of care influence patients' health choices and the ability to implement those choices. Despite the significant impact of care costs on patients' health and daily lives, patient decision aid (PtDA) and shared decision-making (SDM) guidelines almost never mention a discussion of costs of treatment options as part of minimum standards or quality criteria. Given the growing study of the impact of costs in health decisions and the rising costs of care more broadly, in fall 2021 we organized a symposium at the Society for Medical Decision Making's annual meeting. The focus was on the role of cost information in PtDAs and SDM. Panelists gave an overview of work in this space at this virtual meeting, and attendees engaged in rich discussion with the panelists about the state of the problem as well as ideas and challenges in incorporating cost-related issues into routine care. This article summarizes and extends our discussion based on the literature in this area and calls for action. We recommend that PtDA and SDM guidelines routinely include a discussion of direct and indirect care costs and that researchers measure the frequency, quality, and response to this information.
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Affiliation(s)
- Mary C. Politi
- Division of Public Health Sciences, Department
of Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Ashley J. Housten
- Division of Public Health Sciences, Department
of Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Rachel C. Forcino
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon,
NH, USA
| | - Jesse Jansen
- School for Public Health and Primary Care
CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon,
NH, USA
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Li J, Braun RT, Kakarala S, Prigerson HG. How Should Cost-Informed Goals of Care Decisions Be Facilitated at Life's End? AMA J Ethics 2022; 24:E1040-1048. [PMID: 36342486 PMCID: PMC9811733 DOI: 10.1001/amajethics.2022.1040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Interventions near patients' deaths in the United States are often expensive, burdensome, and inconsistent with patients' goals and preferences. For patients and their loved ones to make informed care decisions, physicians must share adequate information about prognoses, prospective benefits and harms of specific interventions, and costs. This commentary on a case discusses strategies for sharing such information and suggests that properly designed advance care planning incentives can help improve communication and decision sharing.
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Affiliation(s)
- Jing Li
- Assistant professor in the Comparative Health Outcomes, Policy, and Economics Institute and in the Department of Pharmacy in the School of Pharmacy at the University of Washington in Seattle
| | - Robert Tyler Braun
- Assistant professor in the Division of Health Policy and Economics in the Department of Population Health Sciences at Weill Cornell Medical College in New York City
| | - Sophia Kakarala
- Research assistant at the Center for Research on End-of-Life Care at Weill Cornell Medicine in New York City
| | - Holly G Prigerson
- Irving Sherwood Wright Professor of Geriatrics at Weill Cornell Medicine in New York City
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Hung A, Sloan CE, Boyd C, Bayliss EA, Hastings SN, Maciejewski ML. Deprescribing medications: Do out-of-pocket costs have a role? J Am Geriatr Soc 2022; 70:3334-3337. [PMID: 35917409 PMCID: PMC10077838 DOI: 10.1111/jgs.17974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Caroline E. Sloan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Susan N. Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Geriatrics Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Desai SM, Chen AZ, Wang J, Chung WY, Stadelman J, Mahoney C, Szerencsy A, Anzisi L, Mehrotra A, Horwitz LI. Effects of Real-time Prescription Benefit Recommendations on Patient Out-of-Pocket Costs: A Cluster Randomized Clinical Trial. JAMA Intern Med 2022; 182:1129-1137. [PMID: 36094537 PMCID: PMC9468947 DOI: 10.1001/jamainternmed.2022.3946] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/18/2022] [Indexed: 12/14/2022]
Abstract
Importance Rising drug costs contribute to medication nonadherence and adverse health outcomes. Real-time prescription benefit (RTPB) systems present prescribers with patient-specific out-of-pocket cost estimates and recommend lower-cost, clinically appropriate alternatives at the point of prescribing. Objective To investigate whether RTPB recommendations lead to reduced patient out-of-pocket costs for medications. Design, Setting, and Participants In this cluster randomized trial, medical practices in a large, urban academic health system were randomly assigned to RTPB recommendations from January 13 to July 31, 2021. Participants were adult patients receiving outpatient prescriptions during the study period. The analysis was limited to prescriptions for which RTPB could recommend an available alternative. Electronic health record data were used to analyze the intervention's effects on prescribing. Data analyses were performed from August 20, 2021, to June 8, 2022. Interventions When a prescription was initiated in the electronic health record, the RTPB system recommended available lower-cost, clinically appropriate alternatives for a different medication, length of prescription, and/or choice of pharmacy. The prescriber could select either the initiated order or one of the recommended options. Main Outcomes and Measures Patient out-of-pocket cost for a prescription. Secondary outcomes were whether a mail-order prescription and a 90-day supply were ordered. Results Of 867 757 outpatient prescriptions at randomized practices, 36 419 (4.2%) met the inclusion criteria of having an available alternative. Out-of-pocket costs were $39.90 for a 30-day supply in the intervention group and $67.80 for a 30-day supply in the control group. The intervention led to an adjusted 11.2%; (95% CI, -15.7% to -6.4%) reduction in out-of-pocket costs. Mail-order pharmacy use was 9.6% and 7.6% in the intervention and control groups, respectively (adjusted 1.9 percentage point increase; 95% CI, 0.9 to 3.0). Rates of 90-day supply were not different. In high-cost drug classes, the intervention reduced out-of-pocket costs by 38.9%; 95% CI, -47.6% to -28.7%. Conclusions and Relevance This cluster randomized clinical trial showed that RTPB recommendations led to lower patient out-of-pocket costs, with the largest savings occurring for high-cost medications. However, RTPB recommendations were made for only a small percentage of prescriptions. Trial Registration ClinicalTrials.gov Identifier: NCT04940988; American Economic Association Registry: AEARCTR-0006909.
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Affiliation(s)
- Sunita M. Desai
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | | | - Jiejie Wang
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Wei-Yi Chung
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Jay Stadelman
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Chris Mahoney
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Adam Szerencsy
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Lisa Anzisi
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Leora I. Horwitz
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
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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: 2] [Impact Index Per Article: 1.0] [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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Brown T, Apenteng BA, Opoku ST. Factors associated with cost conversations in oral health care settings. J Am Dent Assoc 2022; 153:829-838. [PMID: 35589435 DOI: 10.1016/j.adaj.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Patient-provider cost conversations can minimize cost-related barriers to health, while improving treatment adherence and patient satisfaction. The authors sought to identify factors associated with the occurrence of cost conversations in dentistry. METHODS This was a cross-sectional study using data from an online, self-administered survey of US adults who had seen a dentist within the past 24 months at the time of the survey. Multivariable hierarchical logistic regression analysis was used to identify patient and provider characteristics associated with the occurrence of cost conversations. RESULTS Of the 370 respondents, approximately two-thirds (68%) reported having a cost conversation with their dental provider during their last dental visit. Cost conversations were more likely for patients aged 25 through 34 years (odds ratio [OR], 2.84; 95% CI, 1.54 to 5.24), 35 through 44 years (OR, 3.35; 95% CI, 1.50 to 7.51), and 55 through 64 years (OR, 3.39; 95% CI, 1.38 to 8.28) than patients aged 18 through 24 years. Cost conversations were less likely to occur during visits with dental hygienists than during visits with general or family dentists (OR, 0.25; 95% CI, 0.11 to 0.58). In addition, respondents from the South (OR, 1.90; 95% CI, 1.04 to 3.48) and those screened for financial hardship were more likely to report having cost conversations with their dental providers (OR, 6.70; 95% CI, 2.69 to 16.71). CONCLUSIONS Within the study sample, cost conversations were common and were facilitated via financial hardship screening. PRACTICAL IMPLICATIONS Modifying oral health care delivery processes to incorporate financial hardship screening may be an effective way to facilitate cost conversations and provision of patient-centered care.
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Sloan CE, Gutterman S, Davis JK, Campagna A, Pollak KI, Barks MC, Santanam T, Sharma M, Grande DT, Zafar SY, Ubel PA. How can healthcare organizations improve cost-of-care conversations? A qualitative exploration of clinicians' perspectives. PATIENT EDUCATION AND COUNSELING 2022; 105:2708-2714. [PMID: 35440376 DOI: 10.1016/j.pec.2022.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Clinicians increasingly believe they should discuss costs with their patients. We aimed to learn what strategies clinicians, clinic leaders, and health systems can use to facilitate vital cost-of-care conversations. METHODS We conducted focus groups and semi-structured interviews with outpatient clinicians at two US academic medical centers. Clinicians recalled previous cost conversations and described strategies that they, their clinic, or their health system could use to facilitate cost conversations. Independent coders recorded, transcribed, and coded focus groups and interviews. RESULTS Twenty-six clinicians participated between December 2019 and July 2020: general internists (23%), neurologists (27%), oncologists (15%), and rheumatologists (35%). Clinicians proposed the following strategies: teach clinicians to initiate cost conversations; systematically collect financial distress information; partner with patients to identify costs; provide accurate insurance coverage and/or out-of-pocket cost information via the electronic health record; develop local lists of lowest-cost pharmacies, laboratories, and subspecialists; hire financial counselors; and reduce indirect costs (e.g., parking). CONCLUSIONS Despite considerable barriers to discussing, identifying, and reducing patient costs, clinicians described a variety of strategies for improving cost communication in the clinic. PRACTICE IMPLICATIONS Health systems and clinic leadership can and should implement these strategies to improve the financial health of the patients they serve.
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Affiliation(s)
- Caroline E Sloan
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Sophia Gutterman
- University of Michigan School of Medicine, Ann Arbor, MI, USA; Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - J Kelly Davis
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA
| | - Ada Campagna
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University, Durham, NC, USA; Duke Cancer Institute, Duke University Health System, Durham, NC, USA
| | - Mary Carol Barks
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA
| | - Taruni Santanam
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Meghana Sharma
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David T Grande
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - S Yousuf Zafar
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Durham, NC, USA; Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Peter A Ubel
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Durham, NC, USA; Sanford School of Public Policy, Duke University, Durham, NC, USA
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Ospina NMS, Bagautdinova D, Hargraves I, Barb D, Subbarayan S, Srihari A, Wang S, Maraka S, Bylund C, Treise D, Montori V, Brito JP. Development and pilot testing of a conversation aid to support the evaluation of patients with thyroid nodules. Clin Endocrinol (Oxf) 2022; 96:627-636. [PMID: 34590734 PMCID: PMC8897203 DOI: 10.1111/cen.14599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/25/2021] [Accepted: 09/09/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To support patient-centred care and the collaboration of patients and clinicians, we developed and pilot tested a conversation aid for patients with thyroid nodules. DESIGN, PATIENT AND MEASUREMENTS We developed a web-based Thyroid NOdule Conversation aid (TNOC) following a human-centred design. A proof of concept observational pre-post study was conducted (TNOC vs. usual care [UC]) to assess the impact of TNOC on the quality of conversations. Data sources included recordings of clinical visits, post-encounter surveys and review of electronic health records. Summary statistics and group comparisons are reported. RESULTS Sixty-five patients were analysed (32 in the UC and 33 in the TNOC cohort). Most patients were women (89%) with a median age of 57 years and were incidentally found to have a thyroid nodule (62%). Most thyroid nodules were at low risk for thyroid cancer (71%) and the median size was 1.4 cm. At baseline, the groups were similar except for higher numeracy in the TNOC cohort. The use of TNOC was associated with increased involvement of patients in the decision-making process, clinician satisfaction and discussion of relevant topics for decision making. In addition, decreased decisional conflict and fewer thyroid biopsies as the next management step were noted in the TNOC cohort. No differences in terms of knowledge transfer, length of consultation, thyroid cancer risk perception or concern for thyroid cancer diagnosis were found. CONCLUSION In this pilot observational study, using TNOC in clinical practice was feasible and seemed to help the collaboration of patients and clinicians.
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Affiliation(s)
- Naykky M Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL
| | | | - Ian Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | - Diana Barb
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL
| | - Sreevidya Subbarayan
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL
| | - Ashok Srihari
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL
| | - Shu Wang
- University of Florida Health Cancer Center & Department of Biostatistics, University of Florida
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR
- Central Arkansas Veterans Healthcare System, Little Rock, AR
| | - Carma Bylund
- College of Journalism & Communications, University of Florida, Gainesville, FL
| | - Debbie Treise
- College of Journalism & Communications, University of Florida, Gainesville, FL
| | - Victor Montori
- Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Mayo Clinic, Rochester, MN
| | - Juan P Brito
- Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Mayo Clinic, Rochester, MN
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15
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Aviki EM, Abu-Rustum NR, Thom B, Moss HA, Chino F. Oncologists' Attitudes Toward Cancer Care Affordability. JAMA Netw Open 2022; 5:e227863. [PMID: 35438759 PMCID: PMC9020205 DOI: 10.1001/jamanetworkopen.2022.7863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This investigator-designed survey study evaluates oncologists’ attitudes about cancer treatment affordability for patients and acceptability of physician-based solutions.
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Affiliation(s)
- Emeline M. Aviki
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Medical College of Cornell University, New York, New York
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nadeem R. Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Medical College of Cornell University, New York, New York
| | - Bridgette Thom
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Haley A. Moss
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
| | - Fumiko Chino
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Abstract
IMPORTANCE One-third of US residents have trouble paying their medical bills. They often turn to their physicians for help navigating health costs and insurance coverage. OBJECTIVE To determine whether physicians can accurately estimate out-of-pocket expenses when they are given all of the necessary information about a drug's price and a patient's insurance plan. DESIGN, SETTING, AND PARTICIPANTS This national mail-in survey used a random sample of US physicians. The survey was sent to 900 outpatient physicians (300 each of primary care, gastroenterology, and rheumatology). Physicians were excluded if they were in training, worked primarily for the Veterans Administration or Indian Health Service, were retired, or reported 0% outpatient clinical effort. Analyses were performed from July to December 2020. MAIN OUTCOMES AND MEASURES In a hypothetical vignette, a patient was prescribed a new drug costing $1000/month without insurance. A summary of her private insurance information was provided, including the plan's deductible, coinsurance rates, copays, and out-of-pocket maximum. Physicians were asked to estimate the drug's out-of-pocket cost at 4 time points between January and December, using the plan's 4 types of cost-sharing: (1) deductibles, (2) coinsurance, (3) copays, and (4) out-of-pocket maximums. Multivariate linear regression was used to assess differences in performance by specialty, adjusting for attitudes toward cost conversations, demographics, and clinical characteristics. RESULTS The response rate was 45% (405 of 900) and 371 respondents met inclusion criteria. Among the respondents included in this study, 59% (n = 220) identified as male, 23% (n = 84) as Asian, 3% (n = 12) as Black, 6% (n = 24) as Hispanic, and 58% (n = 216) as White; 30% (n = 112) were primary care physicians, 35% (n = 128) were gastroenterologists, and 35% (n = 131) were rheumatologists; and the mean (SD) age was 49 (10) years. Overall, 52% of physicians (n = 192) accurately estimated costs before the deductible was met, 62% (n = 228) accurately used coinsurance information, 61% (n = 224) accurately used copay information, and 57% (n = 210) accurately estimated costs once the out-of-pocket maximum was met. Only 21% (n = 78) of physicians answered all 4 questions correctly. Ability to estimate out-of-pocket costs was not associated with specialty, attitudes toward cost conversations, or clinic characteristics. CONCLUSIONS AND RELEVANCE This survey study found that many US physicians have difficulty estimating out-of-pocket costs, even when they have access to their patients' insurance plans. The mechanics involved in calculating real-time out-of-pocket costs are complex. These findings suggest that increased price transparency and simpler insurance cost-sharing mechanisms are needed to enable informed cost conversations at the point of prescribing.
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Affiliation(s)
- Caroline E. Sloan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Lorena Millo
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Peter A. Ubel
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Fuqua School of Business, Duke University, Durham, North Carolina
- Sanford School of Public Policy, Duke University, Durham, North Carolina
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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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Scott AM, Harrington NG. Are Cost-of-Care Conversations Best Practice? A Qualitative Study of Oncologists' Attitudes and Practice. JCO Oncol Pract 2021; 17:e1424-e1432. [PMID: 34152834 DOI: 10.1200/op.21.00042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients' desire for cost conversations exceeds the incidence of such conversations, and many oncologists report avoiding cost conversations despite reporting willingness to have them. Our objective was to examine oncologists' attitudes toward cost conversations and how those attitudes affect practice. METHODS An experienced investigator conducted individual interviews with oncologists practicing in Kentucky. Participants were asked about their attitude toward and experience with cost conversations and their advice for discussing cost with patients. Interview transcripts were analyzed by a four-member team using qualitative descriptive analysis to identify themes. RESULTS Participants were 32 MDs (male = 68.8%) age 31-77 years who were board-certified in medical oncology (53.1%), surgical oncology (25.0%), or radiation oncology (21.9%). We categorized participants into two groups: (1) those who viewed cost conversations as best practice and reported pursuing such conversations (37.5%) and (2) those who viewed cost conversations as not best practice and reported avoiding them (62.5%). Our analysis revealed three parallel themes for each category: Cost conversation attitudes and practice were based on (1) making good treatment decisions, (2) being a good clinician, and (3) having a good relationship with patients. CONCLUSION Not all oncologists view cost conversations as best practice. To improve cost conversation attitudes and practice, cost conversations can be framed as a strategic tool that-when used well-fosters optimal decision making, professionalism, and the therapeutic relationship.
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Affiliation(s)
- Allison M Scott
- Department of Communication, University of Kentucky, Lexington, KY
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19
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Fischer KA, Walling A, Wenger N, Glaspy J. Cost health literacy as a physician skill-set: the relationship between oncologist reported knowledge and engagement with patients on financial toxicity. Support Care Cancer 2020; 28:5709-5715. [PMID: 32193693 DOI: 10.1007/s00520-020-05406-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/06/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Oncologists are increasingly encouraged to communicate with patients about cost; however, they may lack the cost health literacy required to effectively perform this task. METHODS We conducted a pilot survey of oncologists in an academic medical center to assess potential factors that may influence provider attitudes and practices related to financial toxicity. We assessed perceived provider knowledge of treatment costs, insurance coverage and co-pays, and financially focused resources. We then evaluated the relationship between perceived knowledge and reported engagement with issues of financial toxicity. RESULTS Of 45 respondents (85% response rate), 58% had changed treatment within the past year as a result of patient financial burden. On self-report, 36% discussed out-of-pocket costs with patients, 42% assessed patient financial distress, but only 20% felt they could intervene upon financial toxicity. Self-perceived awareness of cost health literacy concepts were low; only 16% reporting high out-of-pocket cost knowledge, 31-33% high insurance knowledge, and 8% high awareness of financial resources. Report of cost discussion was associated with greater perceived awareness of both out-of-pocket costs and insurance design. However, reported financial distress assessment was only associated with perceived insurance awareness, not perceived cost knowledge. Cost health literacy was not associated with an increased sense of being able to impact on financial toxicity. CONCLUSION Oncologists acknowledge deficits in knowledge and skills that may play a role in the discussion and management of financial toxicity. Some cost health literacy competencies appear to correlate with physician involvement with financial toxicity, suggesting that education on this topic may facilitate physician engagement.
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Affiliation(s)
- Katrina A Fischer
- Department of Medicine, Division of Hematology & Oncology, UCLA School of Medicine, 200 UCLA Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA.
| | - Anne Walling
- Department of Medicine, Division of General Internal Medicine & Health Services Research, UCLA School of Medicine, Los Angeles, CA, USA
| | - Neil Wenger
- Department of Medicine, Division of General Internal Medicine & Health Services Research, UCLA School of Medicine, Los Angeles, CA, USA
| | - John Glaspy
- Department of Medicine, Division of Hematology & Oncology, UCLA School of Medicine, 200 UCLA Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA
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20
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Implementing routine communication about costs of cancer treatment: perspectives of providers, patients, and caregivers. Support Care Cancer 2020; 28:4255-4262. [PMID: 31900612 DOI: 10.1007/s00520-019-05274-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Rising costs in oncology care often impact patients and families directly, making communication about costs and financial impacts of treatment crucial. Cost expenditures could offer opportunities for estimation and prediction, affording personalized conversations about financial impact. We sought to explore providers', patients', and caregivers' preferences towards implementing communication about cost, including when, how, and by whom such information might be provided. METHODS We conducted semi-structured phone interviews with a diverse population including 12 oncology providers, 12 patients, and 8 patient caregivers (N = 32). The constant comparative method was used to identify mutually agreed upon themes. RESULTS Participant groups differed in their concerns surrounding cost communication, namely whether they want to receive this information and how such information might impact provider and patient treatment decisions. All participants agreed that oncology providers should not be leading cost conversations. Patients and caregivers identified social workers or financial advisors as most equipped to communicate about cost. Participants emphasized timely cost conversations, ideally around the time of diagnosis. Participants favored various metrics of financial impact beyond overall costs of care including disability, days lost from work, and out-of-pocket expenses. CONCLUSION Cost transparency should be incorporated into usual care; however, there are several challenges to making cost conversations a part of everyday practice. Patients and family members need resources related to cost to aid in decision-making and those delivering cost information should have competency in oncology, financial advisement, and patient-centered care.
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21
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Greenup RA, Rushing CN, Fish LJ, Lane WO, Peppercorn JM, Bellavance E, Tolnitch L, Hyslop T, Myers ER, Zafar SY, Hwang ES. Perspectives on the Costs of Cancer Care: A Survey of the American Society of Breast Surgeons. Ann Surg Oncol 2019; 26:3141-3151. [PMID: 31342390 DOI: 10.1245/s10434-019-07594-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cancer treatment costs are not routinely addressed in shared decisions for breast cancer surgery. Thus, we sought to characterize cost awareness and communication among surgeons treating breast cancer. METHODS We conducted a self-administered, confidential electronic survey among members of the American Society of Breast Surgeons from 1 July to 15 September 2018. Questions were based on previously published or validated survey items, and assessed surgeon demographics, cost sensitivity, and communication. Descriptive summaries and cross-tabulations with Chi-square statistics were used, with exact tests where warranted, to assess findings. RESULTS Of those surveyed (N = 2293), 598 (25%) responded. Surgeons reported that 'risk of recurrence' (70%), 'appearance of the breast' (50%), and 'risks of surgery' (47%) were the most influential on patients' decisions for breast cancer surgery; 6% cited out-of-pocket costs as significant. Over half (53%) of the surgeons agreed that doctors should consider patient costs when choosing cancer treatment, yet the majority of surgeons (58%) reported 'infrequently' (43%) or 'never' (15%) considering patient costs in medical recommendations. The overwhelming majority (87%) of surgeons believed that patients should have access to the costs of their treatment before making medical decisions. Surgeons treating a higher percentage of Medicaid or uninsured patients were more likely to consistently consider costs (p < 0.001). Participants reported that insufficient knowledge or resources (61%), a perceived inability to help with costs (24%), and inadequate time (22%) impeded cost discussions. Notably, 20% of participants believed that discussing costs might impact the quality of care patients receive. CONCLUSIONS Cost transparency remains rare, however in shared decisions for breast cancer surgery, improved cost awareness by surgeons has the potential to reduce financial hardship.
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Affiliation(s)
- Rachel A Greenup
- Department of Surgery, Duke University, Durham, NC, USA. .,Department of Population Health Sciences, Duke University, Durham, NC, USA. .,Duke Cancer Institute, Duke University, Durham, NC, USA. .,Duke Cancer Control and Population Sciences, Duke University, Durham, NC, USA.
| | - Christel N Rushing
- Duke Cancer Institute, Duke University, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Laura J Fish
- Duke Cancer Institute, Duke University, Durham, NC, USA.,Duke Cancer Control and Population Sciences, Duke University, Durham, NC, USA.,Duke School of Medicine, Duke University, Durham, NC, USA
| | | | | | | | - Lisa Tolnitch
- Department of Surgery, Duke University, Durham, NC, USA
| | - Terry Hyslop
- Duke Cancer Institute, Duke University, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Evan R Myers
- Department of Medicine, Duke University, Durham, NC, USA.,Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - S Yousuf Zafar
- Department of Population Health Sciences, Duke University, Durham, NC, USA.,Duke Cancer Institute, Duke University, Durham, NC, USA.,Duke Cancer Control and Population Sciences, Duke University, Durham, NC, USA.,Department of Medicine, Duke University, Durham, NC, USA
| | - E Shelley Hwang
- Department of Surgery, Duke University, Durham, NC, USA.,Duke Cancer Institute, Duke University, Durham, NC, USA
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22
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Pisu M, Schoenberger YM, Herbey I, Brown-Galvan A, Liang MI, Riggs K, Meneses K. Perspectives on Conversations About Costs of Cancer Care of Breast Cancer Survivors and Cancer Center Staff: A Qualitative Study. Ann Intern Med 2019; 170:S54-S61. [PMID: 31060056 DOI: 10.7326/m18-2117] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Despite recommendations to discuss the cost of care (CoC) with patients with cancer, little formal guidance is available on how to conduct these sensitive conversations in ways that are acceptable to both patients and providers. OBJECTIVE To explore the perspectives of patients and medical and nonmedical cancer center staff on CoC conversations. DESIGN In individual interviews, participants were asked to discuss the content of, timing of, and ideal person to hold CoC conversations. Interviews were transcribed verbatim. Content was analyzed to identify emerging essential elements. SETTING Division of Preventive Medicine, University of Alabama at Birmingham. PARTICIPANTS 42 women aged 60 to 79 years with a history of breast cancer and 20 cancer center staff (6 physicians, 4 nurses, 5 patient navigators, 3 social workers, and 2 billing specialists). RESULTS Both patients and providers identified reassurance and action as essential elements of CoC conversations. Participants expressed the importance of reassurance that recommended medical care would not be affected by affordability challenges. Action was intended as discussions on ways to help patients cover treatment-related costs, such as discussion of payment plans or linkage to financial resources. Optimal timing for CoC conversations was felt to be after an initial consult visit but before treatment started. The person to hold these conversations should be compassionate, helpful, and knowledgeable of the patient's specific situation (for example, treatment plan, insurance coverage) and of the resources available to attain the patient's goals of care. LIMITATION Interviews were limited to older breast cancer survivors and staff at 1 institution. CONCLUSION Conversations about CoC extend beyond discussing costs and must be sensitive to the vulnerability experienced by patients. These findings can guide training of personnel involved in CoC conversations. PRIMARY FUNDING SOURCE Robert Wood Johnson Foundation.
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Affiliation(s)
- Maria Pisu
- Division of Preventive Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham (M.P., Y.S.)
| | - Yu-Mei Schoenberger
- Division of Preventive Medicine and Comprehensive Cancer Center, University of Alabama at Birmingham (M.P., Y.S.)
| | - Ivan Herbey
- Division of Gastrointestinal Surgery, University of Alabama at Birmingham (I.H.)
| | - Aquila Brown-Galvan
- Division of Preventive Medicine, University of Alabama at Birmingham (A.B., K.R.)
| | - Margaret I Liang
- Division of Gynecologic Oncology and Comprehensive Cancer Center, University of Alabama at Birmingham (M.I.L.)
| | - Kevin Riggs
- Division of Preventive Medicine, University of Alabama at Birmingham (A.B., K.R.)
| | - Karen Meneses
- School of Nursing and Comprehensive Cancer Center, University of Alabama at Birmingham (K.M.)
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