A National study of burdensome health care costs among non-elderly Americans

Oncologists' Perceptions of Strategies for Discussing the Cost of Care with Cancer Patients and the Meaning of Those Conversations

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.

Experiences of Financial Stress and Supports in Caregivers During Pediatric Hospital Admission

BACKGROUND AND OBJECTIVE

In Canada and the United States, ∼1 in 5 children live in poverty, contributing to poor health outcomes. Families with children with chronic illness may experience additional financial stress related to hospitalization. This study aimed to capture experiences of financial needs and supports among caregivers with a child admitted to a tertiary care pediatric hospital to inform hospital-based financial services to reduce financial stress in families.

METHODS

We recruited caregivers of children admitted to the general inpatient ward of an academic pediatric center using purposive sampling with no exclusion criteria. Individual, semistructured, in-depth interviews with participants were conducted. Data collected included socio-demographics, financial needs, and experiences with financial supports. Interviews were audio-recorded, transcribed verbatim, coded, and analyzed on NVivo software using a modified-grounded theory approach and summative content analysis.

RESULTS

Fifteen caregivers of diverse backgrounds were interviewed, including non-English speakers (n = 4). Three themes and associated subthemes (in parentheses) were identified: (1) financial stress expressed by participants (acute admission-related and chronic financial stress), (2) challenges associated with accessing and utilizing financial supports (caregiver factors, systemic hospital factors, and systemic government factors), and (3) ideas for financial services at the pediatric hospital (services that will provide acute- and chronic financial assistance including education about financial supports and benefits).

CONCLUSIONS

Our study highlighted acute and chronic financial needs as well as challenges in accessing financial support. Participants were interested in the healthcare system gaining a comprehensive understanding of their financial circumstances and accessing financial services in a hospital setting.

American College of Radiology (ACR) Appropriateness Criteria and EURO-2000 Guidelines Offer Limited Guidance for MRI Imaging of Pediatric Patients

PURPOSE

This study aims to evaluate the clinical scenarios addressed by the EURO-2000 guidelines and the ACR appropriateness criteria for referring children to MRI and assessing the referring physician compliance with both guidelines.

METHODS

In January 2022, clinical scenarios reported in the last 1000 consecutive MRI requests for children (0-16 years) in one university children's hospital and two general university hospitals in Belgium, Europe, were retrospectively matched to the EURO-2000 guidelines and ACR appropriateness criteria. The number of clinical scenarios addressed and the justification for MRI referral were independently assessed for both guidelines. Pooled data from the three centers were evaluated and then analyzed by center, body area and prescriber using McNemar's test for paired proportions and χ2-tests unpaired proportions.

RESULTS

After excluding incomplete or missing MRI requests, 2932 of 3000 requests were included in the analysis. Overall, out of 2932 clinical scenarios, 1229 (37.99%) were addressed by EURO-2000 and 1081 (36.37%) were addressed by the ACR appropriateness criteria (McNemar test, p = 0.12). The proportions of clinical scenarios covered by the two guidelines were statistically similar when comparing centers, but varied across body regions (p < 0.001) and referring physician specialty (p between 0.75 and 0.001). EURO-2000 guidelines provided better coverage for head and spine (p < 0.05), while the ACR appropriateness criteria provided broader coverage for abdomen, pelvis, and musculoskeletal system (p < 0.0001). For addressed clinical scenarios, prescriber compliance for both guidelines was excellent with > 94% of justified MRI examinations in all the centers.

CONCLUSIONS

Both the EURO-2000 guidelines and the ACR appropriateness criteria did not address two-thirds of clinical scenarios in children. Head and neck, chest and abdominal-pelvic examinations are the anatomic regions which should receive a specific attention for the future implementation of evidence-based clinical decision support tools for all referring specialists.

National Trends in Out-of-Pocket Costs Among U.S. Adults With Diabetes Aged 18-64 Years: 2001-2017

OBJECTIVE

To assess national trends in out-of-pocket (OOP) costs among adults aged 18-64 years with diabetes in the U.S.

RESEARCH DESIGN AND METHODS

Using data from the 2001-2017 Medical Expenditure Panel Survey, we estimated total per person annual OOP costs (insurance premiums, prescription drug costs, inpatient and outpatient deductibles, copays, and other payments not covered by insurance) and high OOP cost rate, defined as the percentage of people with OOP spending >10% of their family's pretax income. We examined trends overall, by subgroup (insurance type, income level, insulin use, size of patient's employer, and whether the patient was enrolled in a high deductible health plan), and by type of service. Changes in trends were identified using joinpoint analysis; costs were adjusted to 2017 U.S. dollars.

RESULTS

From 2001 to 2017, OOP costs decreased 4.3%, from $4,328 to $4,139, and the high OOP cost rate fell 32%, from 28 to 19% (P < 0.001). Changes in the high OOP cost rate varied by subgroup, declining among those with public or no insurance and those with an income <200% of the federal poverty level (P < 0.001) but remaining stable among those with private insurance and higher income. Drug prescription OOP costs decreased among all subgroups (P < 0.001). Decreases in total (-$58 vs. -$37, P < 0.001) and prescription (-$79 vs. -$68, P < 0.001) OOP costs were higher among insulin users than noninsulin users.

CONCLUSIONS

OOP costs among U.S. nonelderly adults with diabetes declined, especially among those least able to afford them. Future studies may explore factors contributing to the decline in OOP costs and the impact on the quality of diabetes care and complication rates.

Parent Preferences for Transparency of Their Child's Hospitalization Costs

Importance

Health care in the US is often expensive for families; however, there is little transparency in the cost of medical services. The extent to which parents want cost transparency in their children's care is not well characterized.

Objective

To explore the preferences and experiences of parents of hospitalized children regarding the discussion and consideration of health care costs in the inpatient care of their children.

Design, Setting, and Participants

This cross-sectional multicenter survey study included 6 geographically diverse university-affiliated US children's hospitals from November 3, 2017, to November 8, 2018. Participants included a convenience sample of English- and Spanish-speaking parents of hospitalized children nearing hospital discharge. Data were analyzed from January 1, 2020, to June 25, 2021.

Main Outcomes and Measures

Parents' preferences and experiences regarding transparency of their child's health care costs. Multivariable linear regression examined associations between clinical and sociodemographic variables with parents' preferences for knowing, discussing, and considering costs in the clinical setting. Factors included family financial difficulties, child's level of chronic disease, insurance payer, deductible, family poverty level, race, ethnicity, parental educational level, and study site.

Results

Of 644 invited participants, 526 (82%) were enrolled (290 [55%] male), of whom 362 (69%) were White individuals, 400 (76%) were non-Hispanic/Latino individuals, and 274 (52%) had children with private insurance. Overall, 397 families (75%) wanted to discuss their child's medical costs, but only 36 (7%) reported having a cost conversation. If cost discussions were to occur, 294 families (56%) would prefer to speak to a financial counselor. Ninety-eight families (19%) worried discussing costs would hurt the quality of their child's care. Families with a medical financial burden unrelated to their hospitalized child had higher mean agreement that their child's physician should consider the family's costs in medical decision-making than families without a medical financial burden (effect size, 0.55 [95% CI, 0.18-0.92]). No variables were consistently associated with cost transparency preferences.

Conclusions and Relevance

Most parents want to discuss their child's costs during an acute hospitalization. Discussions of health care costs may be an important, relatively unexplored component of family-centered care. However, these discussions rarely occur, indicating a tremendous opportunity to engage and support families in this issue.

Primary Care Physicians' Strategic Pursuit of Multiple Goals in Cost-of-Care Conversations with Patients

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.

Impact of Cost Conversation on Decision-Making Outcomes

Objective

To understand the impact of cost conversations on the following decision-making outcomes: patients’ knowledge about their conditions and treatment options, decisional conflict, and patient involvement.

Patients and Methods

In 2020 we performed a secondary analysis of a randomly selected set of 220 video recordings of clinical encounters from trials run between 2007 and 2015. Videos were obtained from eight practice-based randomized trials and one pre–post-prospective study comparing care with and without shared decision-making (SDM) tools.

Results

The majority of trial participants were female (61%) and White (86%), with a mean age of 56, some college education (68%), and an income greater than or equal to $40,000 per year (75%), and who did not participate in an encounter aided by an SDM tool (52%). Cost conversations occurred in 106 encounters (48%). In encounters with SDM tools, having a cost conversation lead to lower uncertainty scores (2.1 vs 2.6, P=.02), and higher knowledge (0.7 vs 0.6, P=.04) and patient involvement scores (20 vs 15.7, P=.009) than in encounters using SDM tools where cost conversations did not occur. In a multivariate model, we found slightly worse decisional conflict scores when patients started cost conversations as opposed to when the clinicians started cost conversations. Furthermore, we found higher levels of knowledge when conversations included indirect versus direct cost issues.

Conclusion

Cost conversations have a minimal but favorable impact on decision-making outcomes in clinical encounters, particularly when they occurred in encounters aided by an SDM tool that raises cost as an issue.

Interventions supporting cost conversations between patients and clinicians: A systematic review

BACKGROUND AND AIM

Discussing cost during medical encounters may decrease the financial impact of medical care on patients and align their treatment plans with their financial capacities. We aimed to examine which interventions exist and quantify their effectiveness to support cost conversations.

METHODS

Several databases were queried (Embase; Ovid MEDLINE(R); Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily; the Cochrane databases; and Scopus) from their inception until January 31, 2020 using terms such as "clinician*", "patient*", "cost*", and "conversation*". Eligibility assessment, data extraction and risk of bias assessment were performed independently and in duplicate. We extracted study setting, design, intervention characteristics and outcomes related to patients, clinicians and quality metrics.

RESULTS

We identified four studies (1327 patients) meeting our inclusion criteria. All studies were non-randomised and conducted in the United States. Three were performed in a primary care setting and the fourth in an oncology. Two studies used decision aids that included cost information; one used a training session for health care staff about cost conversations, and the other directly delivered information regarding cost conversations to patients. All interventions increased cost-conversation frequency. There was no effect on out-of-pocket costs, satisfaction, medication adherence or understanding of costs of care.

CONCLUSION

The body of evidence is small and comprised of studies at high risk of bias. However, an increase in the frequency of cost conversations is consistent. Studies with higher quality are needed to ascertain the effects of these interventions on the acceptability, frequency and quality of cost conversations.

Protocol for studying the efficiency of ChemoCalc software in helping patients to understand drug treatment costs for breast cancer: A multicenter, open-label, randomized phase 2 study

Survival of patients with breast cancer can be prolonged by treatment with drugs, particularly new molecular-targeted drugs. However, these agents can be expensive and such treatments can be “an economic burden.” In this ongoing trial, we aim to assess the usefulness of ChemoCalc, a software package for calculating drug costs, to help patients understand the financial outlays. In this multicenter, randomized controlled phase 2 trial, 106 patients with advanced breast cancer will be assigned to either the “ChemoCalc” or “Usual Explanation” group. Treatment using ChemoCalc will be discussed with patients in the ChemoCalc group, whereas standard treatments, without using ChemoCalc, will be discussed with patients in the Usual Explanation group. Subsequently, the participants will decide the treatment and complete a five-grade evaluation questionnaire; those in the Usual Explanation group will receive information about ChemoCalc. Investigators will report if patients subsequently decide to change treatments. The primary endpoint will be the scores of two key questions compared between the groups: “Did you understand the cost of treatment in today's discussion?” and “Do you think the cost of treatment is important in choosing a treatment?“. The secondary endpoints will be to compare discrepancies between treatments recommended by physicians and those selected by patients, the time required for discussion, other questionnaire factors, and the relationship between Comprehensive Score for Financial Toxicity tool and treatment selection. This will be the first randomized controlled trial to assess the efficacy of software to help patients understand drug cost estimates and whether it subsequently affects treatment choice. This study will be conducted according to the CONSORT statement. All participants will sign a written consent form. The study protocol was reviewed and approved by the Clinical Research Review Board of Nagasaki University (19070801). The protocol (version 1) was designed and will be conducted in accordance with the Declaration of Helsinki (1964) and the Ethical Guidelines for Medical and Health Research Involving Human Subjects (2017). The findings will be disseminated through scientific and professional conferences, and in peer-reviewed journals.

Trial registration

UMIN Clinical Trials Registry, UMIN000039904. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000041968

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We aim to verify the efficiency of the drug cost estimation software ChemoCalc

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We will demonstrate whether knowing drug costs will change treatment choice

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We will elucidate whether ChemoCalc will enable patient–physician discussions

Financial Difficulties in Families of Hospitalized Children

BACKGROUND

High costs of hospitalization may contribute to financial difficulties for some families.

OBJECTIVE

To examine the prevalence of financial distress and medical financial burden in families of hospitalized children and identify factors that can predict financial difficulties.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional survey of parents of hospitalized children at six children's hospitals between October 2017 and November 2018.

MAIN OUTCOMES AND MEASURES

The outcomes were high financial distress and medical financial burden. Multivariable logistic regression identified predictors of each outcome. The primary predictor variable was level of chronic disease (complex chronic disease, C-CD; noncomplex chronic disease, NC-CD; no chronic disease, no-CD).

RESULTS

Of 644 invited participants, 526 (82%) were enrolled, with 125 (24%) experiencing high financial distress, and 160 (30%) reporting medical financial burden. Of those, 86 (54%) indicated their medical financial burden was caused by costs associated with their hospitalized child. Neither C-CD nor NC-CD were associated with high financial distress. Child-related medical financial burden was associated with both C-CD and NC-CD (adjusted odds ratio [AOR], 4.98; 95% CI, 2.41-10.29; and AOR, 2.57; 95% CI, 1.11-5.93), compared to no-CD. Although household poverty level was associated with both measures, financial difficulties occurred in all family income brackets.

CONCLUSION

Financial difficulties are common in families of hospitalized children. Low-income families and those who have children with chronic conditions are at particular risk; however, financial difficulties affect all subsets of the pediatric population. Hospitalization may be a prime opportunity to identify and engage families at risk for financial distress and medical financial burden.

The Moral Distress of Nurses When Patients Forgo Treatment Because of Cost

Nursing must recognize an ethical obligation to respond on behalf of these patients.

Problems paying medical bills and mental health symptoms post-Affordable Care Act

Healthcare affordability is a worry for many Americans. We examine whether the relationship between having problems paying medical bills and mental health problems changed as the Affordable Care Act (ACA) was implemented, which increased health insurance coverage. Data from the 2013–2016 Health Reform Monitoring Survey, a survey of Americans aged 18–64, were used. Using zero-inflated negative binomial regression, adjusted for predisposing, enabling, and need factors, we examined differences in days of mental health symptoms by problems paying medical bills (n = 85,430). From 2013 to 2016, the rates of uninsured and problems paying medical bills decreased from 15.1% to 9.0% and 22.0% to 18.6%, respectively. Having one or more days of mental health symptoms increased from 39.3% to 42.9%. Individuals who reported problems paying medical bills had more days of mental health symptoms (Beta = 0.133, p < 0.001) than those who did not have this problem. Insurance was not significantly associated with days of mental health symptoms. Over the 4-year period, there were not significant differences in days of mental health symptoms by problems paying medical bills or insurance status. Despite improvements in coverage, the relationship between problems paying medical bills and mental health symptoms was not modified.

Responsibilities, Strategies, and Practice Factors in Clinical Cost Conversations: a US Physician Survey

BACKGROUND

Physicians play a key role in mitigating and managing costs in healthcare which are rising.

OBJECTIVE

Conduct a cross-sectional survey in 2017, comparing results to a 2012 survey to understand US physicians' evolving attitudes and strategies concerning healthcare costs.

PARTICIPANTS

Random sample of 1200 US physicians from the AMA Masterfile.

MEASURES

Physician views on responsibility for costs of care, enthusiasm for cost-saving strategies, cost-consciousness scale, and practice strategies on addressing cost.

KEY RESULTS

Among 1200 physicians surveyed in 2017, 489 responded (41%). In 2017, slightly more physicians reported that physicians have a major responsibility for addressing healthcare costs (32% vs. 27%, p = 0.03). In 2017, more physicians attributed "major responsibility" for addressing healthcare costs to pharmaceutical companies (68% vs. 56%, p < 0.001) and hospital and health systems (63% vs. 56%%, p = 0.008) in contrast to 2012. Fewer respondents in 2017 attributed major responsibility for addressing costs to trial lawyers (53% vs. 59%, p = 0.007) and patients (42% vs. 52%, p < 0.0001) as compared to 2012. Physician enthusiasm for patient-focused cost-containment strategies like high deductible health plans and higher co-pays (62% vs. 42%, p < 0.0001 and 62% vs. 39%, p < 0.0001, not enthusiastic, respectively) declined. Physicians reported that when they discussed cost, it resulted in a change in disease management 56% of the time. Cost-consciousness within surveyed physicians had not changed meaningfully in 2017 since 2012 (31.7 vs. 31.2). Most physicians continued to agree that decision support tools showing costs would be helpful in their practice (> 70%). After adjusting for specialty, political affiliation, practice setting, age, and gender, only democratic/independent affiliation remained a significant predictor of cost-consciousness.

CONCLUSIONS AND RELEVANCE

US physicians increasingly attribute responsibility for rising healthcare costs to organizations and express less enthusiasm for strategies that increase patient out-of-pocket cost. Interventions that focus on physician knowledge and communication strategies regarding cost of care may be helpful.

Presence of Any Medical Debt Associated With Two Additional Years of Homelessness in a Seattle Sample

Although medical debt has been associated with housing instability, almost no research has connected homelessness to medical debt. We interviewed 60 individuals experiencing homelessness in Seattle, selected from those participating in self-governed encampments organized by a homeless advocacy organization. Most respondents reported having at least one kind of debt, with two-thirds reporting current medical debt. Almost half reported trouble paying medical bills for themselves or family members. Almost one-third believed medical debt was in part responsible for their current housing situation. More than half with medical debt incurred this debt while they were covered under insurance. People who had trouble paying medical bills experienced a more recent episode of homelessness 2 years longer than those who did not have such trouble, even after controlling for race, education, age, gender, and health status. People of color who had trouble paying medical bills reported almost 1 year more homelessness than whites.

Cumulative Burden of Financial Hardship From Medical Bills Across the Spectrum of Diabetes Mellitus and Atherosclerotic Cardiovascular Disease Among Non-Elderly Adults in the United States

Background Atherosclerotic cardiovascular disease (ASCVD) has a strong association with diabetes mellitus (DM), accounting for approximately two thirds of deaths in this patient population. Many individuals with ASCVD and DM are vulnerable to financial hardship associated with treatment-related expenses. Therefore, we examined the burden of financial hardship from medical bills across the spectrum of ASCVD status with and without DM. Methods and Results Using data from the National Health Interview Survey from 2013 to 2017, we used logistic regression analysis to examine the association of ASCVD and DM status with financial hardship and an inability to pay medical bills from a representative sample of non-elderly adults in the United States. Our study population consisted of 121 672 individuals. Approximately 3.1% of the weighted population had ASCVD, 5.6% had DM, and 1.3% had both ASCVD and DM. Nearly 50% of individuals with ASCVD and DM reported financial hardship from medical bills (23% being unable to pay medical bills at all), whereas ≈28% of those with neither ASCVD nor DM reported financial hardship from medical bills (8% being unable to pay medical bills at all). Individuals with concurrent ASCVD and DM had the highest relative odds of expressing an inability to pay at all when compared with those with neither condition (odds ratio, 2.69; 95% CI, 2.21-3.28). Conclusions Individuals with concurrent ASCVD and DM are at a disproportionately high risk of being unable to pay their medical bills. The findings provide strong evidence for developing more effective public health policies that protect vulnerable populations from financial hardship.

Study protocol: CareAvenue program to improve unmet social risk factors and diabetes outcomes- A randomized controlled trial

Despite the burdens costs can place on adults with diabetes, few evidence-based, scalable interventions have been identified that address prevalent health-related financial burdens and unmet social risk factors that serve as major obstacles to effective diabetes management. In this study, we will test the effectiveness of CareAvenue - an automated e-health tool that screens for unmet social risk factors and informs and activates individuals to take steps to connect to resources and engage in self-care. We will determine the effectiveness of CareAvenue relative to standard care with respect to improving glycemic control and patient-centered outcomes such as cost-related non-adherence (CRN) behaviors and perceived financial burden. We will also examine the role of patient risk factors (moderators) and behavioral factors (mediators) on the effectiveness of CareAvenue in improving outcomes. We will recruit 720 patients in a large health system with uncontrolled Type 1 diabetes mellitus (T1DM) or Type 2 diabetes mellitus (T2DM) who engage in CRN or perceive financial burden. Participants will be randomized to one of two arms: 1) receipt of a 15-20 min web-based program with routine follow-up (CareAvenue); or 2) receipt of contact information for existing health system assistance services. Outcomes will be assessed at baseline and 6- and 12-month follow-up. Clinical Trial Registration: ClinicalTrials.gov ID NCT03950973, May 2019.

Discussing Out-of-Pocket Costs With Patients: Shared Decision Making for Sacubitril-Valsartan in Heart Failure

Background

“Financial toxicity” is a concern for patients, but little is known about how patients consider out‐of‐pocket cost in decisions. Sacubitril‐valsartan provides a contemporary scenario to understand financial toxicity. It is guideline recommended for heart failure with reduced ejection fraction, yet out‐of‐pocket costs can be considerable.

Methods and Results

Structured interviews were conducted with 49 patients with heart failure with reduced ejection fraction at heart failure clinics and inpatient services. Patient opinions of the drug and its value were solicited after description of benefits using graphical displays. Descriptive quantitative analysis of closed‐ended responses was conducted, and qualitative descriptive analysis of text data was performed. Of participants, 92% (45/49) said that they would definitely or probably switch to sacubitril‐valsartan if their physician recommended it and out‐of‐pocket cost was $5 more per month than their current medication. Only 43% (21/49) would do so if out‐of‐pocket cost was $100 more per month (P<0.001). At least 40% across all income categories would be unlikely to take sacubitril‐valsartan at $100 more per month. Participants exhibited heterogeneous approaches to cost in decision making and varied on their use and interpretation of probabilistic information. Few (20%) participants stated physicians had initiated a conversation about cost in the past year.

Conclusions

Out‐of‐pocket cost variation reflective of contemporary cost sharing substantially influenced stated willingness to take sacubitril‐valsartan, a guideline‐recommended therapy with mortality benefit. These findings suggest a need for cost transparency to promote shared decision making. They also demonstrate the complexity of cost discussion and need to study how to incorporate out‐of‐pocket cost into clinical decisions.

U.S. Internists' Perspectives on Discussing Cost of Care With Patients: Structured Interviews and a Survey

BACKGROUND

Rising out-of-pocket costs are creating a need for cost conversations between patients and physicians.

OBJECTIVE

To understand the factors that influence physicians to discuss and consider cost during a patient encounter.

DESIGN

Mixed-methods study using semistructured interviews and a survey.

SETTING

United States.

PARTICIPANTS

20 internal medicine physicians were interviewed; 621 internal medicine physician members of the American College of Physicians completed the survey.

MEASUREMENTS

Interviews were analyzed by using thematic analysis, and surveys were analyzed by using descriptive statistics.

RESULTS

From the interviews, 4 themes were identified: Physicians are 1) aware that patients are struggling to afford medical care; 2) relying on clues from patients that hint at their cost sensitivity; 3) relying on experience to anticipate potentially high-cost treatments; and 4) aware that patients are making financial trade-offs to afford their care. Three quarters (n = 466) of survey respondents stated that they consider out-of-pocket costs when making most clinical decisions. For 31% (n = 191) of participants, there were times in the past year that they wanted to discuss out-of-pocket prescription drug costs with patients but did not. The most influential factors for ordering a test are the desire to be as thorough as possible (71% [n = 422]) and insurance coverage for the test (68% [n = 422]).

LIMITATION

Findings are self-reported, the sample is limited to a single specialty, the survey response rate was low, information on the patient population was limited, and the survey instrument is not validated.

CONCLUSION

Physicians are attuned to the burden of health care costs and are willing to consider alternative options based on a patient's cost sensitivity.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

Community-Designed Messaging Interventions to Improve Cost-of-Care Conversations in Settings Serving Low-Income, Latino Populations

BACKGROUND

Little is known about how to promote cost-of-care conversations in health care settings.

OBJECTIVE

To develop and evaluate community-designed messages promoting cost-of-care conversations.

DESIGN

Focus groups and point-of-care surveys.

SETTING

Three pediatric clinics, a family community health clinic, and a community health worker (promotora) program serving predominately low-income, Latino populations in Adams County, Colorado.

PARTICIPANTS

Focus groups included staff (n = 22) and patients or community members (n = 15). At baseline, 107 patients and 9 providers completed surveys, and 111 patients and 11 providers did so postintervention.

INTERVENTION

Setting-specific, community-designed messages about cost-of-care conversations delivered to patients on fliers.

MEASUREMENTS

Qualitative themes about the frequency and nature of cost-of-care conversations, and frequencies of patient- and provider-reported cost-of-care conversations before and after the intervention.

RESULTS

Five themes emerged from the focus groups, and the groups reported more discussion of costs after distribution of the messaging interventions than before in the clinical but not the community setting. Lack of transparent pricing tools was a barrier, and consideration of incidental costs was important. In cross-sectional, point-of-care surveys, fewer patients reported talking about costs with providers at baseline (44.4%) than after the messaging intervention (73.7%). Providers reported similar frequency of talking about costs with patients before (41.0%) and after (44.9%) the intervention. Nearly one third of patient and provider reports were discordant regarding whether costs were discussed.

LIMITATIONS

The response rate was low, cost-of-care conversations were self-reported, generalizability of the findings to other settings is uncertain, and the sample was small. The survey proved infeasible in the promotora setting.

CONCLUSION

Participants reported some favorable perceptions of cost-of-care conversations after implementation of community-designed messages, suggesting promise for this approach to promoting conversations about costs of care in settings serving low-income, uninsured Latino populations.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

The Impact of Cost Conversations on the Patient-Physician Relationship

Previous research has suggested that fear of harm to the patient-physician relationship is an important barrier to conversations about cost of care. However, few experimental studies have investigated the effects of cost of care conversations on the patient-physician relationship, particularly from the patient's perspective. In the current research, we take an experimental approach to investigate patients' attitudes and preferences for a hypothetical physician who discusses cost versus one who does not. Across three studies, using data from both the general population and cancer patients, we find that people prefer a hypothetical physician who discusses cost over one who does not (Pilot Study, Studies 1 and 2). In addition, we find that people use cost information to inform their hypothetical treatment decisions without changing their attitudes toward the physician who includes this information (Study 1). Finally, we examine how and when cost information compares to more traditional medical information (e.g., side effects; Study 2). We discuss the implications of this research for cost communications and the patient-physician relationship, highlighting that cost conversations may not be as harmful as previously thought.

Discussing Health Care Expenses in the Oncology Clinic: Analysis of Cost Conversations in Outpatient Encounters

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.

Solutions to Address Diabetes-Related Financial Burden and Cost-Related Nonadherence: Results From a Pilot Study

BACKGROUND

Cost-related nonadherence (CRN) to recommended self-management behaviors among adults with chronic conditions such as diabetes is prevalent. Few behavioral interventions to mitigate CRN have been tested and evaluated.

AIMS

We developed a financial burden resource tool and examined its acceptability and the preliminary effects on patient-centered outcomes among adults with diabetes or prediabetes seen in a clinical setting.

METHOD

We report a pre-post one-group design pilot study. From an endocrinology clinic, we recruited 104 adults with diabetes who reported financial burdens with their diabetes management or engaged in CRN behaviors. We offered participants the financial burden resource tool we developed, which provided tailored, low-cost resource options for diabetes management and other social needs. Acceptability and self-reported outcomes were assessed 2 months after use of the tool.

RESULTS

Mean age of participants was 50.5 years ( SD = 15.3). Participants found the tool highly acceptable across 15 indicators (e.g., 93% "learned a lot," 98% "topics relevant" 95% "applicable to their lives," 98% "liked the information"). Significant improvements between baseline and 2-month follow-up were observed for discussion of cost concerns with nurses (19% to 29%, p < .05) and pharmacists (13% to 25.5%, p < .01), not skipping doses of medicines due to cost (11% to 4%, p < .03), and financial management (33.83 to 39.62, p < .007). There were no significant changes in perception of financial burden.

CONCLUSION

A financial burden resource tool is highly acceptable to patients, is easy to administer, and can prompt behavior change. This pilot study supports the need for well-powered trials with longer follow-up to further evaluate the effectiveness of such tools in improving CRN and key outcomes.

Patient-physician discussions about costs: definitions and impact on cost conversation incidence estimates

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.

What Strategies Do Physicians and Patients Discuss to Reduce Out-of-Pocket Costs? Analysis of Cost-Saving Strategies in 1,755 Outpatient Clinic Visits

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.