The 7 Habits of Highly Effective Cost-of-Care Conversations
Authors: Caroline E. Sloan, Peter A. Ubel
Journal: Annals of Internal Medicine (2019)

Supplement: Cost-of-Care Conversations7 May 2019The 7 Habits of Highly Effective Cost-of-Care ConversationsFREECaroline E. Sloan, MD and Peter A. Ubel, MDCaroline E. Sloan, MDDuke University School of Medicine, Durham, North Carolina (C.E.S.) and Peter A. Ubel, MDFuqua School of Business, Duke University, Durham, North Carolina (P.A.U.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-0537 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Out-of-pocket expenditures have increased rapidly in the United States over the past decade. In 2018, 29% of people with private insurance were enrolled in high-deductible health plans, compared with just 4% in 2006 (1, 2). Out-of-pocket costs are high for many publicly insured people, too. Medicare beneficiaries with cancer who do not have supplemental insurance, for instance, face average out-of-pocket costs of $8115 per year, equivalent to 24% of their household income (3). As a result, more than one quarter of Americans have trouble paying their medical bills (4). Increased out-of-pocket expenses are associated with lower adherence, delayed or forgone care, and higher mortality (5, 6). One survey published in this supplement reports that 86% to 95% of a representative sample of internists are aware of patients in their panel going without medical care because of cost (7).Given these financial burdens, and the impact they have on people's medical care, health care providers need to talk to their patients about out-of-pocket costs (8). But what are the best ways to engage in cost-of-care conversations? The 8 studies published in this supplement provide early evidence for best practices and have inspired us to propose 7 (preliminary) habits of what we hope will be highly effective cost-of-care conversations.1. You Won't Know If You Don't AskMany physicians report initiating cost-of-care conversations only when they sense patients are having financial difficulties. In an online survey, Perez and colleagues (7) found that fewer than one half of responding internists initiated conversations about out-of-pocket expenses "frequently." In-depth interviews of 20 internists confirmed that many relied on such "clues" as poor adherence, care delays, poorly controlled chronic disease, or direct mention of financial struggles when deciding whether to bring up costs during clinic visits. But this method often fails to catch patients with significant financial burdens.One physician gave an illuminating—and familiar—example: "[I'll] say you know, your numbers come back, and your diabetes isn't doing well. I'm surprised that the medicines I put you on aren't helping. And at that point, and only at that point, the patient says, 'well, I haven't been taking those new medicines because I couldn't afford them.' So, you've wasted months and months and months, and several office visits, just to find out the patient couldn't afford the medicines." It is clearly time for physicians to screen for health care–related financial hardship in a systematic way.2. Discuss the Cost PrognosisPhysicians regularly communicate prognostic information so that patients can make informed decisions and plan for the future. By the same token, we must keep patients apprised of their financial prognoses, so they can anticipate future expenses.Erwin and coworkers (9) interviewed 20 patients and 16 clinicians in a prenatal clinic that serves a predominantly low-income, nonwhite population in Chicago. The discordance of views about cost-of-care conversations was striking. Although physicians recognized that out-of-pocket expenses were a major problem, several were reluctant to talk about them, worrying that discussion of costs would lead patients to skip tests, avoid care, or even end their pregnancies. In contrast, patients thought cost-of-care conversations early in prenatal care would help them plan for the future and would increase their adherence to care plans. It was precisely patients' limited knowledge about future costs that often led them to forgo care.Pisu and associates (10) surveyed 62 patients and providers in a breast cancer survivor clinic that serves an older, predominantly white and educated population. Again, patients were clear: Discussions of costs and payment options should occur early in cancer care. Rather than deterring patients from effective treatments, or creating the perception that providers are trying to ration care, these conversations increase awareness of available resources and increase patients' ability to plan for what will likely be expensive treatments.Patients' desires for regular cost-of-care conversations are consistent throughout the studies presented in this supplement and in the prior literature (9–12). We must consider financial burden as one of the many side effects of medical treatment and help prevent it as much as possible.3. You Can Anticipate Many, If Not All, CostsMany physicians think of diagnostic tests, procedures, and drugs as the main drivers of burdensome costs (7, 9, 10). They object that cost-of-care conversations are not useful, because it is nearly impossible to anticipate out-of-pocket expenses (12), even with the recent advent of cost transparency Web sites and apps. The patient interviews in Erwin and colleagues' study (9), however, revealed that many patients are mainly concerned with the indirect costs of appointments: lost income, transportation, and child care, among others. Costs—and stress—increase when appointments increase in frequency, or run long. The authors estimate that financial loss associated with the indirect costs of prenatal care amounts to $2500 to $2800.In frank discussions with patients, it should often be possible to anticipate many of these costs and develop plans for addressing them.4. Be Systematic: Make Explorations of Out-of-Pocket Costs RoutineSeveral studies reported in this supplement implemented preliminary interventions aimed at systematically initiating cost-of-care conversations in the clinic. Mader and coworkers (13) enlisted staff from a pediatric clinic, a family community health clinic, and a community health worker program serving a primarily Latino population in Colorado. Staff members gave patients information about health insurance availability, local health-related resources, and tools for initiating cost-of-care conversations in the clinic. After the intervention, patients perceived an increase in cost-of-care conversations (44% to 65%) and a reduction in cost concerns (53% to 36%). Providers also felt more comfortable with cost-of-care conversations.Fox and associates (11) provided 6 primary care practices in Maine with assistance using CompareMaine.org, a cost and quality transparency Web site, during clinic visits for low back pain. Interviews with 113 clinic staff, physicians and patients 6 months later revealed that use of the tool increased, but not by much. Because providers were directed to use the online tool only during visits for low back pain, few integrated cost-of-care conversations into their daily routine. Without systematic integration into clinic workflow, this cost transparency tool was not used to its full potential.A cost-conversation screening system could quickly determine whether any problems exist, get around the shame that many patients feel about their financial difficulties (8), and clarify whom patients feel most comfortable speaking to—clinicians or ancillary staff (10).5. Integrate Cost Conversations Into Your Workflow in a Way That Works for YouTwo studies in this supplement provide suggestions for integrating cost-of-care conversations into the workflow, often by involving ancillary staff as much as possible (14, 15).Henrikson and colleagues (14) observed 19 patient–staff interactions in 2 Kaiser Permanente health systems to understand how cost-of-care conversations were integrated into workflows. Unsurprisingly, when patients needed financial assistance, various staff members resorted to researching insurance contracts, calling people in other departments, and using other creative workarounds.Clinic staff suggested 3 potentially effective strategies for more smoothly integrating cost-of-care conversations into clinic workflow: 1) Give one person the role of out-of-pocket cost problem-solver, so they can develop expertise and efficiency; 2) use the electronic health record (EHR) to document patients' financial needs; and 3) use the EHR to gather data on costs and/or insurance coverage, when available. Staff members did not necessarily think that physicians needed to take the lead in these efforts. According to other studies in this supplement, patients agree; many would be just as happy speaking with ancillary staff about costs.In an attempt to systematize cost-of-care conversations in the clinic, Carroll and coworkers (15) conducted a simple 60-minute training for clinicians and staff at 7 primary care practices that serve primarily privately insured, white, middle-income patients. The training addressed the importance of cost-of-care conversations and suggested screening methods and cost-saving strategies. Each clinic could integrate cost conversations into their workflow in their own way. Some had nurses screen for financial difficulties during triage; others had physicians screen during medication reconciliation. Most practices involved ancillary staff to some extent. Patient interviews before and after the intervention revealed that cost-of-care conversations increased from 17% to 32%. In addition, about one half of patients tried out the cost reduction strategies their physicians suggested.6. Enlist Your Ancillary StaffA common theme throughout most of the studies in this supplement is the value of ancillary staff—medical assistants, nurses, front desk staff, and financial counselors—in cost-of-care conversations. In addition to having more flexibility to incorporate cost-of-care conversations into their daily workflow (14, 15), their views on cost-of-care conversations often align much more closely than those of physicians with patients' views (9, 10).These findings are supported by Bradham and associates (16), who hired 5 observers to follow a convenience sample of 67 patients throughout their clinical encounters, from triage to check-out, at 2 Federally Qualified Health Centers in Texas and Pennsylvania. Although only 21% of patients discussed costs with their clinicians, 43% engaged in cost-of-care conversations at some point during their visit—typically with ancillary staff (4). These conversations are clearly already happening, so it makes sense to incorporate them into the workflow in a systematic way.7. It Gets Easier, and BetterThe studies in this supplement show us that as physicians have more cost-of-care conversations, they get better at them. Physicians who have more frequent cost-of-care conversations take costs into account more frequently when making medical decisions (7), and those who use online tools, such as CompareMaine.org, become more efficient users (16).Cost-conversation practice certainly will not make us perfect, given the logistical and informational barriers that exist. However, it will move us closer to the kind of patient-centered care that characterizes the ideals of our profession.References1. Kaiser Family Foundation. Employer health benefits: 2016 annual survey. 2016. Accessed at http://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2016 on 12 March 2019. Google Scholar2. Kaiser Family Foundation. Employer health benefits: 2018 annual survey. 2018. Accessed at http://files.kff.org/attachment/Report-Employer-Health-Benefits-Annual-Survey-2018 on 11 March 2019. Google Scholar3. Narang AK, Nicholas LH. Out-of-pocket spending and financial burden among Medicare beneficiaries with cancer. JAMA Oncol. 2017;3:757-65. [PMID: 27893028] doi:10.1001/jamaoncol.2016.4865 CrossrefMedlineGoogle Scholar4. Hunter WG, Zhang CZ, Hesson A, Davis JK, Kirby C, Williamson LD, et al. What strategies do physicians and patients discuss to reduce out-of-pocket costs? Analysis of cost-saving strategies in 1,755 outpatient clinic visits. Med Decis Making. 2016;36:900-10. [PMID: 26785714] doi:10.1177/0272989X15626384 CrossrefMedlineGoogle Scholar5. Dusetzina SB, Winn AN, Abel GA, Huskamp HA, Keating NL. Cost sharing and adherence to tyrosine kinase inhibitors for patients with chronic myeloid leukemia. J Clin Oncol. 2014;32:306-11. [PMID: 24366936] doi:10.1200/JCO.2013.52.9123 CrossrefMedlineGoogle Scholar6. Tipirneni R, Politi MC, Kullgren JT, Kieffer EC, Goold SD, Scherer AM. Association between health insurance literacy and avoidance of health care services owing to cost. JAMA Netw Open. 2018;1:e184796. [PMID: 30646372] doi:10.1001/jamanetworkopen.2018.4796 CrossrefMedlineGoogle Scholar7. Perez SL, Weissman A, Read S, Smith CD, Colello L, Peter D, et al. U.S. internists' perspectives on discussing cost of care with patients: structured interviews and a survey. Ann Intern Med. 2019;170:S39-45. doi:10.7326/M18-2136 LinkGoogle Scholar8. Ubel PA, Abernethy AP, Zafar SY. Full disclosure—out-of-pocket costs as side effects. N Engl J Med. 2013;369:1484-6. [PMID: 24131175] doi:10.1056/NEJMp1306826 CrossrefMedlineGoogle Scholar9. Erwin K, Fitzpatrick V, Norell S, Gilliam M. Development of a framework and tool to facilitate cost-of-care conversations with patients during prenatal care. Ann Intern Med. 2019;170:S62-9. doi:10.7326/M18-2207 LinkGoogle Scholar10. Pisu M, Schoenberger YM, Herbey I, Brown-Galvan A, Liang MI, Riggs K, et al. Perspectives on conversations about costs of cancer care of breast cancer survivors and cancer center staff. A qualitative study. Ann Intern Med. 2019;170:S54-61. doi:10.7326/M18-2117 LinkGoogle Scholar11. Fox KS, Gray CE, ElbaumWilliamson M, MacKenzie JA. Using public cost information during low back pain visits. A qualitative study. Ann Intern Med. 2019;170:S93-102. doi:10.7326/M18-2223 LinkGoogle Scholar12. Kim SY, Shin DW, Park B, Cho J, Oh JH, Kweon SS, et al. Cancer cost communication: experiences and preferences of patients, caregivers, and oncologists—a nationwide triad study. Support Care Cancer. 2018;26:3517-26. [PMID: 29696426] doi:10.1007/s00520-018-4201-6 CrossrefMedlineGoogle Scholar13. Mader K, Sammen JM, Klene C, Nguyen J, Simpson M, Roland SL, et al. Community-designed messaging interventions to improve cost-of-care conversations in settings serving low-income, Latino populations. Ann Intern Med. 2019;170:S79-86. doi:10.7326/M18-2140 LinkGoogle Scholar14. Henrikson NB, Banegas MP, Tuzzio L, Lim C, Schneider JL, Walsh-Bailey C, et al. Workflow requirements for cost-of-care conversations in outpatient settings providing oncology or primary care. A qualitative, human-centered design study. Ann Intern Med. 2019;170:S70-8. doi:10.7326/M18-2227 LinkGoogle Scholar15. Carroll JK, Farah S, Fortuna RJ, Lanigan AM, Sanders M, Venci JV, et al. Addressing medication costs during primary care visits: a before–after study of team-based training. Ann Intern Med. 2019;170:S46-53. doi:10.7326/M18-2011 LinkGoogle Scholar16. Bradham DD, Garcia D, Galván A, Erb C. Cost-of-care conversations during clinical visits in federally qualified health centers. An observational study. Ann Intern Med. 2019;170:S87-92. doi:10.7326/M18-1608 LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Duke University School of Medicine, Durham, North Carolina (C.E.S.)Fuqua School of Business, Duke University, Durham, North Carolina (P.A.U.)Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-0537.Corresponding Author: Caroline E. Sloan, MD, Duke University Hospital, 2301 Erwin Road, Durham, NC; e-mail, caroline.[email protected]edu.Current Author Addresses: Dr. Sloan: Duke University Hospital, 2301 Erwin Road, Durham, NC 27710.Dr. Ubel: The Fuqua School of Business, 100 Fuqua Drive, Durham, NC 27708.This article is part of the Annals supplement "Fostering Productive Health Care Cost Conversations: Sharing Lessons Learned and Best Practices." The Robert Wood Johnson Foundation provided funding for publication of this supplement. Nextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoPerspectives on Conversations About Costs of Cancer Care of Breast Cancer Survivors and Cancer Center Staff Maria Pisu , Yu-Mei Schoenberger , Ivan Herbey , Aquila Brown-Galvan , Margaret I. Liang , Kevin Riggs , and Karen Meneses U.S. Internists' Perspectives on Discussing Cost of Care With Patients: Structured Interviews and a Survey Susan L. Perez , Arlene Weissman , Susan Read , Cynthia Daisy Smith , Lisa Colello , Doris Peter , and Wendy Nickel Cost-of-Care Conversations During Clinical Visits in Federally Qualified Health Centers Douglas D. Bradham , Deliana Garcia , Alma Galván , and Corey Erb Development of a Framework and Tool to Facilitate Cost-of-Care Conversations With Patients During Prenatal Care Kim Erwin , Veronica Fitzpatrick , Sarah Norell , and Melissa Gilliam Using Public Cost Information During Low Back Pain Visits Kimberley S. Fox , Carolyn E. Gray , Martha Elbaum Williamson , and Jennifer A. MacKenzie Workflow Requirements for Cost-of-Care Conversations in Outpatient Settings Providing Oncology or Primary Care Nora B. Henrikson , Matthew P. Banegas , Leah Tuzzio , Catherine Lim , Jennifer L. Schneider , Callie Walsh-Bailey , Aaron Scrol , and Stephanie M. Hodge Addressing Medication Costs During Primary Care Visits: A Before–After Study of Team-Based Training Jennifer K. Carroll , Subrina Farah , Robert J. Fortuna , Angela M. Lanigan , Mechelle Sanders , Jineane V. Venci , and Kevin Fiscella Community-Designed Messaging Interventions to Improve Cost-of-Care Conversations in Settings Serving Low-Income, Latino Populations Kari Mader , Joseph M. Sammen , Christopher Klene , Jessica Nguyen , Matthew Simpson , Sandra L. Ruland , and John M. Westfall Tools to Help Overcome Barriers to Cost-of-Care Conversations C. Jessica Dine , Domitilla Masi , and Cynthia D. Smith Metrics Cited byDiscussing Cost and Value in Patient Decision Aids and Shared Decision Making: A Call to ActionLeveraging Telemedicine to Reduce the Financial Burden of Asthma CareInterventions to address cancer‐related financial toxicity: Recommendations from the fieldHow can healthcare organizations improve cost-of-care conversations? 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Preferences of Two Distinct Cancer Survivor GroupsUsing Shared Decision-Making Tools and Patient-Clinician Conversations About CostsFactors Associated With Oncologist Discussions of the Costs of Genomic Testing and Related TreatmentsEffective Cost Conversations: Addressing Financial Toxicity and Cost-Related Health LiteracyHealth Insurance Affordability Concerns and Health Care Avoidance Among US Adults Approaching Retirement 7 May 2019Volume 170, Issue 9_SupplementPage: S33-S35KeywordsElectronic medical recordsForecastingHabitsHealth care providersHealth insuranceLower back painPatient advocacyPatientsPrevention, policy, and public healthTriage ePublished: 7 May 2019 Issue Published: 7 May 2019 PDF downloadLoading ...