Tools to Help Overcome Barriers to Cost-of-Care Conversations
Authors: C. Jessica Dine, Domitilla Masi, Cynthia D. Smith
Journal: Annals of Internal Medicine (2019)

Supplement: Cost-of-Care Conversations7 May 2019Tools to Help Overcome Barriers to Cost-of-Care ConversationsFREEC. Jessica Dine, MD, MSHP, Domitilla Masi, MS, and Cynthia D. Smith, MDC. Jessica Dine, MD, MSHPPerelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (C.J.D.), Domitilla Masi, MSAvalere Health, Washington, DC (D.M.), and Cynthia D. Smith, MDAmerican College of Physicians, Philadelphia, Pennsylvania (C.D.S.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-0778 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Many Americans experience financial distress as a result of medical care. Unfortunately, average out-of-pocket costs are rising. In 2015, 24% of Americans with employer-sponsored health insurance spent over $1000 in out-of-pocket costs, compared with 17% in 2005, and these numbers continue to grow (1). In addition to out-of-pocket costs, patients experience nonmedical costs related to their care, such as transportation, childcare, and lost wages, while still having to meet basic needs, such as food, utilities, and housing.Financial issues can be associated with considerable psychological distress in patients, including anxiety, depression, and decreased quality of life (2). Financial distress due to health care costs have also been negatively associated with adherence to care and, thus, patient outcomes. For example, 35% of American adults younger than 64 years reported not getting needed medical care because of out-of-pocket costs (3). Even though both patients and physicians have expressed a desire to talk about the cost of medical care, these cost conversations do not occur as often as they should (4). As part of the Robert Wood Johnson Foundation's (RWJF) Cost Conversation Projects, the American College of Physicians (ACP) partnered with RWJF, America's Essential Hospitals, Avalere Health, the National Patient Advocate Foundation, and 8 research grantees (whose research is included in this supplement) (5–12) to develop resources for clinicians to support conversations with patients about the expected costs of their care.Patients and physicians have identified several barriers to having conversations about cost, including difficulty identifying patients with financial distress, insufficient time and expertise, lack of awareness of available resources, lack of knowledge about the costs of specific tests and treatments, difficulty estimating the total costs of a care plan, difficulty estimating nonmedical costs associated with care, and discomfort initiating and conducting conversations about costs of care (13). In addition to ACP's existing educational resources on high-value care (www.acponline.org/hvc), the ACP has developed several free and publicly available tools to address these barriers (Table 1) that are located at the ACP resource page at www.acponline.org/costofcare.Table 1. Free and Publicly Available Tools Developed by the ACP to Address Barriers to Cost-of-Care Conversations Between Clinicians and Patients (www.acponline.org/costofcare)The 8 projects described in the articles in this supplement also led to the development of additional tools and resources for both clinicians and patients (Table 2). The tools can be found on America's Essential Hospitals' new online library at http://TalkCostofCare.org. The site helpfully organizes the tools and resources into 6 categories. Like ACP's tools, these can be modified to fit specific circumstances. Readers may find the Practice Briefs category particularly useful, because these provide a synthesis of the research conducted, as well as action steps that can be undertaken to improve cost-of-care conversations.Table 2. Additional Tools Intended to Aid Cost-of Care Conversations Between Patients and Clinicians, Available on America's Essential Hospitals' Online Library (TalkCostofCare.org)Increasing health care costs and increased cost sharing can present greater financial burden and associated distress for patients. Although patients and physicians would like to discuss the costs of care, these conversations do not occur frequently or in an organized manner. The resources provided through this RWJF initiative may help clinicians and patients have more routine, efficient, and helpful discussions about the cost of care in the clinical setting. Identifying and addressing health care–related cost distress holds promise to improve patient outcomes.References1. Kaiser Family Foundation. Accessed at www.kff.org on 26 February 2019. Google Scholar2. Delgado-Guay M, Ferrer J, Rieber AG, Rhondali W, Tayjasanant S, Ochoa J, et al. Financial distress and its associations with physical and emotional symptoms and quality of life among advanced cancer patients. Oncologist. 2015;20:1092-8. [PMID: 26205738] doi:10.1634/theoncologist.2015-0026 CrossrefMedlineGoogle Scholar3. Commonwealth Fund. Fewer adults report not getting needed care because of costs, but gains have stalled in recent years. 7 February 2019. Accessed at www.commonwealthfund.org/chart/2019/fewer-adults-report-not-getting-needed-care-because-costs-gains-have-stalled-recent on 19 February 2019. Google Scholar4. Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA. 2003;290:953-8. [PMID: 12928475] CrossrefMedlineGoogle Scholar5. 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-S45. doi:10.7326/M18-2136 LinkGoogle Scholar6. 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 Scholar7. 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 Scholar8. 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 Scholar9. 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 Scholar10. 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 Scholar11. 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 Scholar12. 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 Scholar13. Alexander GC, Casalino LP, Tseng CW, McFadden D, Meltzer DO. Barriers to patient-physician communication about out-of-pocket costs. J Gen Intern Med. 2004;19:856-60. [PMID: 15242471] CrossrefMedlineGoogle Scholar14. de Souza JA, Yap BJ, Hlubocky FJ, Wroblewski K, Ratain MJ, Cella D, et al. The development of a financial toxicity patient-reported outcome in cancer: the COST measure. Cancer. 2014;120:3245-53. [PMID: 24954526] doi:10.1002/cncr.28814 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (C.J.D.)Avalere Health, Washington, DC (D.M.)American College of Physicians, Philadelphia, Pennsylvania (C.D.S.)Disclosures: Dr. Dine reports being a consultant for ACP during the conduct of the study. Ms. Masi reports grants from the RWJF during the conduct of the study. Dr. Smith reports grants from the RWJF during the conduct of the study and other from Merck & Co. outside the submitted work. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-0778.Corresponding Author: C. Jessica Dine, MD, MSHP, Hospital of the University of Pennsylvania, 8 Gates, 3400 Spruce Street, Philadelphia, PA 19104; e-mail, Constance.[email protected]upenn.edu.Current Author Addresses: Dr. Dine: Hospital of the University of Pennsylvania, 8 Gates, 3400 Spruce Street, Philadelphia, PA 19104.Ms. Masi: Avalere Health, 1350 Connecticut Avenue NW, Washington, DC 20036.Dr. Smith: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.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. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAddressing 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 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 Perspectives 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 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 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 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 Cost-of-Care Conversations During Clinical Visits in Federally Qualified Health Centers Douglas D. Bradham , Deliana Garcia , Alma Galván , and Corey Erb Using Public Cost Information During Low Back Pain Visits Kimberley S. Fox , Carolyn E. Gray , Martha Elbaum Williamson , and Jennifer A. MacKenzie The 7 Habits of Highly Effective Cost-of-Care Conversations Caroline E. Sloan and Peter A. Ubel Metrics Cited byEffects of Real-time Prescription Benefit Recommendations on Patient Out-of-Pocket CostsPatient cost consciousness in the emergency departmentFactors associated with cost conversations in oral health care settingsHow can healthcare organizations improve cost-of-care conversations? A qualitative exploration of clinicians' perspectivesEquity in Medical Care for People Living With DiabetesRacial and ethnic differences in cost-of-care conversations among older adultsFinancial Hardship Among Nonelderly Adults With CKD in the United StatesPolicy in Clinical Practice: Hospital Price TransparencyDefining the clinician's role in mitigating financial toxicity: an exploratory studyFinancial Toxicity in Atherosclerotic Cardiovascular Disease in the United States: Current State and Future DirectionsHow do health care experiences of the seriously ill differ by disease? 7 May 2019Volume 170, Issue 9_SupplementPage: S36-S38KeywordsDisclosureFoodHealth careHealth insuranceLibrariesPatient advocacyPatientsQuality of lifeResearch grantsYoung adults ePublished: 7 May 2019 Issue Published: 7 May 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...