Discussing costs of care with patients

If patients are complaining that they’re paying more for their healthcare than in the past, it’s because they probably are. Between 2006 and 2016, employees paid 8.2 percent more than their salary increase for employer-sponsored insurance, and their out-of-pocket costs rose by 53.5 percent, according to the Economic Policy Institute.

Whether or not patients share cost concerns with physicians, financial issues are a growing part of healthcare decision-making. Many patients would like to talk with physicians about those costs.

Until recently, physicians have been wary about these discussions. But the landscape has shifted in the last decade as health plans have steadily raised deductibles and cost-sharing requirements. In 2013, The New England Journal of Medicine published a physician-authored essay that called costs a “side effect” and urged physicians to “disclose the financial consequences of treatment alternatives just as they inform patients about treatments’ side effects.”

Linda Oberstein, MD, an internist in Burlingame, Calif., has been practicing medicine for more than 20 years, and has noticed patients’ growing reluctance in the last five to seven years to undergo a test before finding out what their insurance would cover.

“I’m getting more and more questions about how much tests will cost,” she says. “Patients come back to me and say they had to pay $300 for a blood test, and they have insurance and don’t know why it wasn’t covered,” she says.

As a result, Oberstein now weaves cost into her discussions more frequently, even though that can be uncomfortable at times.

The problem is that not all physicians are engaging their patients on cost the way Oberstein does. While 76 percent of
patients surveyed by Avalere Health felt it was important to discuss the costs of their care with their physician, 21 percent said they received some, little, or no such information during a doctor visit.

The place to start when talking about cost of care with patients is to consider the discussion fair game with every patient. Physicians should not make assumptions about which patients may want to have financial discussions, says Emmy Ganos, Ph.D., a program officer at the Robert Wood Johnson Foundation.

“It’s not just about finding patients who can’t afford to pay their co-pay or for prescribed medications,” says Ganos, a participant in the recently-published Cost Conversation projects. “It’s also for people who want to plan for what’s coming down the road.”

Barriers to discussing cost

Experts cite a variety of reasons why doctors are reluctant to discuss care costs with their patents. Among them:

Cost uncertainty

Most healthcare services don’t come with a set menu of prices. Moreover, the patient’s portion can depend on their insurance plan, deductible, and billing code. So rather than seeking the exact cost of each treatment option, says Ganos, find out the relative cost of the most-frequently prescribed medications or services, and places with potentially lower pricing.

While Oberstein doesn’t always know which lab charges preferred rates for which insurance plan, patients sometimes know which labs or imaging centers their insurance company prefers. Or she’ll tell them that there may be a cost for the service, and suggest that the patient find out what lab the insurance company recommends.

She may ask the patient to find out if their insurer will cover a blood test as preventive lab, and if not, she sometimes can order it using a different code, like noting a strong family history of the disease.

Time

Doctors think cost discussions with patients are more time-consuming than they  are, since data show that the amount of time they actually take is quite short. A study in the Journal of Oncology Practice showed that cost conversations took a median 33 seconds in a 12-minute appointment. Moreover, cost conversations can potentially save time in the long run, as the doctor may be able to avoid subsequent calls from the pharmacy for an alternative prescription, or not have to identify potential adherence issues at future visits, says Ganos.

Lack of ready solutions

“I think that physicians often experience stress asking [patients] about cost because they’re not always aware of resources to help patients,” says Syed Yousuf Zafar, MD, a cost-of-care researcher  and medical oncologist at Duke University, in Durham, N.C. “Primary care physicians have more alternatives than oncologists, in that there are often generic medications, which might be less expensive,” he says.

Primary care doctors can also refer patients to pharmaceutical companies’ financial assistance programs or use apps such as GoodRx, which can sometimes provide discounts on prescription drugs.

While some medical treatments and diagnostic tests are unavoidable, others can be spread out to help with budgeting. This may give the patients the option to choose between different treatment pathways, or delay a test or procedure the patient ultimately decides is not worth the cost.

Oberstein sometimes delays ordering tests for patients who are clinically stable so they won’t have to pay for tests they might not need. She says that while she talks with patients about the costs of outside treatment, she is uncomfortable bringing up the cost of her own visits, especially follow-ups.

“I want them to come back, to see how they’re doing. I sometimes will say to follow up with me in six weeks, or if that’s difficult, to email me and let me know how you’re doing” through the secure portal. She offers that option for issues such as blood pressure monitoring, if she is confident their equipment is accurate.

Quality of care

Even if doctors bring up cost issues, patients may be reluctant to discuss them,  out of concern that they won’t be offered all care options in the future, or that they’ll receive lower quality care, says Ganos. So after determining that finances are an issue, Ganos recommends that doctors reassure patients that they’ll make all medical decisions together, and that the patient will be presented with all options, regardless of cost.

Oberstein, though, has seen patients share less with her during the annual physical or wellness visit, since the session may not be fully covered by the payer if additional health issues are discussed. The receptionist gives patients coming for their Medicare annual wellness visit or private payer check-up information alerting them that there may be some charges for an office visit instead.

For the insurance-covered wellness visit, “I can’t talk about anything but what’s covered in the annual visit, by strict guidelines,” she says. “If we talk about your blood pressure and it’s high and I change your prescription, I have to charge for it.” Oberstein says this puts her at odds with her patients, who come expecting a free annual visit. Some tell her they have other medical issues but won’t share them because it means they’ll have to pay for the visit.

How to talk about cost

It’s important for the physician to bring up cost of care, because patients don’t always know they can ask about it.

“It’s clearly something that patients worry about, and we’ve seen in our research the stress that the financial impact of medical care puts on people at a vulnerable time,” Ganos says.

Some patients feel ashamed and don’t want to raise the issue. To create a welcoming environment, physicians can use language like “a lot of my patients have trouble affording medications. Has that been an issue for you?” Ganos says. People don’t want assumptions made about their financial situation, so physicians can say that it’s something they ask all patients. “The universal approach makes people feel more comfortable,” Ganos says.

Zafar frames cost as a side effect patients should expect. “We’re careful to inform our patients about the side effects they might experience from treatment, and cost is one of the side effects,” he says. Even if he can’t give an exact amount, he tells patients if they will face expenses not covered by insurance as a result of the treatment he’s prescribing.

Zafar prefers to talk about affordability rather than cost. “If I tell the patient I want to make sure they can afford the treatment, that helps align my interest with theirs,” he says. He’ll say, “I want to make sure you get the best treatment possible and that you can afford that treatment. Let me know if you have problems paying for your care.”

The physician is often the best person to initiate the cost discussion, says Zafar, because they are responsible for the treatment plan. But other team members can sometimes help as well. If the office uses a nurse or medical assistant for medication reconciliation, that person can include a question about the affordability of medications during the intake.

A practice’s financial navigator can take this on as well. Smaller practices that don’t have a financial navigator can train someone for this role. Zafar suggests meeting with practice staff to find out what patient questions they’re getting about cost, and who gets which questions. They they can  share resources, such as which facilities offer less expensive imaging, procedures or medical supplies.

Cost of care tools

One outcome of RWJF and Avalere’s Cost Conversation projects is a series of practice briefs available to physicians on America’s Essential Hospitals website. It includes examples of conversation starters, such as “Have you ever had trouble going to your appointments due to things like travel or childcare?” or “Do any of these medications/treatment plans represent a significant financial burden for you? If so, which ones?” or “How about if we take another look at your medications/care plan and see if there are any less expensive alternatives?”

The practice briefs also include resources on medication discount programs, how to integrate cost conversations into the workflow, and examples of flyers practices can post to make patients more comfortable asking about cost issues.

Care costs can also include transportation, child care and lost wages. “Oftentimes physicians and care providers have strategies they can share, or resources that make a difference, but you don’t know if someone will need that help unless you ask,” Ganos says.

While a solution may not exist for every cost issue a patient faces, physicians are better able to help their patients if they know the patient’s challenges. “Not talking about it isn’t working,” Ganos says.