#172 Cost-of-Care Conversation Are Crucial

September 11, 2019 | By Elena Gibson

Actionable cost-of-care resources for clinicians. Guests: Gwen Darien and Jessica Dine MD, MHSP

Recognize the importance of cost-of-care conversations and identify resources to facilitate these discussions with help from Gwen Darien, executive vice president at the National Patient Advocate Foundation, and Dr. Jessica Dine, Associate Professor and Chief of the division of Pulmonology and Critical Care at Perelman School of Medicine.  We review barriers to cost-of-care conversations and identify tools to help make these conversations a part of routine care discussions. 

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Credits

Written and Produced by: Elena Gibson, MD

Infographic and Cover Art: Elena Gibson, MD

Hosts: Elena Gibson MD; Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP  

Editor: Matthew Watto MD, FACP; Emi Okamoto MD 

Guest: Gwen Darien and Jessica Dine MD

Partners and Grant Support

Time Stamps

• 00:00 Pun, disclaimer, sponsor
• 01:10 Intro, guest bios
• 06:10 Guest one-liners
• 07:22 Picks of the week*: Sing Unburied Sing (book) by Jesmyn Ward ; The Quiet American (book) by Graham Greene; An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (book) by Elisabeth Rosenthal
• 09:35 Best Advice: Always question received wisdom; Listen!
• 14:10 Cost of treatment versus cost of care
• 15:35 How does cost of care affect outcomes?; Talking about money (finances) with patients
• 18:52 Defining “underinsured”; High deductible plans
• 22:41 Why are physicians scared to talk about cost?
• 26:16 Why is cost of care so difficult to determine? Who’s benefiting from lack of transparency?
• 28:35 Stuart explains his theory on why costs make no sense
• 30:00 How to have cost of care conversations
• 32:10 How to estimate cost; Specific tools
• 42:10 Cost of care plans
• 50:03 Take home points and plugs: National Patient Advocate Foundation; NeedyMeds.com; ACP High Value Care; AAFP Neighborhood Navigator Tool
• 53:00 Outro

Cost-of-Care Conversations Pearls

“I’m going to prescribe tests and medications and I’ve heard from a lot of my other patients that sometimes the copay is too much, and it’s cost prohibitive. If that happens, please reach out to me and you and I will figure out another plan.”

Dr. Jessica Dine MD on The Curbsiders #172 Cost-of-Care Conversations

Many Americans have financial concerns regarding their medical care, with 35% reporting not following treatment plans due to cost. 

Cost-of-care conversations between physicians and patients can lead to improved outcomes for patients. 

Both physicians and patients want to talk about healthcare cost, but it rarely happens. 

Physicians should aim to normalize cost-of-care conversations by having them with every patient and screening for healthcare cost concerns. 

Clinical teams (physicians, social workers, patient advocates) can all contribute, and dedicated training sessions may improve the success of these conversations.

Effectively addressing the impact of healthcare costs on care requires aiming for high-value care.

Cost-of-Care Conversation Show Notes

Healthcare Costs 

Many Americans find it difficult to afford medical care, and cost concerns are associated with medication non-adherence and avoidance of care (Sloan 2019) .  A 2018 insurance survey found 35% of adults reported not following recommended treatment due to cost (Commonwealth Fund 2019). Among cancer patients, research has even identified concerning associations between increased mortality and financial stress (Ramsey 2016, Withrow 2019). There are various types of costs to consider when discussing healthcare costs with patients. Among many others, these include finances, time, transportation, and work leave.

Why are cost-of-care conversations so important? 

Cost-of-care conversations between patients and physicians have been shown to improve adherence to treatment and patient outcomes (Meluch 2015). Each patient will have unique concerns, and our guests recommend starting these conversations early to create a relationship where both the patient and the provider feel comfortable discussing cost-of-care openly.

“Underinsured”

As cost sharing rises, the prevalence of underinsurance also increases (Advisory Board 2019). Our guests describes how most patients don’t anticipate they will be ill, so they often choose insurance based on current circumstances and may choose high-deductible plans for lower premiums. Physicians should aim to discuss how a treatment plan would fit into the type of insurance a patient has. 

Barriers to Cost Conversations

Our guests discuss how physicians and patients want to have cost-of-care conversations, but they happen infrequently (Alexander 2003). Physicians recognize patient’s are struggling with healthcare costs and want to have conversations with patients about cost, but barriers to initiating conversations include unclear out-of-pocket costs and time constraints (Perez 2019).  Tools to help screen, estimate costs, and address financial distress are available online (Dine 2019). 

Lack of Cost Transparency

Lack of cost transparency is a common barrier to engaging in conversations about cost among physicians (Perez 2019). As varying insurance policies and price negotiations influence price, it is difficult to give patients an exact estimate of cost. However, our guests recommend researching the most frequent tests and medications you prescribe and using cost estimation tools such as Healthcare Bluebook  and Fair Health Consumer to research what patients are being charged. Although patients may only pay a percentage of the estimated cost, this can provide a relative price to consider when prescribing.

Kashlak pearl: Research the most frequent tests and medications you prescribe and using cost estimation tools such as Healthcare Bluebook  and Fair Health Consumer to estimate what patients are being charged. 

Consider Value 

Our guests detail how the delivery of high-value care is essential to addressing the rise of healthcare costs. If an unaffordable test or treatment is the only option recommended, the patient may receive no treatment at all. Patients report fear of receiving suboptimal care if they bring up cost concerns with physicians (Erwin 2019). Therefore, physicians should aim to present the plan as options and regularly discuss the various costs and benefits with patients to establish high-value treatment plans.

How to Have Effective Conversations about Cost

Physicians should consider how to best incorporate cost conversations into the regular flow of patient interactions (Sloan 2019) . Conversations may involve various members of a clinical team including physicians, nurses, social workers, and patient advocates. Dedicated training sessions for this may improve the frequency and success of conversations (Carroll 2019).

Normalize the Conversation 

Our guests repeatedly emphasize the importance of normalizing the conversation so it occurs during each patient interaction. This should help alleviate some of the concern for bias based on demographics and provider assumptions. Consider using a standard phrase to bring up or screen for cost concerns such as Dr. Dine’s phrase, “I’m going to prescribe tests and medications, and I have heard from many of my patients that the copay is too expensive. If that happens, please call me and we will figure something out.” 

Kashlak Pearl: Normalize the conversation so it occurs during each patient interaction to alleviate the patient’s concern for bias based on demographics and provider assumptions.

Outline Cost Expectations 

After a treatment plan is established, consider outlining future expectations, including financial and non-financial costs,  to provide patients with information to plan (Pisu 2019). Our guests emphasize how important it is to avoid making ANY assumptions. Ask patients what would be most helpful to them in regarding  a treatment plan, and consider various aspects of care such as supportive care, childcare, transportation, parking and copayments. Some patients may find it helpful to have multiple appointments and tests on one day, while others would benefit from multiple short days. Involve caregivers and family who also participate and incur costs. Physicians can familiarize themselves with estimated diagnostic and procedure costs using resources such as Fair Health Consumer, HealthCare BlueBook and Medicare Procedure Cost.

Goal

Listeners will recognize the need for routine cost-of-care conversations and identify resources to improve the quality of such conversations in order to deliver high-value care. 

Learning objectives

After listening to this episode listeners will…  

1. Recognize the importance of cost-of-care conversations between physicians and patients 
2. Describe barriers to conversations concerning healthcare costs
3. Feel comfortable initiating routine conversations with patients on the cost-of-care 
4. Identify where and how to access resources to assist with healthcare cost conversations

Links*

1. Book recommendation: Sing Unburied Sing by Jesmyn Ward 
2. Book recommendation: The Quiet American by Graham Greene 
3. Stuart’s Pick of the Week: An American Sickness: How Healthcare Became Big Business and How You Can Take It Back
4. ACP High Value Care Resources for Clinicians: Cost of Care Conversations 
5. Fair Health Consumer
6. HealthCare BlueBook 
7. Medicare Procedure Cost 
8. ACP Treatment cost planning
9. National Patient Advocacy Foundation
10. NeedyMeds
11. AAFP Neighborhood Navigator

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

References

1. Commonwealth Fund. Fewer adults report not getting needed care because of costs, but gains have stalled in recent years. 2019. Link
2. Ramsey SD, et al.Financial Insolvency as a Risk Factor for Early Mortality Among Patients With Cancer.Journal of clinical oncology, 2016. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4933128/]
3. Withrow DR, et al. Trends in Mortality Due to Cancer in the United States by Age and County-Level Income, 1999–2015, JNCI. 2019. [https://doi.org/10.1093/jnci/djz123]
4. Meluch, AL, & Oglesby, WH. Physician–patient communication regarding patients’ healthcare costs in the US: A systematic review of the literature. Journal of Communication in Healthcare, 2015. [https://www.tandfonline.com/doi/full/10.1179/1753807615Y.0000000010]
5. Advisory Board, Commonwealth Fund. Who’s underinsured in America, in 4 charts. 2019. [https://www.advisory.com/daily-briefing/2019/02/08/underinsured]
6. Morgan SG, Lee A. Cost-related non-adherence to prescribed medicines among older adults: a cross-sectional analysis of a survey in 11 developed countries. BMJ Open. 2017. [https://www.ncbi.nlm.nih.gov/pubmed/28143838]
7. Fostering Productive Health Care Cost Conversations: Sharing Lessons Learned and Best Practices. Ann Intern Med. 2019. [https://annals.org/aim/issue/937992?_ga=2.19055480.1387784815.1565103555-2001710574.1565103555] **This includes multiple articles researching cost-of-care conversations and tools to address barriers and assist with conversations 
8. Alexander GC et al. Patient-physician communication about out-of-pocket costs. Jama. 2003. [https://www.ncbi.nlm.nih.gov/pubmed/12928475]
9. Dine CJ et al. Tools to Help Overcome Barriers to Cost-of-Care Conversations. Ann Intern Med. 2019. [https://www.ncbi.nlm.nih.gov/pubmed/?term=10.7326%2FM19-0778]
10. Carroll, JK, et al. Addressing Medication Costs During Primary Care Visits: A Before-After Study of Team-Based Training. Ann Intern Med, 2019.[https://www.ncbi.nlm.nih.gov/pubmed/?term=10.7326%2FM18-2011]
11. Perez SL et al. Internists’ Perspectives on Discussing Cost of Care With Patients: Structured Interviews and a Survey. Ann Intern Med. 2019.[https://www.ncbi.nlm.nih.gov/pubmed/?term=10.7326%2FM18-2136]
12. Erwin, K., Fitzpatrick, V., Norell, S., & Gilliam, M. (2019). Development of a Framework and Tool to Facilitate Cost-of-Care Conversations With Patients During Prenatal Care. Ann Intern Med, 2019. [https://www.ncbi.nlm.nih.gov/pubmed/?term=10.7326%2FM18-2207]
13. Sloan CE & Ubel PA. The 7 Habits of Highly Effective Cost-of-Care Conversations. Ann Intern Med, 2019. [https://www.ncbi.nlm.nih.gov/pubmed/?term=10.7326%2FM19-0537]
14. Pisu M 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 [https://www.ncbi.nlm.nih.gov/pubmed/?term=10.7326%2FM18-2117]

Disclosures

Gwen Darien and Dr. Jessica Dine report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Dine J, Darien G, Gibson E, Brigham SK, Williams PN, Okamoto E, Watto MF. “#172 Cost-of-Care Conversations”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list September 11, 2019.