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Measuring the Effectiveness of Cost-of-Care Conversations

Summary

With support from the Robert Wood Johnson Foundation, Avalere assesses opportunities to normalize cost-of-care conversations through measurement.

Cost continues to pose a barrier to accessing healthcare for millions of Americans. Research has shown that conversations addressing costs among patients, caregivers, and the clinical team can help build a more trusted relationship between patients and clinicians.

Avalere has partnered with Robert Wood Johnson Foundation (RWJF) since 2015 to work toward normalizing cost-of-care (CoC) conversations in clinical settings, including identifying barriers and facilitators to engaging in conversations about cost. CoC conversations can be defined as discussions that address any costs patients and families might face, from out-of-pocket (OOP) to non-medical costs (e.g., transportation, childcare, lost wages). To that end, Avalere collaborated with the National Patient Advocate Foundation to explore the feasibility of patient-centered measure concepts to support quality improvement, increase satisfaction, and improve outcomes. This issue brief highlights the challenges associated with measurement in this space alongside alternative solutions to encourage CoC conversations in practice.

Avalere thoroughly evaluated clinician and patient needs and developed a set of measure concepts and improvement activities to improve the frequency and quality of CoC conversations. Based on the gaps identified, Avalere assessed the following individual concepts and improvement activities:

  • Concept 1: Discussion of a CoC with patient during a clinic visit
  • Concept 2: Assignment of a case worker to address financial concerns
  • Concept 3: Documentation of treatment plan modification based on a CoC conversation
  • Concept 4: Patient-reported assessment of a CoC conversation during a clinic visit
  • Activity 1: Use of a patient-facing tool to prepare patients for CoC conversations
  • Activity 2: Use of a discharge-planning tool to outline costs of prescriptions post-discharge

Concepts identified through this work can move the needle toward normalizing these conversations. However, more research is needed to transform them into quality measures that could be used for accountability and improvement purposes. Our findings indicate the following research opportunities for consideration:

  • Accessibility of Data: Many clinicians are doing the best they can to address cost concerns in the absence of OOP cost information. To optimize conversations, clinicians need access to more data to feel comfortable engaging in meaningful and productive CoC conversations. There are opportunities to collaborate with public and private payers to determine the operations and functionality of accessing this data in a timely manner.
  • Roles and Responsibilities: CoC conversations are a newer concept to healthcare; thus, there is no clear role within the care team as to who should lead these conversations—and the right role may depend on the type of cost concern and on who is capable of working to address the concern. Team-based care is about meeting patients where they are by aligning the appropriate clinical team member to varying patient needs during the care episode. Having the right conversation at the right time could have a significant impact on how the patient engages with the care team and their long-term outcomes.
  • Validating the Needs of Patients: Patients—particularly low-income and vulnerable patients—may feel they are subject to unintended consequences as a result of CoC conversations (this includes lack of access to treatments as a result of a patients’ financial status). A patient’s assessment of the quality of a conversation and whether they have the information they need to make a decision about their care signals the need for more patient-reported outcome measures to ensure patients’ needs are met and that they are being heard throughout their care journey.

Thoughtful, sensitive CoC conversations can facilitate a more trusted partnership between clinicians and patients and prevent missed opportunities to address cost concerns that may have not been raised otherwise. Normalizing these conversations has the potential to reduce stigma and help to reduce disparities in outcomes. This issue brief highlights specific strategies for encouraging clinicians to talk to their patients about costs of care. Future testing and validation should ensure the measures introduced in this Issue Brief are feasible in practice to facilitate integration into existing or novel payment models. In addition, CoC measure development efforts should address the varied priorities and needs of all patients, including financial issues and barriers to equitable outcomes.

Download the issue brief.

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