E3 – A Guide to Integrating Cost-of-Care Conversations into Workflow

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Tune in to hear the third episode in our 4-part series that provides clinicians with actionable approaches for integrating cost-of-care conversations into workflow. Nora Henrikson will talk with Avalere’s Katherine Steinberg on 3 pathways that clinicians can use to best integrate cost of care conversations into their clinical workflows. Support for this podcast was provided by the Robert Wood Johnson Foundation and the New York State Health Foundation (NYSHealth). The views expressed here do not necessarily reflect the views of the foundations.
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“What we heard loud and clear from both our clinical partners and the patients that we talked to — there was a very strong endorsement of a team approach. There certainly could be somebody on a team that could have that responsibility to help patients with a budget, or help connect people with financial resources, or even hunt down the prices for 2 different alternatives that a physician is considering with their patient for a clinical decision. ” Nora Henrikson


Guest Speaker
Nora Henrikson, PhD, MPH , Assistant Investigator, Kaiser Permanente Washington Health Research Institute
Nora Henrikson is passionate about understanding the influences of policy and culture on patient choices and experiences of clinical care.

This interview was originally published as a podcast. The audio is no longer available, but you can read the transcript below. For updates on our newly released content, visit our Insight Subscription page.

Explore Other Interviews in This Series

E4 – Recommendations for How to Overcome Common Barriers When Implementing Cost-of-Care Conversations

E1 – Why Should Primary Care Clinicians Routinely Talk with Their Patients About the Expected Costs of Care?

E2 – Quick Tips for Clinicians on How to Talk with Patients About the Expected Costs of Care


Katherine: Welcome to the third episode of Avalere’s podcast series to support cost of care conversations in primary care. This series was funded through the generous support of the New York State Health Foundation (NYSHealth) and the Robert Wood Johnson Foundation (RWJF). The views expressed here do not necessarily reflect the views of the foundations. Hi, I’m Katherine Steinberg from Avalere Health. Cost of care conversations are discussions between patients and clinicians regarding the costs that patients and their families incur during their care, including out-of-pocket (OOP) and indirect costs such as transportation, child care, and lost wages. In this third episode, we will discuss approaches for integrating cost of care conversations into workflow. Today, I am joined by our special guest: Nora Henrikson. Nora is an Assistant Investigator at Kaiser Permanente Washington Health Research Institute. Nora is a social behavioral scientist with deep expertise in patient education with a focus on how patients make choices. Her recent work has focused on improving price transparency. Welcome, Nora.

Nora: Thank you, happy to be here.

Katherine: Nora, you recently completed a grant for RWJF that aims to document what a patient typically goes through in their journey to find cost information and the processes that healthcare teams encounter when they try to help a patient with cost questions. Can you tell us a bit about your approach to this research?

Nora: Yes, sure. For this research, this built on some previous work that I had done with my team where we had done qualitative work with both people experiencing cancer treatment and with clinicians. What we found there was that people with cancer really wanted to be discussing cost with their clinicians, and clinicians were really open to that idea and certainly recognized the financial hardship that people with cancer experience very acutely and wanted to be able to help and serve patients in that way. But they did not have any tools with which to do that. They didn’t have training about how to discuss cost, and they also didn’t have a way to access what costs would be for a given patient to be able to discuss that in the context of treatment and decision making. Our big take home from that earlier work was that we really needed workflow, some research into how to build workflows, and how to adjust workflows so cost of care conversations could really have a place in the clinical experience.

Katherine: Great. Can you talk a little bit about some of the learnings as it related to workflow that providers might be able to integrate into their practice?

Nora: So we did our project at 2 different Kaiser Permanente regions, so at ours, Kaiser Permanente Washington, which is based in Seattle, Washington and also at Kaiser Permanente Northwest, which is based in Portland, Oregon, with my research partner, Dr. Mateo Banegas down there. One of the things that really leaped out quickly, again, was that this idea of talking about costs conversations — we realized there was a lot more nuance and depth into that term of cost conversations because as we were observing, the folks working in the clinics and as we were interacting with patients, we realized that sometimes people didn’t seem to always mean the same thing when they talked about this idea of discussing costs. And so one of the things that we did for this project was we came up with a framework, to help clinicians understand what kind of costs conversations their patients might be having. So we came up with 3, what we call conversation pathways. Each of those we think has slightly different patient resources, follow-up implications, and also workflow implications. And so I can go through the 3 of those.

The first one is really around clinical decision making. So this is a situation when a patient really could choose between multiple different approaches to treatment, either how it’s administered, or which treatment is given, or which drug is chosen. Cost might be a part of that decision and indirect costs like how many times I might have to come into the clinic or actual direct OOP costs. One is, you know, sort of cheaper than the other for the patient. That’s one where the physician really does need to get involved a lot of time and say, “well, we could do this or this and here are the trade-offs and let’s look at the costs”. So that’s almost like a shared decision-making model. So that’s one bucket, we call that clinical decision making.

And then the second one is really for people who have already decided on a course of treatment, they don’t have any other questions for their doctor about their treatment or what is planned for that. But they really want to understand what to expect. And we see this particularly in people who have cancer or other chronic diseases who are embarking on a course of treatment that might last months, and months, and months, or even longer. And they really want to understand and forecast and anticipate what those costs are going to be. Sometimes they’re going to have affordability issues and maybe they’re not. But what we know from other research by Dr. Banegas and others is that a very large proportion of people who are experiencing cancer treatment change their spending habits and experience some form of financial hardship or change just because of the large costs associated with long courses of treatment. And so this second bucket, we call it the planning and budgeting pathway, is for people who don’t really have further questions for their doctor, but they really want to know what to expect and how to plan for the costs that are coming.

And then the third bucket or the third pathway is really around people who are already in acute financial distress before they even start, or they have recently started experiencing financial distress related to their care costs. These are situations where a patient might need relatively, sometimes very acutely or certainly in the short-term, to be connected with resources that can help with affordability. This can range from connecting people to social services, or to financial medical assistance, or to drug assistance programs. A physician might get those questions and they might need a trusted colleague on the team to introduce those patients or connect them with resources at that point. So those are the 3 conversation pathways that we think most of the questions, if not all questions, that came up in the course of our research can be described from a workflow perspective.

Katherine: Those are really interesting and comprehensive. I’m curious how you envision the clinicians using these 3 pathways?

Nora: Yes, that’s a great question. Well, if you think of a clinician, so if you’re a busy physician or an oncologist or you’re in the primary care setting (which was one of the settings where we conducted this study), and you already don’t have very much time to discuss all the things that you need to connect with these patients — and somebody has a cost of care question, you might say, “oh, my patient is asking me if they can change their treatment because of affordability concerns.” So then that might be a flag for you to say, “oh, I’m needed here as a clinician. I’m really needed to really engage with this patient to talk through the specifics of these treatment alternatives that we’re considering.” Whereas if you had somebody who said, “okay, I’m all set, this is the cancer treatment that we’re going for and now I’d really like somebody to help me make a household budget,” you might think about having a member of your team who could help at that point and then you could get on with seeing the zillion other patients that you need to see that day. I think what we’re hoping, and we’re hoping to test this in future work, is that a physician or anyone, a nurse, or a social worker, or anybody who is on a care team could say, “this is the kind of question that we’re dealing with; this is the kind of team member we think is best suited or the person with the most training that’s best suited to answer this particular question, and these are the kinds of resources that we think that this patient’s going to need.”

Speaking of the resources that each patient would need on each pathway, for like the planning and budgeting pathway, the end result for that really might be a budget or some way to help a patient anticipate when those bills are going to come, what they might look like, and how to set aside money to be able to anticipate those costs. This is a very different patient take home resource than somebody who needs immediate enrollment and financial assistance programs, which the take home resource for that might really involve something that is more like an application or a proof that you’ve already applied for a certain financial assistance program. In our study, we designed prototypes for each of those different patient take home resources that would be at the end of each pathway.

Katherine: As a follow on to that, and this will be our last question for this podcast, I imagine that clinicians might have anxiety about raising some of these cost questions. Even the opportunity to build a budget with a patient might be new to many clinicians. For providers that are interested in implementing these new pathways but don’t have experience necessarily in some of those outputs that you just described, what’s the first step in engaging these patients and helping them?

Nora: So what we did to synthesize all of the data that we collected over the course of our RWJF study, was we synthesized all of that into a set of requirements for workflow that could enable these clinician-patient cost of care conversations according to these 3 different pathways. Every team is different and there certainly could be physicians who really want and have time to sit and make a budget with a patient. But what we heard loud and clear from both our clinical partners and the patients that we talked to — there was a very strong endorsement of a team approach. There certainly could be somebody on a team that could have that responsibility to help patients with a budget, or help connect people with financial resources, or even hunt down the prices for 2 different alternatives that a physician is considering with their patient for a clinical decision. There certainly can be a team approach that can be put in place, so an entire team works together and says, “this patient is on this pathway, let’s get them to the end and get them what they need.” For this study we were intentionally trying to be as general as possible but still be specific enough so that other organizations could see themselves in those requirements, and they could look at those and say, “okay, we can implement these in a specific way that works in our particular environment.” I think some places it takes the form of a financial navigator, or a financial counselor, or another team member takes on an extra scope of work for their job. I think it could take a different format in different organizations, and we tried to make this not just useful for our organization but actually useful for other folks. We’ve tried to present that and provide tools in a way that organizations or clinical teams or individual clinicians could figure out how that could work in their specific setting.

Katherine: That’s really helpful. Thank you, Nora, so much for taking the time to talk about integrating cost conversations into workflow. To our listeners, I want to share that we have several more episodes in this series focused on increasing the value and frequency of cost of care conversations in addition to our first 2 episodes that covered why it’s important for these conversations to take place, as well as tips for clinicians on how to talk with patients about cost-of-care. We also have our next podcast where we will hear from Peter Ubel about recommendations for how to overcome common barriers when implementing these conversations. I hope you’ll join us for those podcasts as well. For now, have a great day. Thank you.

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