SummaryTune in to hear the first episode in our 4-part series that focuses on how clinicians and other care team members can improve the quality and frequency of cost-of-care (CoC) conversations. To kick-off this series, Gwen Darien and Jim Hardee, will talk with Avalere’s Katherine Steinberg on why clinicians should speak with their patients about the expected costs of their care. 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.
Katherine: Welcome to the first installment of Avalere’s podcast series to support cost-of-care (CoC) 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. I’m Katherine Steinberg from Avalere Health. CoC conversations are discussions between patients and clinicians regarding the costs that patients and their families incur during their care, including out-of-pocket and indirect costs such as transportation, child care, and lost wages. In this first installment, we will discuss why it’s important for primary care clinicians to routinely talk with their patients about the expected costs of their care.
Today, I am joined by our special guests: Gwen Darien, executive vice president for Patient Advocacy & Engagement at the National Patient Advocate Foundation. She has done extensive work on the impact of costs of care on patients, including her own personal experience as a 3-time cancer survivor. I am also joined by Dr. Jim Hardee. He’s a practicing internist in the Department of Internal Medicine at Kaiser Permanente Colorado. Jim has published on this topic and has developed a training program for physicians to talk about costs of care.
Gwen, I’m going to start with you. Why is it important for primary care physicians to talk about the costs of care with their patients
Gwen: I think one of the fundamental issues about conversations about costs of care is that you can’t have true shared decision-making unless you also address the economic impact and the cost of care. Cost of care, as you described it, is more than just the cost of what your co-pay for your medicine is. It is also the cost of opportunity and life costs. If you don’t speak about those, you aren’t really delivering holistic care and you also aren’t giving people the opportunity to really co-create their care with their healthcare provider. There are not always options of different treatments to choose and different paths to choose for treatment, but there generally are. If we are looking for a system that is about health, and care, and dignity we need to integrate the impact on patients’ lives that goes beyond just the impact of the disease.
Katherine: That makes sense. Thank you. Jim, from a clinical perspective, do you think that CoC conversations can help drive high-quality care and improved outcomes?
Jim: Well certainly, being aware of the financial context of our patients’ lives can help us better frame and advise therapeutic and care plan options for them. You know, I’ve heard it said before if we as physicians have the ability to put our patients and their families into financial hardship, or even financial ruin with the tests and treatments that we prescribe, then we really need to be making this at least a part of the discussion with them. In addition, we know that when patients and families are unable to afford their care, be that prescriptions, tests, radiologic studies, referrals, or even emergency room (ER) or hospital admissions, they will often forego these important therapies and interventions. And we know from our study and work in this area that patients and families appreciate when the physician displays a sensitivity and an awareness regarding cost concerns. The physician-patient relationship manifests as trust, and rapport is strengthened when we partner with our patients in this way. So, while some patients may actively and overtly voice cost concerns, saying something like, “Doctor, there is simply no way that I can afford to keep taking this medication; I either take this pill or put gas in my car.” There are other patients that may feel a sense of shame or even embarrassment regarding their financial situation and not say anything. So we can open the door for this dialogue simply by asking something like, “Mrs. Jones, I know that you’ve been through a lot with your healthcare this past year, many of these medications and tests are not exactly cheap. How are you managing so far?” By opening the door for the dialogue, we can improve outcomes. And again, I’ll mention that patients appreciate this awareness and sensitivity on the part of their physician and their care team. Their response to us, allows us to intervene, make changes, suggestions or even financial referrals, if needed. And lastly just one other thing that we’ve uncovered, and perhaps not surprisingly, is that a huge patient dissatisfier is the unexpected bill, that shows up 2, 3, or even 4 months later after the service or visit has been rendered and provides a type of sticker-shock-type phenomenon. So anytime that we can anticipate the cost concerns upstream and have that discussion, certainly benefits everyone.
Katherine: Thanks, Jim. I love all of the reasons you articulated about why clinicians should raise CoC conversations with their patients. I’m curious, Gwen, we’ve heard from clinicians that they are often worried about offending their patients when they bring up costs. Is there evidence related to this that you might be able to share?
Gwen: So I think one of the things that has become more and more clear is that there is a very big gap between a discussion about cost and a discussion about money. In our research, at the Patient Advocate Foundation (and we serve a lower-income population with serious and life-threatening diseases), they generally call our case managers because they are having a financial crisis and barriers to care, and that’s why our case managers work with them — to reduce these barriers in whatever way that they can. So people want to talk about costs. Our patients have also said that the costs of care and conversations about CoC are really important to them as they are making their decisions about treatment. And again, on the other side, a study done by Public Agenda, showed that patients in a market research program also wanted to talk about costs of care. But what I think people conflate and confuse is the difference between talking about the cost of care in an overall sense and talking about money in a personal sense. And that’s where some of the shame comes in, that’s where some of the reluctance comes in, that’s where people may feel – I don’t know if they feel offended, but I think that people are concerned that they may be treated differently if their physician or healthcare provider doesn’t think that they can afford the treatment that’s been prescribed for them. When that happens, the impact of that and the outcomes of that can be life threatening, such as when people stop taking their medications, as Jim referenced, or cut their pills in half, or just stop coming to the doctors. So I think one of the things to really address is this gap between cost as a larger issue and a sort of healthcare system issue and money as a personal issue — an issue that you don’t bring out of the family and that you don’t bring out into the public.
I did a video that’s on our website about dealing with the financial impact of care. I talked a little bit about my first diagnosis of cancer when I was a young adult and had fantastic insurance and how long it took me to pay-off all of the costs of my care which were larger than just the costs of care. This was completely unanticipated, I had no idea that was going to happen, and I had excellent insurance. I was directing art centers, so I wasn’t making much money, n’t making good money, but I did have really good insurance.
Jim: I love the notion of cost versus money. I’ve never framed it quite that way but that really is it — what it’s ok to talk about and what is socially not ok to talk about. But that is a really interesting nuanced point that is really important, so I thought that was great.
Katherine: Thank you, Gwen. As our final question, we’ve heard now why this is important to both patients and clinicians, as well as some of the barriers for each in raising these conversations. But a major barrier that I’ve heard from a clinician perspective, that’s not been raised so far in this conversation, is that clinicians just don’t have time to hold these conversations. Jim, do you agree with that?
Jim: Certainly time seems to be a universal stressor in healthcare these days and definitely we see it in busy outpatient clinical settings. We seem to have less and less time to accomplish more and more tasks. That said, cost conversations can be held pretty quickly and efficiently within the typical flow of an office visit. The questions we ask and the discussions we have can and should be held with empathy at the core. Building and strengthening the therapeutic relationship through partnership, open dialogue, transparency, whenever possible, is really key. And we need to be clear that patients are not helped by cost conversations that degenerate into blaming insurance companies, blaming pharmaceutical companies, blaming hospitals and politicians and such. While this may fill a need for us and feel cathartic in the moment, it really doesn’t do anything to help our patients. So empathetically asking a patient if they’re doing OK managing the cost of their care is a simple question. It’s also important to note that uncovering a financial concern does not necessarily obligate the physician or clinician to fix everything right then and there. We as doctors are always worried about opening the proverbial can of worms in the midst of a busy visit. But we can acknowledge the concern, we can consider in the moment if there might be a less expensive alternative, and we can also make note for later to refer the patient to financial resources, who frankly may be better equipped than us to discuss options and payment. But at least by knowing that cost may be a concern for a particular patient or family, sets the stage for ongoing discussions in the future. We’ve also seen in our work that patients don’t necessarily expect their doctors to know everything about all the minute cost details and prices. They are aware that we are physicians and we likely don’t have all the specific financial data, but we can certainly acknowledge and partner with them and guide and direct them to the needed information. Lastly, I’ll say it can be really eye-opening and humbling for us as physicians when we learn how much our patients may be struggling with healthcare costs. In the exam room, we can get these “wow, I never had any idea, thanks for making me aware of that” types of moments. And I’ll just add that uncovering these concerns and helping our patients in this way can be really rewarding for us as physicians – knowing that we make the effort to understand the financial context of our patients’ lives and meet their care goals in a way that they are comfortable with shows that we care about the whole person and that we truly are partners in care.
I got an email this morning that Kaiser just put into place starting February 1 a “Chat with a Financial Counselor” feature so patients can go online and in a chat form they can “utilize the ‘Chat with a Financial Counselor’ for price estimates for upcoming services and procedures, payment plan options, and medical office billing. So for me, as a busy doctor seeing patients every 20 minutes, this gives me a resource where I can say “I know that medicine is expensive, and I know that a MRI is expensive, here’s an option for you, we have this chat with a financial counselor” and it sort of offloads that I ask, I hear, that I note it and acknowledge it, empathize, and get them to a resource so that I can move on.
Gwen: I think that’s really fantastic and really important. And also, you don’t always think about these questions in the moment and you want to feel as a patient or a caregiver that you can go back and ask questions later on and ask questions that aren’t necessarily for your doctor. And to know that there are these other resources is really important.
Katherine: Thank you, Jim, and thank you, Gwen, for talking with us today about why it’s so important for primary care clinicians to routinely talk with their patients about the expected costs of their care. To our listeners, I want to share that we have several more installments of this series scheduled over the next few weeks. Some of the topics that we’ll continue to talk about are tips for clinicians on how to talk with patients about the expected costs of care, we’ll also be introducing a guide for integrating CoC conversations into workflow, and finally we’ll hear recommendations for how to overcome common barriers when implementing these conversations—some of those barriers which we heard a little bit about during our conversation today. Hope you’ll join us for those podcasts. Have a great day!
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