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Explore Other Interviews in This Series

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

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?

Transcription:

Katherine: Welcome to the second installment of Avalere’s podcast series to support cost-of-care (CoC) conversations in primary care. Support for this podcast was provided by the Robert Wood Johnson Foundation (RWJF) and the New York State Health Foundation (NYSHealth), however, the views expressed here do not necessarily reflect the views of the foundations. 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 second episode of our podcast series, we will discuss actionable tips and a simple framework for how clinicians can structure CoC conversations with their patients. Today I’m joined by two special guests. Maria Pisu is an Associate Professor of Medicine from the University of Alabama at Birmingham. Maria has done a lot of work on communicating cost information that is understandable and useful to patients and recently developed a framework on how to structure CoC conversations to meet patient need. I’m also joined by Susan Perez, who is an Assistant Professor from California State University of Sacramento. Susan has done extensive work with Consumer Reports to understand the needs of patients as it relates to the costs of care. Susan, I’m going to start with you, we heard in our first podcast episode from a patient advocate that many patients may be hesitant to bring up cost for several reasons, including not wanting to appear like they are challenging their clinician and worrying that cost discussions might be inappropriate to have with their clinician. And yet we also heard how important they are to have and their impact potentially on improving health outcomes. In light of your research, what are some of your suggested strategies that clinicians can use to help facilitate CoC conversations with their patients?

Susan: Thank you, Katherine. One strategy could be to integrate CoC conversation starters into all visits. This is key, the part of doing it in all visits with all patients, because we found that across all socioeconomic backgrounds, cost of healthcare is a concern. And for this reason, it’s important that we open up opportunities with patients to talk about costs. Patients knowing that cost conversations are something that their provider is bringing up with all patients reduces that stigma of discussing cost, for all the reasons you mentioned above. Something as simple as the provider saying, “Based on what we discussed today, do you have any questions or concerns about the cost of any treatments that we discussed, or medications ordered, or labs ordered?” Another example is if a patient expresses or hints about challenges with affording their care, a provider may follow-up with, “You know, what you’re experiencing is incredibly common so let’s work together to see what you and I can come up with.”

The other strategy is to develop and share patient education materials on cost with patients. Some examples are posters in the waiting room or even the exam room, we all know how long we sit there staring at the walls. Wallet cards that patients can take home and videos about patients and providers modeling CoC conversations, or even patients sharing and reflecting upon their experiences with engaging in CoC conversations. We found that when provided with the materials and resources about engaging in CoC conversations, or even when they observe the ways in which a doctor and a patient can model a conversation about cost, patients feel empowered and are far more receptive to the idea that cost is an important issue to bring up with their doctor. Seeing how to model these conversations and messages about engaging with providers about the cost of care, really normalizes this idea and patients are more likely to ask about cost and willing to engage in these difficult or even awkward conversations. It’s my understanding that there are some really great resources on the America’s Essential Hospital’s website.

Katherine: That’s great. Thanks for clarifying the need to have these conversations with all patients and also sharing some specific conversation starters and materials that clinicians might use. I know that much of the research that I’ve seen points to the importance of tailoring these conversations to best address the individual needs and goals of patients. In some cases, those needs might vary from the need of someone with an acute financial need to someone that’s planning to manage a chronic condition or a newly diagnosed chronic condition. In the next episode in this series, we’re going to share more about some of these specific ways of integrating these conversations into workflow based on these specific needs. For now, though, I’m hoping to hear more about Maria’s research and specifically, Maria, I know you developed this framework that consists of 3 pieces: Reassurance, Action, and Resources, that can probably apply to all patients regardless of their need in some way. Can you share a little bit more with our listeners about your framework and how it might be implemented by clinicians?

Maria: We developed this framework based on a set of interviews that we did with breast cancer survivors and also with cancer center staff – any providers in the cancer center who may have these kinds of conversations, be it physicians, nurses, navigators, social workers, or any others. Both of these groups came up with the same framework.

They said that the conversation should start with some reassurance — some reassurance that the patient will receive care or there is support that will help them with the cost of their cancer care. The person who would approach a patient about this should use some compassionate messaging such as, “I know this is a difficult time for you and you may have a lot of questions. I am here to help you with some of the financial questions.” So, approach and be aware of the vulnerability of that patient at that point. The providers also emphasized that the purpose of the conversation was to guide and support the patient and should not be perceived as a conversation to collect money but to guide them through this process.

After the compassionate wording and reassurance, the next part would be about action. The provider proposes some action to reduce the problem. That could be evaluating alternative treatment, switching to generic drugs, providing free samples, combining office visits to reduce transportation and parking costs, anything that could reduce any of the costs that the patient would incur to get the care that they need.

After the action, the conversation will lead into linking the patient to resources or staff who may help them. Some examples may be patient assistance programs, if these are available, and organizations that can help with these kinds of costs. One patient navigator told us, “we’ll go over the next steps that need to be taken and link them to the resources that the patient qualifies for, and then we go from there. We move forward, we move toward allowing the patient to get the treatment that they need.” So that’s the basic framework that came out from our research.

Katherine: That’s great. Thank you, Maria. Before I conclude, I just want to see if either of you have anything else that you want to add that you feel like would be useful for the discussion.

Maria: One thing that I didn’t mention, we did develop this framework for patients with cancer who are definitely in a vulnerable position, but if you think about it, this would apply to any patient who is feeling vulnerable and needs support to get the care they need.

Susan: I would absolutely agree that it does apply to all patients in general. Specifically, during a visit, the patient might not have ordered a new treatment or medication or lab – that visit itself might not have incurred new costs, but it’s also important to understand that the patient might have recurring costs based on previous medications or other specialists that they are seeing. I’ve observed and learned in our own research that they are making these sacrifices, big and small. Sometimes it’s giving up date night with their loved one or having to choose between feeding their family and affording their medications. While during the visit there might not be new costs incurred, for some individuals it’s an ongoing struggle and for that reason I think it’s something to just bring up or ask about or discuss during all visits.

Maria: I agree. The same thing came up in our interviews, especially with those with cancer. The financial piece – what we call financial toxicity — doesn’t come up right away at the beginning, but as the expenses accumulate, then they start feeling the burden. It may get to a point where they need to stop treatment if they don’t have their resources so assessing along the course of the disease at every visit would be important.

Susan: I think Maria made an excellent point about combining visits. Sometimes when we ask about costs, patients are often thinking about the money that they have to put forth. But it’s also important to bring up the other costs of time, gas, and transportation. We found this stat in a rural community that we conducted some focus groups in, something as simple as a broken arm for their child resulted in lost wages for a 45-minute car drive both ways and so that was lost wages, that was having to eat meals out and about for that day, gas was a huge burden. So, in addition to discussing costs, it’s also opening the conversation about those other auxiliary costs that come with seeking that care.

Maria: Yes.

Katherine: Thank you, Susan and Maria for talking with us today about actionable tips for how clinicians can structure these conversations with their patients. To our listeners, I want to share that we have several more episodes in this series scheduled over the next few weeks. In addition to last week’s topic on why it’s important for clinicians to talk with patients routinely about cost of care, we will also be introducing a guide for integrating CoC conversations into workflow and hear recommendations for how to overcome common barriers when implementing these conversations. As mentioned already, more resources on these topics and a deeper dive into this conversation in particular can also be found on the website of America’s Essential Hospitals. Hope you’ll join us for future podcasts – have a great day.

For More Information

• See this practice brief, which outlines concrete suggestions for how to welcome cost-of-care conversations in your practice
• See this practice brief, which provides you with actionable tips and simple frameworks for how to structure cost-of-care conversations
• See here for example patient educational materials, including posters and wallet cards