This article examines the influence of cost on patient use of behavioral counseling services. Smoking and obesity are two major public health challenges, but few health insurance plans cover counseling services to help individuals lose weight or stop smoking. Little is known about how the cost of behavioral counseling services affects the consumption of such services.

The authors carried out a pre-post study in which counseling services were offered to eligible patients. For the first five weeks, eligible patients referred by their physician could receive counseling services for free. For the subsequent three weeks, patients could still be referred to counseling services but would have to pay out-of-pocket for counseling. In total, 1,860 patients in the Virginia Ambulatory Care Outcomes Research Network were flagged for eligibility and 407 were referred for intensive counseling.

Key Findings:

• Patients who had to pay for counseling services out-of-pocket were almost never referred for counseling. Only .7 percent of patients who had to pay for services were referred for counseling, while 22 percent of patients offered the service for free were referred.
• Doctors were much less likely to advise patients to change their health behaviors when patients were responsible for counseling costs (6%) than when patients could obtain counseling for free (29%).
• Of the patients who received physician recommendations to obtain counseling, patients eligible for free care were much more likely to accept a referral for counseling (76%) than patients responsible for the costs of counseling (14%).

This study shows results from a specific intervention designed to refer eligible patients to behavioral counseling. Patients were much more likely to obtain counseling if the counseling service was free, suggesting that out-of-pocket costs are a significant deterrent to use of intensive behavioral counseling services.