Costs of Care: Getting the Patient-Provider Conversation Right

Jun 15, 2016, 9:00 AM, Posted by

Doctors and patients want to talk transparently about the costs and value of health care, but it’s easier said than done.

A medical assistant checks a patient's blood pressure.

Health care is too often the most stressful part of the American family's budget. In a 2015 survey from the Kaiser Family Foundation, 42 percent of respondents reported that it is somewhat or very difficult to afford health services. This difficulty ranked higher than monthly utilities, housing, food expenses and transportation costs. In the same survey, more than half of respondents said that making information about the price of medical appointments, procedures and tests more available to patients should be a “top health care priority” for the President and Congress.

Rising out-of-pocket costs helped shape these attitudes, and they are hitting patients in the U.S. at all levels. For people with job-based insurance, the number of individuals with plan deductibles—and the size of those deductibles—has grown rapidly in recent years. In 2015, the rate of covered workers enrolled in a plan with an annual deductible of $1,000 or more for single coverage was 63 percent, a significant jump from 10 percent in 2006. This year, deductibles in marketplace plans are even higher than employer insurance, averaging $3,064 for coverage in the popular "silver" tier. For low-income marketplace enrollees, they might qualify for cost-sharing reductions, but they aren’t completely shielded from out-of-pocket expenses.

How can we lower the burden of health care costs in the U.S.?

Price transparency tools are increasingly available, and both patients and providers are interested in incorporating elements of cost and value into clinical decision-making. Research to date, however, suggests that there are many barriers to holding these conversations effectively. Clinicians and patients cite a variety of barriers, and there are few established best practices to guide providers in initiating these critical conversations. Patients and clinicians want to have these conversations, but they aren't having them as often or as effectively as they could. A reported 59 to 80 percent of patients said they want to discuss out-of-pocket costs during medical visits and an overwhelming majority of doctors consider “managing patient costs” important. However, neither party is fully equipped to engage in these conversations right now.

Even though physicians report that they "should consider patients' out-of-pocket costs" as part of clinical decision-making, building these discussions into the encounter is easier said than done. Providers may be unfamiliar with a patient’s insurance—the specific details of coverage and cost-sharing—complicating efforts to discuss out-of-pocket expenses on a granular level. Moreover, providers are often unaware of how much medical interventions cost; even if they have access to their institution’s “chargemaster,” actual charges will vary by payer. These barriers are made worse by the short amount of time a clinician is able to spend on any given visit, not to mention the expressed discomfort physicians have raising cost of care with patients for fear of seeming inappropriate or losing trust. Contrary to some concerns, discussions that signal sensitivity to patients’ financial situations and seek to include them in decision-making can actually build trust in the doctor-patient relationship.

From the patient perspective, there’s worry that doctors will be unhelpful in reducing costs, or that bringing up financial concerns will lead to lower-quality care. Vulnerable, low-income patient populations can face even more challenges talking about cost, like greater financial constraints, challenges accessing or utilizing transparency tools and lack of trust in the health care system. Missed opportunities to have conversations that could potentially reduce out-of-pocket burdens have consequences, like not adhering to prescribed regimens because patients cannot afford services or medication.

It’s critical that patients are supported in these decisions; clinicians are ideally situated to not only help patients understand and navigate their options, but to also adapt care plans to patients’ individual goals and life circumstances.

Calls for price transparency have led to a large increase in price and cost-estimation tools from insurers, consumer groups and other independent organizations. To maximize the impact of these tools, they need to be used effectively in a shared decision-making context: cost should be weighed with patient preferences and clinical evidence so that patients obtain care that they personally consider “valuable.” It’s critical that patients are supported in these decisions; clinicians are ideally situated to not only help patients understand and navigate their options, but to also adapt care plans to patients’ individual goals and life circumstances.

Barriers to integrating cost-of-care conversations into the clinical encounter take many different forms. Providers might want electronic health records (EHRs) modified to make charge data and decision-support tools available at their fingertips. Recognizing that the care continuum is not limited to discrete medical visits, care teams could consider engaging patients before or after appointments, by phone, through patient portals or using other forms of contact that are most satisfactory for their patients. Beyond building a new infrastructure of resources, routinely engaging patients in effective conversations may require cultural change among staff.

At the Robert Wood Johnson Foundation (RWJF), we are committed to improving our country’s health care system in order to achieve better outcomes for everyone. This includes ensuring that individuals and families have the tools and information they need to make informed decisions about their health and care, and that health care professionals have the tools they need to deliver equitable, patient-centered, high-value care. Working with Avalere Health, we found that there is a current need to develop standards and best practices to support integrating dimensions of cost and value into shared decision-making, so RWJF will fund projects addressing this issue across different vulnerable patient populations, care settings, and geographic areas.

Cost-of-care conversations have the potential to transform care delivery, moving our health care system toward higher-value care and enabling patients to make the best choices for their needs. But first, we need to figure out how to get that conversation right. Projects supported by these grants will help do just that.

Emmy Ganos

Emmy Ganos, PhD, is a program officer at the Robert Wood Johnson Foundation where she focuses on ensuring our economy is less burdened by excessive and unwarranted health care spending. Read her full bio.