Cost of Care: 5 Tips on How to Talk to Patients

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It is often the elephant in the room in a patient encounter. The physician tells the patient that they require a battery of tests or long-term treatment with a prescription medication. The patient is thinking: How will I pay for this? Can I afford it?

“That has a tremendous impact on adherence and following through on treatment plans,” says Wendy Nickel, MPH, Director of the Center for Patient Partnership in Healthcare, American College of Physicians (ACP).

Physicians should not be afraid to discuss finances with patients, said Nickel, who gave a presentation on the out-of-pocket costs of care at the ACP Internal Medicine Meeting 2018 in New Orleans, Louisiana.

Unfortunately, the conversation is not happening often enough, Nickel said in an interview with Patient Care.

According to one survey published in JAMA¹, 79% of internists believed that patients wanted to discuss out-of-pocket costs, and 63% of their patients agreed. However, only 15% of patients said they had ever discussed those costs with the physician.

“As a physician, I need to acknowledge the fact that this is impacting my patients, but it is also impacting the care that I recommend,” says C. Jessica Dine, MD, Senior Fellow at the University of Pennsylvania Leonard Davis Institute of Health Economics, Philadelphia. “If I recommend something and a patient can’t afford it, it’s not going to happen.”

Next: Five Simple Strategies

In a recent ACP survey, physicians estimated that about 80% of patients changed their behavior with regard to prescription medication due to concerns about cost. For example, they may have taken fewer doses, or maybe they did not fill the prescription as often.

Fortunately, talking out-of-pocket costs with patients is a learnable skill. “There are already a lot of great resources out there,” Dine says. “To do this well, you don't need to learn a lot more, and it doesn't take as much time as we think.”

Here are five strategies Dine and Nickel shared on how to help patients navigate cost of care:

1. Screen to Make it Routine

The first step is to make sure that cost concerns are routinely identified and addressed at each patient encounter. They suggest screening for “financial sensitivity,” possibly even before the patient is seen in the office, but it does not need to be the physician who starts the conversation. For example, front desk staff or other departments within a healthcare organization could use intake forms that include questions on whether the patient has any concerns about paying for treatment, or is having trouble paying medical bills.

2. Empower Patients to Ask

Having handouts, posters, or discussion guides in the office can help cost-sensitive patients understand the kind of questions they should be asking in advance. That includes not only questions related to co-pays or cost of medication, but also questions related to the indirect costs of care, such as, how much will parking cost? Or, how long can I expect to be at the appointment? since medical appointments may mean taking time off from work and arranging child care.

Next: Identify Lower Cost Options

3. Identify Lower Cost Options

Several online resources are available to help physicians and patients estimate out-of-pocket costs before any care is delivered. Sites such as Healthcare Bluebook, which offers a free “fair price search” and GoodRx, which compares prescription medication prices based on data from 60,000 US pharmacies.

Dine, a pulmonologist, says she uses GoodRx to research costs of common inhalers and programs the manufacturers may have for individuals with low income or high co-pays. “Now I know, for example, that if I prescribe Advair I can contact the company and sometimes get six months of the inhalers free or at reduced cost,” she says.

Another route to consider is purchasing medications outside of the US. Dine started simply by calling a few Canadian pharmacies to ask about prices and co-pays and then sent in a few prescriptions to confirm that they would deliver the same medication at the same potency. “We have a few pharmacies that we worked with that we now refer patients to,” she says.

Next: Consider a Plan Change and Use Body Language

4. (Potentially) Change the Care Plan

Once costs are clear, the physician and patient can ask whether a change to the plan of care is warranted based on that information. Most commonly, the strategy simply involves switching to a different medication, whether that be a generic option, a similar medication in the class, or one that has better insurance coverage for the patient.

5. Ramp Up Your (Verbal and Non-Verbal) Communication Skills

Empathetic communication strategies can help physicians connect with patients to ensure that cost concerns do not get in the way of optimal care, Dine says. Two examples include the Four Habits Model², framework that links communications strategies with medical and functional outcomes of care, and the E4 model³ for patient-physician communication that is useful regardless of specialty, experience, or practice setting, according to developers.

Body language is an important communication skill that should not be overlooked, even if it is something as simple as making eye contact, or avoiding multi-tasking (ie, not working on the computer while talking to the patient). “We really have to pay attention to body language when having conversations with patients, especially about some things that might feel uncomfortable, like cost of care,” Dine says.
 

References:

1. Caleb Alexander G, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA. 2003;290:953-958.

2. Frankel RM, Stein T. Getting the most out of the clinical encounter: the four habits model. J Med Pract Manage. 2001;16:184-191. 

3. Keller VF, Gregory Carroll J. A new model for physician-patient communication. PEC. 1994;23:131-140.