Exam room taboo: Talking about money

  | October 4, 2017

It was Mark Twain who reportedly said, “Everybody talks about the weather, but nobody does anything about it."

He might have said the opposite about the cost of healthcare: Everyone wants to do something about it, but no one talks about it.

For patients and clinicians, it's time to break with that tradition. Or so says the Robert Wood Johnson Foundation (RWJF), which is sponsoring an ongoing initiative to determine the best ways to introduce cost discussions into office visits without damaging the clinician-patient relationship.

Across the board, patients' out-of-pocket costs are on the rise, driven primarily by the increase in high-deductible health plans.

study funded by the foundation and conducted earlier this year by the public policy group Public Agenda found that 70 percent of Americans think it's a good idea for doctors and their staffs to discuss prices with patients, but only 28 percent say a doctor or staff member has brought up price in conversation with them.

“Patients want to talk about price. It's important to find ways to start this conversation so it is positive and constructive," says Andrea Ducas, a program officer for the project.

Research by Duke University professor Peter Ubel, M.D., also funded by RWJF, determined that conversations as short as one minute could save patients money. But that short talk can be tricky to fame correctly. One reason why is that vulnerable patient populations can be hesitant to broach cost with their physicians. Another issue is process-related: How can providers ensure that patients have the electronic tools and staff support they need to follow through with cost-related recommendations?

Facilitating cost-of-care conversations

To tackle both those issues, the foundation worked with the consulting group Avalere Health to design two calls for proposals to support cost-of-care conversations in clinical encounters.

About $1 million is funding projects that explore how to optimize cost conversations for vulnerable patient populations, such as racial and ethnic minorities, low-income populations, the newly insured, and populations for which English is not a primary language.

“We spoke with a lot of experts as well as [conferring] internally, and the more we did, the more we heard that not every [patient] feels the same way," says RWJF program officer Emmy Ganos. “There are lots of sensitivities about race, ethnicity and social class, and fears about receiving lower-quality care. The more we unpacked this, the more we knew you can't just have a group of experts come together and decide on best practices."

An additional $900,000 is funding studies looking at how to incorporate cost conversations into the clinical workflow, such as ensuring the successful integration of cost tools into electronic health records and including non-clinical staff who are trained to support patients in cost-of-care issues.

“This area is in our sweet spot," says Katherine Steinberg, vice president of Avalere's Center for Payment and Delivery InnovationFour grantees for each year-long project began work in December 2016.

One project, focusing on high-risk ob-gyn patients at a clinic in Chicago, aims to create tools to help women understand the cost of their care throughout their journey, “including upstream costs like time off from work, getting to and from appointments, childcare, those kinds of things," Steinberg says. “How do we help create insight into what they can plan for?"

Another project is looking at how pricing websites affect treatment of low back pain at 12 sites in Maine. Consumers Union is engaging with members of vulnerable populations and their physicians, using multi-step rapid-cycle testing to design effective messaging and dissemination of information about the websites.

“[The projects] really run the gamut, and having a short turnaround — a year is short for this type of research — creates more rapid opportunities for addressing the use and value of cost-of-care conversations," Steinberg says.

Early takeaways

Final results won't be available until next year, but “based on what has been done so far, we have learned a lot," Ganos says. “It is more than just price transparency." Some takeaways from the studies so far:

  • We know that cost conversations are happening a lot, and our data have corroborated that," Ganos says. “Lots of patients are asking about cost, so the message [to providers] is, 'Like it or not, here it comes.'"
  • Providers might not always recognize these discussions as cost conversations. “They may hear things like 'This drug is really expensive,'" she says. “It doesn't solve a problem, but questions are coming up quite a bit."
  • Cost concerns vary by condition and individual comfort level. “A lot of people have real fears of talking about cost or don't think it is the best use of their doctor's time," Ganos says.
  • Focus groups are finding that pricing “is a really emotional topic to talk about," Ganos says. “It's about tradeoffs people have to make in their lives. They are forgoing procedures or not having as many visits with the doctor because they can't afford it. It has brought up complex and traumatic stories. Whether physicians are comfortable having these conversations or not, they have real consequences for patients."

That last point is at the core of RWJF's research. Cost and financial stress are important to everybody, Steinberg says, but “we know that there is a lot of discomfort in these conversations. The more we can make people feel comfortable discussing this, the more effective we can be in addressing it."

David Levine is a regular contributor to athenaInsight.

Exam room taboo: Talking about money