Physicians order tests, prescribe drugs, give referrals to specialists, and recommend surgery — almost always without ever addressing how much all of it costs.
“Even though patients and physicians alike express positive attitudes about having cost conversations, the rates are still quite low,” says Nancy Grant Harrington, PhD, director of the University of Kentucky Health Communication Research Collaborative.
Cost conversations occurred in only about 28% of visits, according to a recent review of 54 studies.1 It is not because patients do not want to discuss it. “Among the studies that included data on both desire for cost conversations and incidence of cost conversations, desire exceeded incidence each and every time,” Harrington reports.
Clearly, money conversations are not part of most healthcare visits. “We think one of the main reasons is because people just don’t know how to talk about cost,” Harrington offers. Some other key findings:
• Patients preferred a physician who discussed cost over one who did not. This flies in the face of a common misconception — that patients do not want to talk about money with their doctors.
• Conversation timing is important. Ideally, it happens before a treatment plan is finalized. “If a treatment decision is made, then later it’s determined that the patient simply cannot afford it, then it’s like starting from scratch. That’s a waste of time that no one wants,” Harrington explains.
• Conversations that included discussion of cost were somewhat longer than those that did not. Physicians already are stressed about patient flow. They worry if they bring up money, it is going to wreak havoc on their schedule — and there is some truth to that. “Still, considering the negative impact that cost can have on patient financial and psychological well-being, a slightly longer office visit may be worth the investment,” Harrington suggests.
Physicians can address costs without it taking over the entire visit. “It is the quality of the conversation, not the quantity, that matters,” Harrington notes.
Try a simple statement: “We want to make sure to consider the treatment options that are right for you. We’ll want to consider cost to make sure that we find a treatment option that works for you financially.”
• Patients may assume if they do not fill a costly prescription, their physician will realize it is too expensive. “One of the unsettling findings was that some patients hope that nonadherence to treatment will be a clue to their physicians that cost is an issue,” Harrington says.
Telling physicians the true reason is a much better idea. That gives everyone a chance to come up with an alternate plan (e.g., finding a lower-cost medication, or giving patients free samples).
To learn more about cost-of-care conversations between physicians and patients, the same group of researchers interviewed 36 primary care physicians.2 Some physicians directly addressed cost, some avoided any discussion of costs, and some falsely reassured patients about cost concerns.
“Physicians need to develop communication skills to discuss what is perceived to be a difficult topic. This is an important gap that needs to be addressed,” Harrington says. What keeps physicians from talking about money?
• Neither patients nor physicians are comfortable bringing up money. It is no wonder physicians avoid it. After all, they do not know what portion of the bill the health plan is going to cover. “No one expects physicians to have all sorts of cost information at hand,” Harrington observes.
Physicians should acknowledge that part of their role is coming up with a plan that will not financially devastate the patient. “When there are treatment options, including cost as a factor in decision-making should be a matter of course,” Harrington suggests.
• Physicians already are pressed for time. It is not realistic or desirable for physicians to spend loads of time navigating the complexities of health coverage. “Physicians should not be having deep financial conversations. It is not their area of expertise,” says Jonathan Wiik, principal of healthcare strategy at TransUnion Healthcare.
Physicians are trained to diagnose and treat patients, not deal with health plans. “In my experience, it has proved very difficult to engage physicians in cost. They want what is best for their patient, regardless of cost,” Wiik reports.
Investigators surveyed 45 oncologists to assess their knowledge of treatment costs, insurance coverage, and copays.3 Generally, respondents said they did not know much about out-of-pocket costs. One-third said they were confident about their insurance knowledge, but only 16% expressed confidence about their out-of-pocket costs knowledge and 8% expressed confidence about their copay knowledge.
Still, 58% of respondents had changed a patient’s treatment plan in the previous year specifically because it cost too much. Overall, 36% of respondents talked about costs with patients.
A primary care physician would not try to manage someone’s myocardial infarction; they would call a cardiologist. Likewise, physicians need someone with insurance expertise with whom they can discuss cost issues. That is where revenue cycle staff come in. “The physicians need to direct all patients to the financial navigators. Dentist offices have been doing this for decades, that little desk you stop at on your way out,” Wiik says.
Patients stop to pay and ask financial questions. Ideally, says Wiik, hospitals could use the same approach, with financial counselors stationed right next to the registration area. “Financial discussions should occur as close to treatment as possible,” Wiik offers.
• Physicians do not want costs to stand in the way of patients’ medical needs. “However, not discussing payment with patients prior to service could actually increase risk,” says Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP, a Medicare regulatory specialist with Chicago-based R1 RCM Physician Advisory Solutions.
That is because patients agree on a treatment plan during the office visit. At that time, they may not know what their insurance will cover. The trouble starts later, when patients find out the bad news on their coverage. Some decide to forgo the ordered tests or expensive drugs.
That is a bad model, according to Hirsch. Telling patients the cost earlier buys time to come up with a better plan. “For example, many of the new medications for diabetes have costs that exceed $500 a month,” he notes.
If cost is going to be a barrier to filling a prescription or undergoing a test, physicians should ask patients to contact the office so everyone can work together on an alternate treatment plan.
• Physicians usually do not know what health plans are going to cover. “Physicians need easily accessible information to ensure every prescribed medication is on the insurer’s formulary,” Hirsch says.
A patient visits the pharmacy — and learns about an astronomical copay because that particular drug is not on the health plan’s formulary. “No condition has ever been successfully treated by a medication that the patient wasn’t able to purchase,” Hirsch says.
Physicians need this information in real time as part of their normal workflow. For example, when a physician orders a diagnostic test, automated tools can perform checks: Is prior authorization needed? Is the test a covered service? Are medical necessity criteria met? Is the plan even in network?
Likewise, if a non-formulary medication is ordered, other options should appear automatically. “This can reduce denials, improve the patient and physician experience, and help patient access teams work more efficiently,” Hirsch says.
- Harrington NG, Scott AM, Spencer EA. Working toward evidence-based guidelines for cost-of-care conversations between patients and physicians: A systematic review of the literature. Soc Sci Med 2020;258:113084.
- Scott AM, Harrington NG, Spencer E. Primary care physicians’ strategic pursuit of multiple goals in cost-of-care conversations with patients. Health Commun 2020;4:1-13.
- Fischer KA, Walling A, Wenger N, Glaspy J. Cost health literacy as a physician skill-set: The relationship between oncologist reported knowledge and engagement with patients on financial toxicity. Support Care Cancer 2020;28:5709-5715.