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How to Talk With Patients About Payment Issues

Physicians sometimes struggle with how a patient's finances should affect treatment options. On the surface, most doctors recognize the need to deal with costs in some way. In a 2019 survey of internists, for example, three quarters said that they considered out-of-pocket costs when making most clinical decisions.

Many physicians are aware that patients may modify or even abandon treatment because of financial concerns, often without the doctor's knowledge. One quarter of US residents admitted to skipping medical care because of the cost, according to a 2020 survey.

How should doctors deal with this problem? Rather than allow patients to make bad choices, such as rejecting essential treatment, physicians can work with these patients and help them make better choices. When patients are incapable of paying for the full array of services, reducing the number or extent of services may not be the perfect option, but it may prove to be acceptable.

Many physicians, however, believe that any form of abbreviated care is unacceptable. In a 2016 survey of physicians in an accountable care organization, many respondents said cost reduction for patients was not the doctor's responsibility. Another survey of physicians was even clearer: Only one third said that they were required to reduce healthcare costs.

That is, many physicians prefer to focus only on clinical factors. These decisions, they might argue, should be made irrespective of cost.

Studies have shown that most doctors don't change their practice style when treating financially strapped patients. A 2017 study regarding so-called low-value services — such as inappropriate imaging or narcotics for acute low back pain — found that the number of physician orders were basically the same for uninsured and insured patients.

Possibility of Malpractice Accusations

Doctors may face legal issues when ordering fewer services for certain patients. Another study found that physicians who generated higher costs — presumably because they ordered more tests, procedures, and consultations — were less likely to be accused of malpractice the next year than colleagues who ordered fewer tests.

There are ways, however, for physicians who order fewer services to avoid malpractice lawsuits to some degree. Working with patients in shared decision-making, so that both agree on the care plan, has been shown to reduce liability. When the doctor and patient choose a nonstandard plan of care, the physician must then chart why it was selected and verify that the patient was informed of the risks involved.

Should You Alter Your Practice Style?

Deciding if and when to alter clinical care is a decision each physician has to make on the basis of their own research, the views of trusted colleagues, and specialty society recommendations, such as those made for the Choosing Wisely program.

Choosing Wisely, launched in 2012 by the American Board of Internal Medicine Foundation, asked specialty societies to identify at least five common interventions that often provide little benefit and could be used less frequently. By 2018, the program encompassed 552 recommendations from more than 70 specialty societies, covering such areas as imaging, screenings, exams, and medications.

Imaging is often seen as an appropriate place to reduce services. In fact, most physicians seem willing to at least discuss this possibility. In a survey by Choosing Wisely, 81% felt comfortable talking to patients about why they should avoid an unnecessary test or procedure. Doctors who knew about the costs ordered 8.6% fewer tests and procedures, according to a 2013 study.

Why Cost Conversations With Patients Rarely Happen

When physicians contemplate reducing services, they need to have a conversation with the patient. However, studies show that these discussions rarely occur, primarily because most physicians are uncomfortable discussing patients' ability to pay for services.

Likewise, patients tend to avoid raising this issue. So it's usually up to physicians and their staff take the initiative.

Doctors who don't want to change their practice style may decide there's little reason to broach monetary issues with patients. However, being aware that a patient has cost concerns can help determine whether the patient is following all treatment directives.

Although physicians may be concerned that such conversations will take too much time, the American College of Physicians estimates that financial talks usually last less than 5 minutes. In fact, a study of oncologists found that these conversations took a median of 33 seconds in a 12-minute appointment. Moreover, having the conversation earlier in the course of care saves time later if a patient doesn't adhere to the treatment plan owing to monetary concerns.

Some physicians may believe a cost conversation isn't useful because the price of treatment can't be predicted ahead of time. Still, it's possible to provide a ballpark estimate, with provisos that if such-and-such happens, costs will increase. Many physicians, however, don't have this option because they are unaware of basic costs.

Know About the Cost of Care

Estimating prices can be a daunting task, primarily because these numbers, even for a doctor's own services, vary depending on the type of payment: cash, negotiated fee for a particular insurer, or the fixed Medicare or Medicaid reimbursement. Deductibles add yet another dimension to determining costs.

In addition to the physician's own charges, primary care practices' staff can gather price estimates on typical charges from imaging centers, labs, ambulatory surgery centers, and even certain specialists.

Moreover, rather than just knowing what the physician charges, patients want to know what they would be paying. Most patients who require surgery, for example, have to pay a facility fee, an anesthesiologist's fee, and perhaps more if complications develop.

Discerning hospital prices can be particularly difficult, because most hospitals don't want to reveal the discounts that they negotiated with payers. This barrier may disappear for selected services under the Centers for Medicare & Medicaid Services (CMS) rule that requires hospitals to list standard and cash-pay prices for 300 healthcare services that consumers can schedule in advance.

The CMS rule went into effect in January 2021, however, many hospitals are not complying with the rule. Under the new rule, hospitals must post three price levels: gross charges, the price negotiated with insurers, and the cash price for patients.

Physicians and their staff won't be able to provide exact amounts ahead of time, but if they're willing to gather basic information and do some arithmetic, they'll be able to provide useful cost estimates for some typical services.

How to Discuss Costs With Patients

Discussing costs with patients takes some practice. Research shows that most patients want to discuss costs of care but they want physicians to start the conversation.

Doctors, for their part, often wait for clues of payment problems, such as patients not filling prescriptions, before asking about cost concerns. At this point, however, some damage has already been done. Many patients simply soldier on without disclosing their financial burdens.

Ideally, you or your practice should ask every patient about potential payment problems. This can be done in a mailed survey before a visit, on the questionnaire the patient completes while in the waiting room, during vital sign assessment, or by the doctor in the exam room.

To encourage patients to be frank about this sensitive topic, you and others should be clear that you are not being judgmental. Preface the conversation with a statement like, "I have a lot of patients who have trouble affording medications. Has that been an issue for you?"

When patients express monetary concerns, show them that you're their ally, not their taskmaster. It helps to use the pronoun "we" and to say "I wish" to indicate empathy with the patient, as in: "I wish there was a less expensive alternative for us to treat your pneumonia, but…"

Some patients may still be mistrustful. For instance, they may be convinced that your real motive for prescribing an expensive drug is that you're getting kickback payments from the drug company. Or they may think that there are less pricy ways to treat their condition that you're not disclosing.

Putting concerns on the table lets the patient retain some control, which is important for adherence and gives you a chance to provide the real story. In a 2016 study, Medicaid recipients said they were more likely to follow medical advice if providers collaborated with them on a care plan and respected their preferences.

Bring In Staff to Help

It's a good idea to rely on your staff to identify patients in financial need, find out about their concerns, research low-cost alternatives, survey prices, and help patients contact providers and agencies.

Staff may be more successful than physicians in eliciting candid responses from patients. Some patients are less reluctant to talk about nonadherent behaviors with staff than with physicians. Such conversations should be conducted out of earshot of other patients or staff, not only to comply with privacy laws but to generate openness.

In a small practice, a designated staff member may develop expertise on issues such as costs and available providers. Larger practices and hospitals often assign staff in the billing office to help patients with payment options and financial assistance.

These staffers, often called financial counselors, are a sizable workforce in large institutions. In 2019, for example, UCHealth in Colorado reported having 65 financial counselors who educated patients about costs, payment responsibilities, and financial assistance programs.

Advisors who are referred to as financial navigators are now common in oncology because bills can be very high, and patients may need emotional as well as practical assistance. Data have shown that financial navigators help reduce no-show rates, boost collections, and improve patient satisfaction scores. The field is growing; in 2019, the Advisory Board reported that 43% of cancer care centers were planning to add to their financial advocacy programs in the next 12 months.

Be Sensitive to Patients' Issues

Many physicians and other caregivers who have worked closely with the uninsured and underinsured are now particularly sensitive to patients' financial anxieties. When addressing monetary issues with your patients:

Be aware of the deductible year. For patients with high deductibles, schedule appointments at the end of the calendar year, when it's more likely that the deductible has been met and insurance coverage has started. In the case of treatments spanning several months, try to keep the last visit from spilling over into the next year. Sometimes, however, the opposite strategy may be beneficial. Scheduling an expensive procedure at the beginning of the year, for example, means that the patient will have then met the deductible for the rest of the year, thereby reducing his or her out-of-pocket costs.

Know the preventive services that are not subject to deductibles. Under the Affordable Care Act, certain preventive services have to be covered by the insurer and are not subject to the deductible. These include basic colonoscopy; diabetes screening; lung cancer screening; obesity screening and counseling; statin medication for high-risk adults; HIV screening; and many immunizations, including influenza, shingles, and tetanus.

Avoid inadvertent out-of-network care. Insured patients may have to pay much more for out-of-network care because these services aren't covered in negotiated agreements with the insurer. These extra charges can be unexpected, such as for a surgery where the anesthesiologist is out-of-network. Many states, however, have passed surprise billing laws that limit when out-of-network billers can charge, and the federal government recently enacted a similar law.

Offer shared appointments. Patients with the same chronic disease, such as diabetes or stroke, can participate in group sessions and pay a lower fee than they would for a one-on-one visit. In some cases, these visits can be provided through telehealth.

See patients during evenings or on weekends. Many uninsured patients who work full-time often don't get paid time off during their workweek. Consider occasionally providing extended hours to allow those patients to see you later in the day or on weekends.


You may decide to alter your practice style to accommodate patients who have financial difficulties. This is often easiest to do by forgoing tests that have been cited by the profession as unnecessary in many cases.

Because patients are typically unwilling to inform their doctors about financial problems, it will usually be up to you and your staff to elicit this information. Successfully discussing costs with patients requires being cognizant of and sensitive to patients' concerns and working with patients as a team — both undertakings that do not take a lot of time.

Though the costs of care cannot be predicted with exactitude, prices can be presented as estimates. However, this requires the practice to gather cost estimates and calculate total costs, and the physician must be willing to present different care scenarios.

In Chapter 5, about medications, many of these principles will apply. Although physicians usually don't bill for medications, their decisions regarding which drugs to prescribe can greatly affect patients' medical expenses.

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John Dickens; In K. Kim, MD, MBA; Beth A. Spurlin, MD, PhD, MBA

| Disclosures | January 01, 2022

Authors and Disclosures

John Dickens
MD/MBA student
University of Louisville School of Medicine
Louisville, Kentucky

Disclosure: John Dickens has disclosed no relevant financial relationships.

In K. Kim, MD, MBA
Executive Vice Chair and Professor of Pediatrics
University of Louisville School of Medicine
Louisville, Kentucky

Disclosure: In K. Kim, MD, MBA, has disclosed no relevant financial relationships.

Beth A. Spurlin, MD, PhD, MBA
Pediatric Emergency Medicine
University of Louisville School of Medicine
Louisville, Kentucky

Disclosure: Beth A. Spurlin, MD, PhD, MBA, has disclosed no relevant financial relationships.