Delivering the "New Bad News": Discussing Cost With Patients

Roxanne Nelson

June 16, 2010

June 16, 2010 (Chicago, Illinois) — Discussing the cost of cancer care with patients might be the "new bad news" that oncologists are going to have to discuss with their patients.

Although many physicians are uncomfortable discussing healthcare costs with patients or don't feel that it is the physician's job to do so, there is a growing consensus that cost has become an issue that can no longer be ignored.

"As physicians, we're trained to make treatment decisions without the influence of money or insurance companies, and should be guided by what is best for the patient and not constrained by financial concerns," explained Lidia Schapira, MD, who moderated a session on addressing the cost of cancer care with patients here at the American Society of Clinical Oncology (ASCO) 2010 Annual Meeting. Dr. Schapira is assistant professor of medicine at Harvard Medical School in Boston, Massachusetts.

"We've learned to talk to our patients about sex, we've learned to talk to our patients about death. Now the question is should we talk to patients about money and the cost of care," said Dr. Schapira. "The fundamental question is: What can we accomplish by discussing cost of care in the clinical setting?"

Escalating costs and the national debate over healthcare reform are forcing physicians to grapple with the financial side of care. But there are many barriers to physician–patient discussions about cost, explained Dr. Schapira.

It's kind of messy territory for us.

One is that "as physicians, we have mixed loyalties; we are drivers of medical costs and, on the other hand, we are advocates for our patients," she said. "It's kind of messy territory for us."

Patients might be embarrassed to discuss their finances with their physician and fear that it will affect treatment decisions, she continued. There are also time constraints.

"It may be very difficult to have this discussion in the context of an often busy and very rushed medical practice," Dr. Schapira noted. "Let's face it, patients may be unwilling to mention their cost concerns because they don't want you to recommend anything except what you think is best for them."

Finally, patients may feel that physicians "don't have a clue about this sometimes," she said. "If the doctor is not going to be able to solve the problem, they probably have learned from experience that they're not very interested or keen in talking about it. We've seen the same evolution in other topics that physicians often find difficult to talk about."

Many Oncologists Willing to Discuss

Financial concerns affect treatment decisions, and out-of-pocket expenses have an impact on individual and family budgets. As previously reported by Medscape Oncology, studies have shown that even for patients with private health insurance, many face huge debts, personal bankruptcy, and delay or forgo treatment. Other research has shown that trying to cope with the financial impact of cancer care is associated with symptoms that include extremely high levels of anxiety, depression, and other mental health problems.

Some surveys indicate that many oncologists are willing to discuss issues of cost and feel that it is important to explain how treatment choice could affect a patient's finances.

"We need a strategy to address these issues in the context of medical consultations and office visits that will serve patients and strengthen the therapeutic alliance between physicians and patients," said Dr. Schapira.

How to Communicate

Discussing the nuts and bolts of cost can be a challenge for oncologists and, during his presentation, Anthony Back, MD, offered some practical communication tools that clinicians can use in the day to day office setting.

Clinicians should talk to patients about the costs that they have to pay out of pocket, said Dr. Back, professor of medicine at the University of Washington in Seattle. "It would be wonderful if I lived in a world where I didn't have to worry about cost, but the fact is, it is coming into my clinic several times, every clinic session," he said.

When patients hear bad news, they want empathy and guidance, Dr. Back explained. "They want their situation to be recognized but they want help in being guided and leadership from the doctor."

Talking about costs can build trust and enable discussion about value, he said, and using a cognitive map or a series of steps to provide scaffolding for a tough conversation can be helpful.

One such map is SPIKES:

  • Setup: Is there a private place to discuss the issue? Does the physician have the needed information to be convincing?

  • Perception: What does the patient know and what information are they coming into the discussion with?

  • Invitation: Checking in before proceeding (e.g., "I have something serious to discuss with you"). This gives the patient a moment to prepare, and perhaps some control over the flow of information coming at them.

  • Knowledge: Use language the patient understands.

  • Emotion: Respond empathically.

  • Summary.

Another set of tools is a simple 3-step program, said Dr. Back.

Step 1: Listen without trying to fix. "Stories about financial hardship are 'out of the box'," and they can be hard to listen to," he explained. "But they are not just venting — these stories give clues as to what's important in the patient's life."

That puts me in a must better position to be a trustworthy advisor.

"As I learn how their experience shapes what they are looking for and how they choose to live with cancer, that puts me in a much better position to be a trustworthy advisor," he added.

Step 2: Keep the real options in view. It is tempting to "bond" with the patient in bashing the insurance companies. Although on one level it is satisfying, it really doesn't move the conversation forward, Dr. Back pointed out.

"Focus on the options and lay out the pros and cons," he said. "Always lay out what is the more expensive option and lay out the pros and cons, and then the less expensive option and the pros and cons of that, and so on."

Step 3: Leave space for decision making. "Clinicians do not have the final say on how the patient and family should use his or her resources, and I need to respect that decision-making space and process," Dr. Back explained. "We have to realize that it might not be linear, it might not be rational, and it might not be just in terms of how I think families should operate; its their system and their disposable income."

With that in mind, the physician should ask the patient how they "would like to proceed in thinking about these options and the financial issues." Dr. Back acknowledged that it might take another session, either by phone or in person, for the patient to decide. The physician needs to gauge how well the patient has absorbed and understands this information.

ASCO Guidelines for Physician–Patient Communication

Last year, ASCO released a guide to help patients and doctors communicate about the costs associated with cancer care. It includes tools to help patients speak with their providers about managing the cost of cancer care, a summary of the costs associated with treatment, and a list of financial resources for patients in need of assistance.

"Our goal as doctors is to provide our patients with the best medicine possible based on the best science available, but the cost of care is starting to creep into the exam room and affect the treatment decisions we make with our patients," said Richard L. Schilsky, MD, former president of ASCO and professor of medicine at the University of Chicago Medical Center, in a release. "Helping doctors and their patients navigate the difficult and often emotional issues surrounding the cost of cancer care is a top priority for ASCO.

Dr. Schapira and Dr. Back have disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 2010 Annual Meeting: Presented June 6, 2010.



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