Physicians Often Consider Cost in Treatment Decisions, Survey Finds

Norra MacReady

May 07, 2019

Most internal medicine physicians recognize that the costs of care may be a burden to patients and are willing to discuss options with them, but few raise the issue, results of a new survey show.

Of 621 physicians responding to an email questionnaire, 89% said they knew of at least one patient who did not fill a prescription because of the cost, and 84% knew of at least one patient who went without medical care because he or she could not afford the tests, treatment, or follow-up care.

However, the survey also revealed that many physicians do not routinely bring up these concerns, preferring instead to look for "clues" that the patient may be struggling with costs, such as reluctance to follow through with certain treatments or tests, or poor control of chronic illnesses such as diabetes, the survey authors write.

The drawback to this approach, they caution, is that "such clues may not be present if patients are making sacrifices in other aspects of their lives in order to meet medical expenses," write Susan L. Perez, PhD, and coauthors in an article published online yesterday in Annals of Internal Medicine. The article appears in a special supplement on cost-of-care conversations, which includes tools for facilitating those conversations.

Perez and colleagues found that physicians also frequently cited lack of transparency of healthcare costs as a barrier to having these conversations with patients. However, the authors write, "not knowing precise costs does not prevent including cost concerns in conversations about treatment decisions."

There were other prominent themes emerging from the study: Physicians often relied on their own professional experience to anticipate what treatments might be most expensive, and clinicians are usually aware that patients may be making financial trade-offs in order to afford care, Perez and colleagues note.

Interviews and Survey

There were two components to the study designed by Perez, of the Department of Health Science, California State University, Sacramento, and colleagues. The first consisted of hour-long telephone interviews conducted with 20 internal medicine physicians across the United States. The participants were randomly selected from a national database of internal medicine physicians.

The second component consisted of a questionnaire developed from the themes identified in the interviews and from a literature review. The survey was emailed to 3000 randomly selected members of the American College of Physicians. Of 2927 eligible physicians, 621 responded, for a response rate of 21%. "Responders and nonresponders did not differ in terms of age, race, subspecialty, professional activity, or geographic region," the authors write.

Of these participants, 478 (77%) reported knowledge of cases in which a patient had taken medication less often or in smaller doses than recommended because of the expense. Similarly, 555 (89%) and 519 (84%), respectively, knew of at least one patient who did not fill a prescription or went without treatment because of cost concerns.

Yet, just 50% of the survey respondents "reported having frequent discussions about [out-of-pocket] costs on a daily basis with their patients," Perez and colleagues write.

In a breakdown of factors considered when prescribing drugs, 564 (91%) respondents cited cost to the patient as the most or second most important consideration, other than medical necessity.

In a similar question pertaining to medical tests, 550 respondents (89%) reported that cost was a somewhat, moderately, or extremely important factor in the decision to order certain tests, beyond medical need.

Lessons Learned

The supplement also includes an article on how physicians can have effective cost-of-care conversations with patients. "It is clearly time for physicians to screen for health care-related financial hardship in a systematic way," write Caroline E. Sloan, MD, of Duke University School of Medicine, Durham, North Carolina, and Peter A. Ubel, MD, of Fuqua School of Business, Duke University.

Their other key recommendations include:

  • Discuss the "cost prognosis:" future costs related to the diagnosis

  • Anticipate indirect costs of appointments, such as child care, transportation, and time lost from work

  • Incorporate routine discussions of out-of-pocket costs into the medical visit

  • Integrate these conversations into the appointment in a way that best fits with the overall workflow of the practice

  • Empower ancillary staff to have these discussions with patients

  • Realize that it does get easier: "as physicians have more cost-of-care conversations, they get better at them"

Overall, Sloan and Ubel write, including cost conversations could "move us closer to the kind of patient-centered care that characterizes the ideals of our profession."

One of the study authors reports a grant from the Robert Wood Johnson Foundation and a grant subcontract from Consumer Reports, as well as employment by the American College of Physicians, during the conduct of the study, and spousal employment by Merck & Co outside the submitted work. Sloan, Ubel, and the other study authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online May 6, 2019. Full text, Guide to Effective Patient Conversations

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