Conversations About Financial Issues in Routine Oncology Practices

A Multicenter Study

Rahma Warsame, MD; Cassie C. Kennedy, MD; Ashok Kumbamu, PhD; Megan Branda, MS; Cara Fernandez; Brittany Kimball, MD; Aaron L. Leppin, MD; Thomas O'Byrne, MAS; Aminah Jatoi, MD; Heinz-Josef Lenz, MD; Jon C. Tilburt, MD


J Oncol Pract. 2019;15(8):e690-e703. 

In This Article

Abstract and Introduction


Purpose: To describe the frequency, content, dynamics, and patterns of cost conversations in academic medical oncology across tumor types.

Patients and Methods: We reviewed 529 audio recordings between May 3, 2012, to September 23, 2014, from a prospective three-site communication study in which patients at any stage of management for any solid tumor malignancy were seen in routine oncology appointments. Recordings were deidentified, transcribed, and flagged for any mention of cost. We coded encounters and used qualitative thematic analysis.

Results: Financial issues were discussed in 151 (28%) of 529 recordings. Conversations lasted shorter than 2 minutes on average. Patients/caregivers raised a majority of discussions (106 of 151), and 40% of cost concerns raised by patients/caregivers were not verbally acknowledged by clinicians. Social service referrals were made only six times. Themes from content analysis were related to insurance eligibility/process, work insecurity, cost of drugs, cost used as tool to influence medical decision making, health care–specific costs, and basic needs. Financial concerns influenced oncology work processes via test or medication coverage denials, creating paperwork for clinicians, potentially influencing patient involvement in trials, and leading to medication self-rationing or similar behaviors. Typically, financial concerns were associated with negative emotions.

Conclusion: Financial issues were raised in approximately one in four academic oncology visits. These brief conversations were usually initiated by patients/caregivers, went frequently unaddressed by clinicians, and seemed to influence medical decision making and work processes and contribute to distress. Themes identified shed light on the kinds of gaps that must be addressed to help patients with cancer cope with the rising cost of care.


The cost of cancer care in the United States is projected to balloon to $157 billion by 2020.[1,2] This cost is transferred to patients, resulting in financial burden, increased declarations of bankruptcy, decreased adherence to treatment, poorer quality of life, and worse survival.[3,4] Although aware of financial issues, oncologists feel ill equipped to address them.[5–8] In an effort to aid oncologists in addressing cost, the ASCO Value Framework highlights the toxicity and quality of life impact of care costs,[9,10] and the National Comprehensive Cancer Network (NCCN) evidence blocks now take cost into consideration.[11] Although these initiatives may not yet be suited for routine clinical use and may focus too heavily on comparing costs of two treatments (ASCO) or on costs of medications (NCCN), they highlight the need for specificity about how clinicians and patients broach this subject.

Little is known about the actual content of discussions about costs and other financial issues between patients and providers in real-world practice. Without this insight, it is difficult to offer improved training or devise interventions to adequately address costs in oncology care. Although the landscape of addressing value and cost of care in oncology is rapidly evolving, to shed some light on the broad range of economic stressors in cancer care and begin to gain insights into what to do about them, we turned to clinical conversations in real time. In this study, we sought to describe the baseline frequency, content, dynamics, and patterns of cost conversations in diverse academic settings using qualitative and quantitative methods.