Discussing Costs in the Doctor-Patient Encounter

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Abstract

The cost of illness and medical care has a profound impact both for society as a whole and for each patient and family as they experience being sick and seeking treatment. Yet discussion of these costs between patients and their doctors has been largely discouraged. There are several reasons for the aversion to any discussion of costs including concerns about how possibly insensitive and disrespectful attention to money might be when treating a sick patient. Yet there are several ethically defensible reasons why one might encourage clinicians to talk to patients and their families about financial issues. Health care expenditures are rising at an unsustainable rate and emergent strategies to bend the cost curve will almost certainly put pressure on clinicians to deliver cost-effective care to patients. To the extent that clinicians have as their purview the well-being of their patients, ignoring the financial consequences of illness and medical care is ethically untenable and entails too narrow a focus of engagement of clinicians with patients. Finances affect patients whether or not clinicians discuss them in the clinical encounter. If physicians address costs during encounters, on the other hand, the doctor and patient might be able to work together to find affordable options for care, improve well-being, and trust might be enhanced. Furthermore, discussing costs openly in a way that allow patients to be active moral agents in considering treatment options is consistent with the physicians ethical duty to be honest and transparent with patients and matches the paradigm of patient-centered care that is commonly practiced today. Another reason to discuss costs in the clinical encounter is that when medical care is unaffordable, patients often go without treatment. Finances have been shown to affect the likelihood that patients receive the care that physicians advise them to receive. While one can make the case for the appropriateness of talking about costs in the doctor-patient encounter, unfortunately little is known about whether patients would welcome such a discussion and if so, how they would like the discussion to be handled. This project thus involves the conduct of 22 focus groups, including 2 pilot groups,to ascertain patients views about the discussion of cost in the doctor-patient encounter. Groups will include either English or Spanish speaking adult patients with the following varied characteristics: age (working adults with and without dependents and retirees); ethnic/racial groups (African American, Latino, Non-Hispanic whites); varied economic status (incomes below 300% of the Federal poverty threshold, and above); and geographic distribution (urban, suburban, and rural). The focus groups have been moderated by experienced facilitators from the RAND Corporation. We developed and then tested a moderator guide. The guide included open-ended questions and prompts that aim to elicit patient perspectives and experiences about costs of illness and health care, what role doctors should have in keeping costs down, and whether and how doctors should talk about costs/finances during patient encounters. Following more non-directive discussion at the outset, the moderator explored the responses of participants to a combined strategy of (a) informing them about the combined societal and personal costs of illness and medical care and (b) engaging in empathic communication is in making treatment choices. Group discussions have been digitally recorded to guarantee high fidelity of the recording. Focus groups that have been conducted in Spanish will be transcribed, translated by an interpreter, and transcribed into English. While this is an exploratory study, our analytic strategy examines several hypotheses. We anticipated that patients will generally be more receptive to talking to physicians about personal costs and their personal financial concerns thanabout societal costs. We anticipated that patients will be willing to discuss comparative effectiveness and cost effectiveness as a factor in choosing medical interventions. We hypothesized that following the presentation of instructive materials patients will be more likely to appreciate the societal cost of medical care which may enhance their willingness to partner with their physicians in addressing costs. We hypothesized that among various strategies for discussion patients will prefer empathic communication strategies in discussing costs. We anticipated that addressing both societal and personal costs will require a combination of both enlightening patients about the reality of the combined costs and then negotiating with them empathically. We expectd that patients will find approaches that involve greater explanation and shared decision-making will be more acceptable than more directive and abrupt approaches. Data has now been analyzed. One manuscript has been submitted for publication and one manuscript is in preparation.