Patient Advocate Foundation and National Patient Advocate Foundation, Washington, DC
Dr Balch is the chief executive officer at the Patient Advocate Foundation and National Patient Advocate Foundation, Washington, DC.
J Clin Pathways. 2018;4(8):34-35. doi:10.25270/jcp.2018.10.00041
In Part 1 of this 2-part column series on shared decision making, we discussed the need for health care teams to create a safe and inviting environment for patients to talk about financial concerns and questions related to their treatment. In this Part 2 of the series, practical next steps are outlined that providers can take to ensure that these conversations are integrated into the workflow and how to make the most of these conversations.
In the last column, the importance of conversations between patients and their health care providers related to the costs of care—both the direct costs of medical treatment and those resulting from the impact of their illness on their lives—was discussed.1 While there are a number of barriers to having these conversations, there are also potential solutions, steps that both patients and their physicians can take to integrate these discussions into the clinical workflow and assure that they contribute to genuine shared decision making.
That process begins before the actual patient appointment. Patients and their providers benefit from having timely, accessible information before they sit down to make treatment decisions. Similarly, patients who have a general understanding of their diagnoses and their treatment options prior to provider/patient discussions are better able to assess the financial impact of their care and make plans to address those consequences. This is not a small issue. Most people do not have a thorough understanding of how the health care system works or of the expenses they are likely to incur if they become seriously ill. As case manager Pat Jolley at the Patient Advocate Foundation said in a recent conversation:
Almost everyone who has insurance just assumes that their health care expenses will be covered, and that is increasingly not the case. Patients are bearing more and more of the costs of their care through high deductibles, copays, and uncovered or out-of-network care. It’s very important to know what your insurance covers and what it does not before the bills start piling up.
These issues are even more significant for people who are uninsured or have no coverage.
Providers also have an obligation to be aware of the financial impact of their treatment choices on their patients’ lives. It is no longer acceptable to view money issues as outside of the physician’s area of responsibility or to plead ignorance of the cost of care. Providers need to make sure patients have the information they need and to inquire proactively about patient concerns related to the financial impact of their care. These conversations usually require only a few minutes, especially when they are standardized and included on a regular basis—and they often save time in the long run. One physician participant in a recent study funded by the Robert Wood Johnson Foundation summed it up this way:
I’ll see a patient back in a few months, and their diabetes is under poor control. But they don’t tell me anything. And I’ll call them back in a few days and say, “Your diabetes isn’t doing well. I’m surprised that the medicines I put you on aren’t helping.” And only at that point, the patients says, “Well, I haven’t been taking them because I couldn’t afford them.” So, we’ve wasted months and months, just to find out the patient couldn’t afford the medicines. 2
This “waste of time” cuts both ways. The physician’s time has not been well spent following a pathway that the patient did not adhere to, and the patient has lost valuable time in controlling his disease. It is a strong argument for having the discussion up front at the beginning.
There is also a critical need to develop and use tools and resources that directly address cost-of-care issues. These can include print, audiovisual, and digital materials that help patients understand treatment-related costs as well as readily available information on the resources that exist for patients facing or already dealing with financial burden from their care. Involving patients and caregivers in developing these tools assures that they are appropriate for various conditions, levels of health literacy, and cultural orientations.
Good education and effective tools work best when they are fully integrated into the clinical workflow. Providers can prepare cost-of-care questions in advance and embed them in the clinical assessment. Physicians have primary responsibility for ensuring that these conversations take place, but nurse practitioners, nurses, and social workers play a critical role as they often have more time to spend with patients and may be more attuned to financial distress signals. This is not a one-size-fits-all proposition. Large academic centers are likely to have more personnel and resources dedicated to helping people mitigate the financial burdens of their care. But the core of these efforts is scalable to any clinical setting.
In some instances, clinical pathways may actually discourage cost-of-care conversations. When pathways dictate or strongly guide treatment choices, they may cut off or limit patient-provider exchanges designed to assess financial impact. This is another good argument for standardizing questions that allow patients to express their concerns about both direct and indirect costs of their care and align their choices with therapies that fit both their clinical condition and their lives.
On the other hand, clinical pathways could potentially be utilized when it comes to measurement. As with all clinical interventions, measuring both process and outcomes is critical. These measures should include hearing the patient voice as well as assessing the impact of cost-of-care discussions on patient adherence to care recommendations and treatment outcomes.
The real key to addressing this issue is recognizing the importance of having these conversations and taking the necessary steps to make them a regular component of everyday clinical interactions.
1. Balch A. Talking about costs of care during shared decision making—part one: the problem. J Clin Pathways. 2018;4(6):32-33.
2. Consumers Union. Patient and Provider Cost Conversations [proprietary report].