Physicians and patients rarely discuss costs

August 19, 2003

Although patients and physicians agree that discussion of out-of-pocket costs is important, researchers from the University of Chicago have found that these discussions rarely occur. Sixty-three percent of patients felt the need for such talks, according to a study in the August 20 issue of JAMA, but only 15 percent of patients reported that they discussed costs with their doctors.

Since patients pay about 20 percent of health care costs in the United States, this is an important omission. Out-of-pocket costs are a persistent concern to the public, creating enough of a burden that many patients forgo prescribed medications.

"This means that patients are changing the plan of care for financial reasons without consulting their doctors," said study author Caleb Alexander, MD, instructor of medicine, associate faculty in the MacLean Center for Clinical Medical Ethics and a member of the Robert Wood Johnson Clinical Scholars program at the University of Chicago.

"Although national changes in health care financing are needed," he said, "there are also things that individual physicians can do right now to help patients burdened by their out-of-pocket costs, such as using generic or less expensive medicines whenever possible. But that process has to begin with a conversation."

A survey of 133 physicians found that nine out of ten doctors felt they should consider a patient's out-of-pocket costs, four out of five believed that patients wanted to discuss costs, yet only one out of three reported actually discussing costs with the study patients.

"The difference between what physicians reported they should do and what they actually do is striking," said Alexander. "Of course, physicians are under enormous time pressures and there may be many legitimate reasons why this discrepancy exists."

The 484 patients interviewed as they left the doctor's office told a similar tale. Sixty-three percent said they would prefer to talk about out-of-pocket costs before receiving a test or treatment, yet 85 percent said they had never discussed these costs with the doctors in this study.

Although 90 percent of study patients had insurance that covered at least part of the costs of prescription drugs, 25 percent complained that out-of-pocket costs were a burden, and 16 percent reported that they had skipped or stretched a medicine during the previous 12 months due to costs.

Patients seen in a community practice were slightly more likely to have discussed costs than were those seen in academic setting. But even in the most likely circumstances, 75 percent of patients reported that they did not discuss medical expenses.

When doctors and patients did talk it made a difference. Discussing out-of-pocket costs made physicians more aware of the burden on patients and may have enabled them to seek less expensive alternatives.

Patients should be encouraged to raise their concerns about out-of-pocket cost with their doctors, said Alexander. "Our findings suggest that although physicians may not frequently discuss these costs, that they are sensitive to the issue and concerned about patients' burden."

Physicians, on the other hand, should be aware of the risk factors that suggest patients may be burdened by out-of-pocket costs, note the study authors, such as low income, advanced age, and multiple health problems.

Additional authors of the paper were Lawrence Casalino, MD, PhD, and David Meltzer, MD, PhD, of the University of Chicago. The research was supported by the Robert Wood Johnson Clinical Scholars Program.

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