Background More than 1 in 4 Americans report difficulty paying medical bills. Cost-reducing strategies discussed during outpatient physician visits remain poorly characterized. Objective We sought to determine how often patients and physicians discuss healthcare costs during outpatient visits and what strategies, if any, they discussed to lower patient out-of-pocket costs. Design Retrospective analysis of dialogue from 1,755 outpatient visits in community-based practices nationwide from 2010–2014. The study population included 677 patients with breast cancer, 422 with depression, and 656 with rheumatoid arthritis visiting 56 oncologists, 36 psychiatrists, and 26 rheumatologists, respectively. Results Thirty percent of visits contained cost conversations (95% confidence interval [CI], 28 to 32). Forty-four percent of cost conversations involved discussion of cost-saving strategies (95% CI, 40 to 48; median duration, 68 seconds). We identified 4 strategies to lower costs without changing the care plan – in order of overall frequency, (1) Changing logistics of care; (2) Facilitating copay assistance; (3) Providing free samples; (4) Changing/adding insurance plans – and 4 strategies to reduce costs by changing the care plan – (1) Switching to lower-cost alternative therapy/diagnostic; (2) Switching from brand name to generic; (3) Changing dosage/frequency; (4) Stopping/withholding interventions. Strategies were relatively consistent across health conditions, except for switching to lower-cost alternative (more common in breast oncology), and providing free samples (more common in depression). Limitation Focus on three conditions with potentially high out-of-pocket costs. Conclusions Despite price opacity, physicians and patients discuss a variety of out-of-pocket cost reduction strategies during clinic visits. Almost half of cost discussions mention one or more cost-saving strategies, with more frequent mention of those not requiring care-plan changes.

BackgroundNearly one in three Americans are financially burdened by their medical expenses. To mitigate financial distress, experts recommend routine physician-patient cost conversations. However, the content and incidence of these conversations are unclear, and rigorous definitions are lacking. We sought to develop a novel set of cost conversation definitions, and determine the impact of definitional variation on cost conversation incidence in three clinical settings.MethodsRetrospective, mixed-methods analysis of transcribed dialogue from 1,755 outpatient encounters for routine clinical management of breast cancer, rheumatoid arthritis, and depression, occurring between 2010–2014. We developed cost conversation definitions using summative content analysis. Transcripts were evaluated independently by at least two members of our multi-disciplinary team to determine cost conversation incidence using each definition. Incidence estimates were compared using Pearson’s Chi-Square Tests.ResultsThree cost conversation definitions emerged from our analysis: (a) Out-of-Pocket (OoP) Cost -- discussion of the patient’s OoP costs for a healthcare service; (b) Cost/Coverage -- discussion of the patient’s OoP costs or insurance coverage; (c) Cost of Illness-- discussion of financial costs or insurance coverage related to health or healthcare. These definitions were hierarchical; OoP Cost was a subset of Cost/Coverage, which was a subset of Cost of Illness. In each clinical setting, we observed significant variation in the incidence of cost conversations when using different definitions; breast oncology: 16, 22, 24 % of clinic visits contained cost conversation (OOP Cost, Cost/Coverage, Cost of Illness, respectively; P < 0.001); depression: 30, 38, 43 %, (P < 0.001); and rheumatoid arthritis, 26, 33, 35 %, (P < 0.001).ConclusionsThe estimated incidence of physician-patient cost conversation varied significantly depending on the definition used. Our findings and proposed definitions may assist in retrospective interpretation and prospective design of investigations on this topic.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1353-2) contains supplementary material, which is available to authorized users.

We identified cost conversations in approximately one in five breast cancer visits. Cost conversations were mostly oncologist initiated, lasted < 1 minute, and dealt with a wide range of health care expenses. Cost-reducing strategies were mentioned in more than one third of cost conversations and often involved switching antineoplastic agents for lower-cost alternatives or altering logistics of diagnostic tests.

Some experts contend that requiring patients to pay out of pocket for a portion of their care will bring consumer discipline to health care markets. But are physicians prepared to help patients factor out-of-pocket expenses into medical decisions? In this qualitative study of audiorecorded clinical encounters, we identified physician behaviors that stand in the way of helping patients navigate out-of-pocket spending. Some behaviors reflected a failure to fully engage with patients’ financial concerns, from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending. Many of these failures resulted from systemic barriers to health care spending conversations, such as a lack of price transparency. For consumer health care markets to work as intended, physicians need to be prepared to help patients navigate out-of-pocket expenses when financial concerns arise during clinical encounters.

In forming an impression of a speaker, listeners are attentive to the frequency of nonstandard language features, using it to calibrate their judgments. We show that the ability to track and socially evaluate nonstandard variant frequency is subject to individual differences. Listeners judged an aspiring newscaster on the standardness of her speech in a series of read-aloud passages that had been manipulated for proportional frequency of a nonstandard pronunciation. Judgments of conditions at the poles of the frequency continuum were predicted by listener sociodemographic factors. For conditions in the middle of the frequency continuum, listener judgments were predicted by Broader Autism Phenotype Questionnaire scores for communication skills. Language attitudes may therefore be affected by both social and cognitive listener attributes, where cognitive attributes are most relevant for ambiguous inputs.

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The speech of older adults (65+ years old) is a rich resource for a wide range of researchers, including oral historians, developmental psychologists, health communication scholars, speech and hearing specialists, and discourse analysts. Yet in variationist sociolinguistics—the study of language variation, language change, and their social motivations—older adults have fallen afoul of a kind of scholarly ageism. Often consigned to the status of a historical benchmark against which the speech of younger people is compared, and with only rare acknowledgment of their biological, psychological and social diversity, old‐age speakers deserve greater attention. This article provides linguists with an overview of relevant conceptualizations of age and ageing in gerontology, explains why a focus on older speakers is critical to the advancement of the study of language variation and change, and offers practical suggestions for overcoming some of the challenges associated with old‐age research.

Objective High out-of-pocket expenses have been associated with worse quality of life, decreased adherence, and increased risk of adverse health outcomes. Treatment of depression has high potential out-of-pocket expenses. There are limited data characterizing psychiatrist-patient conversations about healthcare costs. Methods Content analysis of dialogue from 422 outpatient psychiatrist-patient visits for medication management of major depressive disorder in community-based private practices nationwide from 2010-2014. Results Patients’ healthcare expenses were discussed in 38% of clinic visits (95% confidence interval [CI], 33% to 43%). Uninsured patients were significantly more likely to discuss expenses than patients enrolled in private or public plans (64%, 44%, 30%, respectively; P=0.0003). Sixty-nine percent of cost conversations lasted less than one minute (median: 36 seconds; interquartile range [IQR]: 16 to 81 seconds). Cost conversations most frequently addressed psychotropic medications (52%). Physicians initiated 50% of cost conversations and brought up costs for psychotropic medications more often than patients (62% vs. 40%; P=0.009). Conversely, a greater percentage of patient-initiated cost conversations addressed costs for provider visits (26% vs. 10%; P=0.008). Overall, 45% of cost conversations mentioned cost reducing strategies (95% CI, 37% to 53%). The most frequently discussed cost reducing strategies were 1) lowering cost by changing the source or timing of an intervention (e.g. changing pharmacies), 2) providing free samples, 3) switching to a lower cost therapy or diagnostic. Conclusions Psychiatrists and patients regularly discuss patients’ healthcare costs in visits for depression. These discussions address a wide variety of clinical topics and frequently include strategies to lower patients’ costs.