Discussing Out-of-Pocket Expenses During Clinical Appointments: An Observational Study of Patient-Psychiatrist Interactions

Abstract

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.

Patterns of borrowing to finance out-of-pocket prescription drug costs in Canada: a descriptive analysis

“…31,32 Prescribers can improve medication affordability for patients by staying up to date on drug costs, prescribing the most costeffective alternative, frequently reviewing medication regimens for opportunities to deprescribe and prescribing generic drugs. 31,33 Multiple policy interventions can be used to address the negative impacts on patients who are struggling to pay for prescription drugs. 34 For example, some provinces have recently implemented policy changes to help address costrelated nonadherence: Ontario implemented a pharmacare program for youth under the age of 25 who lack private prescription drug insurance, and British Columbia has reduced or eliminated public drug insurance deductibles for families earning less than $45 000 per year.…”

“…33.8%], 95% CI 28.1-39.5) borrowed money to pay for comparatively low drug costs, $200 or less. Another estimated 195 859 (26.8%)…”

Parent Preferences for Transparency of Their Child’s Hospitalization Costs

“… 10 , 11 , 12 , 13 , 14 , 15 , 16 However, discussions of costs are infrequent in clinical encounters. 10 , 11 , 14 , 17 , 18 , 19 …”

“…[10][11][12][13][14][15][16] However, discussions of costs are infrequent in clinical encounters. 10,11,14,[17][18][19] Similar to adult care, spending on pediatric care is increasing. 20 However, little research has examined parental preferences for transparency in their children's costs of care.…”

Impact of Cost Conversation on Decision-Making Outcomes

“…8 One approach to preventing and addressing patients' financial hardships is through cost conversations between patients and their clinicians. [9][10][11][12][13][14] Cost conversations at the point of care have the potential to result in costsensitive care plans that patients can feasibly implement, lessen the need for future discovery and remediation of cost-related adherence issues, and mitigate their harms. [15][16][17] Despite the potential benefits of increased discussion of cost, studies document that the incidence of cost conversations varies from 15% to 65%.…”