Trust in physician eases talks about medical expenses

Strong relationships with physicians, particularly those that are long standing, are likely to increase patients' openness to talk about health care costs when decisions are being made about their treatment options. According to a new study by Marion Danis from the National Institutes of Health Clinical Center in the US, and colleagues, rushed visits with insufficient time to talk about important issues can undermine efforts to bring sensitive topics like costs into the doctor-patient relationship and can be counterproductive. The work appears online in the Journal of General Internal Medicine, published by Springer.

Physicians are increasingly expected to take costs into account when they offer treatment recommendations and make decisions for patients. Several communication strategies have been considered to help doctors broach the topic of insurer and out-of-pocket costs with patients. These include:

• Using empathy so doctors and patients are working as a team to address the issue of cost
• Each party doing their part to address costs so the decision-making is fair
• Emphasizing that the less expensive option is good enough and debunking the notion that the newest, most expensive treatment is the better choice
• Educating patients of the impact of rising health care costs on their premiums.

Danis and team convened 22 focus groups of 211 insured patients to explore attitudes towards discussing and considering insurer and out-of-pocket costs in the doctor-patient encounter. They also examined whether proposed communications strategies would make the patient more receptive to discussing cost.

In the focus groups, patients were led though a series of scenarios. For example, patients were asked to imagine they had experienced the worst headache of their life for three months, for which their doctor recommended an imaging study e.g. MRI or CT scan. The doctor explained that the difference between the two tests was marginal; the MRI however was twice as expensive as the CT. For all scenarios, participants discussed whether and how they would want their physicians to broach the topic of costs with them, and which treatment option they would ultimately choose. The researchers also observed participants' reactions to the four communications strategies.

Patients were more willing to talk to doctors about personal, out-of-pocket costs than insurer costs. Older and sicker participants were more willing to talk to their doctor about costs than younger and healthier participants..

Overall, patients did not endorse recommended communications strategies for discussing costs in the clinical encounter. In contrast, patients stated that trust in their doctor would make them more willing to discuss costs. Barriers to having those discussions included rushed, impersonal visits and clinicians who were insufficiently informed about costs.

The authors conclude: "Our findings suggest that trust is a valuable ingredient for honest conversations about how to make cost-effective treatment decisions. Given that patients are more receptive to discussing out-of-pocket costs, stronger efforts to educate the public about the importance, for their own sake, of controlling insurer costs is a possible strategy for enabling discussions about these costs."