 some situations. This group of individuals reported comparing costs and investigating or participating in financial assistance programs to help cover the costs of care.
The exact amount of costs saved (if any at all) as a result of participating in both the risky and beneficial cost-saving behaviors was not investigated in this study, however, it is promising to see that risky behaviors were not being utilized on a much more frequent basis than the beneficial behaviors. This pattern may point toward patient desire to be adherent to their care, and willingness to try other, safer cost-saving practices.
Physician-patient conversations about costs may help uncover patient financial burden and help direct consumeristic behaviors toward safer options rather than patient self-directed nonadherence, thus potentially increasing overall health outcomes and treatment adherence, while decreasing OOPCs. Conversations about cost with insured patients are being initiated by physicians at incredibly low rates, perhaps due to the potentially incorrect perception that these individuals may be financially prepared for the cost of their care. However, identifying this population as one that would benefit from such conversations, despite having insurance, may help to decrease patient’s overall financial burden and lead to greater healthcare outcomes and personal satisfaction (19).
While past research has suggested that insured patients are not taking advantage of options that may help reduce OOPCs, Our results highlight beneficial cost-saving behaviors in a significant proportion of patients (1,8-11).
In line with previous literature, we did find that concerns about finances and financial strain were more prevalent amongst individuals with a greater number of chronic conditions, and insurance status may not shield patients from this burden as much as anticipated (15,16-19). Also similar to previous studies, we did find that although many individuals may be struggling, much fewer are actually having conversations with their HCPs. Our results pointed toward a potentially higher frequency of cost-related conversations between patients and HCPs than other studies (perhaps higher than 50% depending on the type of cost discussed versus less than a third in the literature) (2,9, 20,21).
Of concern is the proportion of patients with chronic condition who engage in treatment non-adherence as a costcutting measure. This seemed to be a much higher percentage of patients that has been reported in the literature. Also providing a contrast to the literature is the large majority of insured individuals who report experiencing financial hardship, and a larger proportion of these individuals initiating costrelated conversations with their HCP than reported elsewhere.
Unsurprisingly, although many chronically ill, insured individuals in our survey reported financial hardship, a much smaller percentage reported asking their physician about how to reduce costs, and even fewer reported their physician initiating such conversations. This indicates a severe need for conversations about costs with patients. Past research has suggested that a variety of barriers may exist that impede the frequency of these conversations, such as lack of time, concerns of appropriateness, embarrassment, confusion on who should initiate the conversation, physician or patient discomfort with the subject matter, and lack of physician knowledge on costs or cost-saving options [3,5,35,24]. We put forth several suggestions for facilitating these conversations that may lead to less stress for all involved.
In regard to issues of time, discomfort, or lack of knowledge, it may be beneficial for practices to enlist the support of a financial expert who specializes in healthcare costs. It may serve a practice well to have a dedicated professional for these conversations, thus avoiding any concerns about impacting the physician-patient relationship or discussing topics perceived as uncomfortable or inappropriate during clinical encounters. However, if physicians or their practice do not have the resources to enlist the support of a financial navigator, or if they feel as though cost conversations should occur between physician and patient, physician education should be encouraged. Exposure to finance-related issues are often insufficient during medical training, and costs of services can be difficult to find, even for those prescribing them [3,5,25]. Providing designated training during medical education to navigating healthcare costs and facilitating healthcare costrelated conversations may lead to increased physician comfort with these issues. This may lead to physicians feeling more confident in these matters, and lead to an increase in the perception that physicians can initiate these discussions, rather than deferring to a patient who may be in distress, yet too uncomfortable to bring financial issues up. Although this may not be feasible in all medical curricula, even optional training sessions or online modules may help start facilitating personal research around these topics that can be used in clinical practice. Price transparency tools and cost information that is standardized and easy to access by physicians may also be a positive step in providing physicians with adequate confidence and information to facilitate cost-related discussions. It’s also plausible that patients are unaware that cost-saving options, like coupons or manufacturer-sponsored financial assistance programs exist, and as such, may benefit from physicians or other cost navigators sharing this information as well. Patient awareness of these programs may lead to a greater degree of use, lower OOPCs, and a decrease in risky cost-saving behaviors [26].
Several limitations exist within the design of our study and survey responses. First, we recruited a convenience sample from Health Union, LLC’s condition-specific community populations. Unsurprisingly, we had a large number of respondents who reported specific chronic conditions represented by these communities, such as migraine, rheumatoid arthritis, and multiple sclerosis. Further, since survey participation and recruitment were all performed online, all of our respondents must have had access to the internet and frequent the online communities and/or social media. This may have impacted the socioeconomic level, insurance status, educational attainment, and age diversity of our sample. Our sample also had a large skew toward female respondents, with 86% of participants being female. This may be the result of the typical demographic of members of online communities dedicated to chronic illnesses.
Although an online survey was cost-effective and feasible, subsequent studies into this topic would benefit from a more balanced sample population that includes individuals with a wider variety of chronic conditions and a wider socioeconomic background. Future studies may also benefit from surveying a sample that is more heterogeneous in age and gender, including individuals from gender identities outside of the traditional male/female binary. These individuals may have further financial impacts or barriers to conversations and care that may be significant.
One other important limitation to our study was that it relied on patient-reported perceptions of conversations with their HCP. As mentioned, although an online survey may be beneficial for time or cost constraints, it is possible that self-reported data may be inaccurate. It’s also possible that questions may not have been understood in the same manner by each participant, since responses were based on individual perception of the question, rather than asked in person to ensure understanding. For example, over 70% of insured respondents reported that they recognized that the cost of a medical service may vary based on the location it’s performed at (such as in a doctor’s office versus in a hospital). However, only about a third of individuals indicated that they’ve asked their physician about the options and costs for a medical service, including testing, procedures, or surgeries. This may be due to barriers related to cost-related discussions, as mentioned previously, or it could be that participants did not understand that “options” for a medical service may include inquiring about different locations.
This research indicates that although nearly three-quarters of insured individuals with a chronic condition experience financial strain, a much smaller proportion are asking their physician about healthcare costs. An even smaller proportion reports their physician initiating conversations about this topic.
In response to the costs of care, nearly half, or more, of chronically ill, insured individuals are practicing cost-saving behaviors that may be characterized as either beneficial or risky. Our findings indicate that patients may engage in both risky and beneficial cost-cutting behaviors with similar frequency. This suggests that patients may be open and interested in trying to practice more positive consumer behaviors before resorting to treatment non-adherence as a cost-saving measure. Treatment non-adherence or self-adjustment can pose a serious health risk and highlights the importance of facilitating cost-related conversations between patients and physicians in order to preemptively address financial burdens before they arise.
One implication of this research is that there is a need for resources and services, such as a cost navigator, that can discuss cost-related issues with patients. Another important consideration is the need to increase HCP, and in particular, physician education on cost-related issues and how to initiate these patient discussions during medical training. Finally, there is a need to ensure that there are patient education efforts around positive consumeristic options they may be able to utilize (such as coupons or manufacturer-sponsored financial assistance programs). It is clear from our research that although insured individuals are often perceived to have financial means for their care and thus, not targeted by their HCPs for healthcare cost-related conversations, insurance does not equal financial stability. A lack of open conversation amongst all patients, regardless of insurance status, may inadvertently lead to financial hardship and risky cost-cutting behaviors.
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