Nora B. Henrikson, PhD, MPH; Matthew P. Banegas, PhD, MPH; Leah Tuzzio, MPH; Catherine Lim, MDes; Jennifer L. Schneider, MPH; Callie Walsh-Bailey, MPH; Aaron Scrol, MS; Stephanie M. Hodge, MA
Financial Support: By the Robert Wood Johnson Foundation (grant 74123).
Disclosures: Dr. Banegas reports grants from AstraZeneca outside the submitted work. Ms. Hodge reports grants from Robert Wood Johnson Foundation during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2227.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Proctor & Gamble, Pfizer, and Johnson & Johnson. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Corresponding Author: Nora B. Henrikson, MD, MPH, Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1466; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Henrikson, Ms. Tuzzio, Ms. Lim, Ms. Walsh-Bailey, and Mr. Scrol: Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1466.
Dr. Banegas and Ms. Schneider: Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227-1098.
Author Contributions: Conception and design: N.B. Henrikson, M.P. Banegas, L. Tuzzio, C. Lim, J.L. Schneider.
Analysis and interpretation of the data: N.B. Henrikson, M.P. Banegas, L. Tuzzio, C. Lim, J.L. Schneider, C. Walsh-Bailey, A. Scrol.
Drafting of the article: N.B. Henrikson, M.P. Banegas, L. Tuzzio, C. Lim, J.L. Schneider, C. Walsh-Bailey, S.M. Hodge.
Critical revision of the article for important intellectual content: N.B. Henrikson, M.P. Banegas, L. Tuzzio.
Final approval of the article: N.B. Henrikson, M.P. Banegas, L. Tuzzio, C. Lim, J.L. Schneider, C. Walsh-Bailey, A. Scrol, S.M. Hodge.
Provision of study materials or patients: N.B. Henrikson, M.P. Banegas, J.L. Schneider, A. Scrol, S.M. Hodge.
Statistical expertise: N.B. Henrikson, M.P. Banegas.
Obtaining of funding: N.B. Henrikson, M.P. Banegas, A. Scrol, L. Tuzzio.
Administrative, technical, or logistic support: M.P. Banegas, C. Walsh-Bailey, A. Scrol, S.M. Hodge.
Collection and assembly of data: N.B. Henrikson, M.P. Banegas, L. Tuzzio, C. Lim, J.L. Schneider, C. Walsh-Bailey.
Patients prefer to discuss costs in the clinical setting, but physicians and teams may be unprepared to incorporate cost discussions into existing workflows.
To understand and improve clinical workflows related to cost-of-care conversations.
Qualitative human-centered design study.
2 integrated health systems in the U.S. Pacific Northwest: a system-wide oncology service line and a system-wide primary care service line.
Clinicians, clinical team members, operations staff, and patients.
Ethnographic observations were made at the integrated health systems, assessing barriers to and facilitators of discussing costs with patients. Three unique patient experiences of having financial concerns addressed in the clinic were designed. These experiences were refined after in-person interviews with patients (n = 20). Data were synthesized into a set of clinical workflow requirements.
Most patient cost concerns take 1 of 3 pathways: informing clinical care decision making, planning and budgeting concerns, and addressing immediate financial hardship. Workflow requirements include organizational recognition of the need for clinic-based cost-of-care conversations; access to cost and health plan benefit data to support each conversation pathway; clear team member roles and responsibilities for addressing cost-of-care concerns; a patient experience where cost questions are normal and each patient's preferences and privacy are respected; patients know who to go to with cost questions; patients' concerns are documented to minimize repetition to multiple team members; and patients learn their expected out-of-pocket costs before treatment begins.
Results may have limited generalizability to other health care settings, and the study did not test the effectiveness of the workflows developed.
Clinic-based workflows for cost-of-care conversations that optimize patients' care experience require organizational commitment to addressing cost concerns, clear roles and responsibilities, appropriate and complete data access, and a team-based approach.
Robert Wood Johnson Foundation.
Henrikson NB, Banegas MP, Tuzzio L, Lim C, Schneider JL, Walsh-Bailey C, et al. Workflow Requirements for Cost-of-Care Conversations in Outpatient Settings Providing Oncology or Primary Care: A Qualitative, Human-Centered Design Study. Ann Intern Med. 2019;170:S70–S78. doi: 10.7326/M18-2227
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Published: Ann Intern Med. 2019;170(9_Supplement):S70-S78.
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