Douglas D. Bradham, DrPH, MA, MPH; Deliana Garcia, MA; Alma Galván, MHC; Corey Erb, BS
Financial Support: By the Robert Wood Johnson Foundation (project ID 48851).
Disclosures: Ms. Garcia reports a grant from the Robert Wood Johnson Foundation during the conduct of the study. Mr. Erb reports a grant from the 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=M18-1608.
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: Douglas D. Bradham, DrPH, MA, MPH, Migrant Clinicians Network, PO Box 164285, Austin, TX 78716; e-mail, DBradham@migrantclinician.org.
Current Author Addresses: Dr. Bradham, Ms. Garcia, and Ms. Galván: Migrant Clinicians Network, PO Box 164285, Austin, TX 78716.
Mr. Erb: The Settlement Home for Children, 1500 Crossing Place, #333, Austin, TX 78741.
Author Contributions: Conception and design: D.D. Bradham, D. Garcia, C. Erb.
Analysis and interpretation of the data: D.D. Bradham, A. Galván.
Drafting of the article: D.D. Bradham, D. Garcia, C. Erb.
Critical revision for important intellectual content: D.D. Bradham, A. Galván.
Final approval of the article: D.D. Bradham, D. Garcia, A. Galván, C. Erb.
Provision of study materials or patients: D.D. Bradham.
Statistical expertise: D.D. Bradham, C. Erb.
Obtaining of funding: D.D. Bradham, D. Garcia.
Administrative, technical, or logistic support: D.D. Bradham, D. Garcia, A. Galván, C. Erb.
Collection and assembly of data: D.D. Bradham, D. Garcia, A. Galván, C. Erb.
The Centers for Disease Control and Prevention estimates that 10% of the U.S. population delays or avoids health care because of cost concerns. It is unknown whether and how cost-of-care conversations occur in primary encounters, especially settings that provide care to vulnerable patients.
To describe cost-of-care conversations with financially vulnerable (<400% federal poverty level) adult patients during clinical encounters.
Five observers shadowed a convenience sample of patients during encounters and then interviewed patients and clinicians after the encounter.
Federally Qualified Health Centers in Texas (n = 2) and Pennsylvania (n = 2).
A convenience sample of 67 adult patients seeking chronic disease management or prenatal care from 9 clinicians (5 medical doctors, 2 physician assistants, and 2 nurse practitioners).
Self-reported characteristics of patients, and frequency and characteristics of interviewer-observed cost-of-care conversations.
Because of missing responses from patient and clinician interviews, data are reported for 67 consenting patients. During 46.3% of encounters, some discussion of costs of care was observed. Discussion of indirect costs (lost work time or transportation) was observed in only 2.9% of encounters. In only 11.9% of encounters did the physician discuss costs of care. When costs were discussed, the conversation was not organized and did not take place in conjunction with the discussion of the treatment plan.
This exploratory work involved a small convenience sample, and generalizability to other settings is uncertain. Missing data prohibited meaningful analysis of patient and clinician interview data.
In the 4 federally funded health centers studied, cost-of-care conversations occurred in a minority of clinical visits, discussions were unorganized, and indirect costs of care were rarely addressed. Whether more frequent discussion of the costs of care improves patient adherence and outcomes requires further study.
Robert Wood Johnson Foundation.
Table 1. Patient Characteristics
Table 2. Observers' Records of Cost-of-Care and Treatment Plan Conversations: Discussants
Table 3. Observers' Records of Cost-of-Care Conversations: Content and Communication Style
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Bradham DD, Garcia D, Galván A, et al. Cost-of-Care Conversations During Clinical Visits in Federally Qualified Health Centers: An Observational Study. Ann Intern Med. 2019;170:S87–S92. doi: 10.7326/M18-1608
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Published: Ann Intern Med. 2019;170(9_Supplement):S87-S92.
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