Susan L. Perez, PhD, MPH; Arlene Weissman, PhD; Susan Read, PhD; Cynthia Daisy Smith, MD; Lisa Colello, MPA; Doris Peter, PhD; Wendy Nickel, MPH
Acknowledgment: The authors thank the Consumer Reports Health Ratings Center for providing valuable feedback on the content of this article.
Financial Support: By the Robert Wood Johnson Foundation (grant 74121).
Disclosures: Dr. Smith reports a grant from the Robert Wood Johnson Foundation and a grant subcontract from Consumer Reports, and employment by ACP, during the conduct of the study and spousal employment from Merck & Co. outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2136.
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: Susan L. Perez, PhD, MPH, Department of Health Science, California State University, Sacramento, 6000 J Street, Solano Hall 3002, Sacramento, CA 95819-6073; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Perez: Department of Health Science, California State University, Sacramento, 6000 J Street, Solano Hall 3002, Sacramento, CA 95819-6073.
Drs. Weissman, Read, and Smith: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Ms. Colello and Dr. Peter: Consumer Reports, 101 Truman Ave, Yonkers, NY 10703.
Ms. Nickel: 140 Lucerne Boulevard, Cherry Hill, NJ 08003.
Author Contributions: Conception and design: S.L. Perez, C.D. Smith, L. Colello, D. Peter.
Analysis and interpretation of the data: S.L. Perez, A. Weissman, S. Read, C.D. Smith, L. Colello, D. Peter, W. Nickel.
Drafting of the article: S.L. Perez, S. Read, C.D. Smith, L. Colello, W. Nickel.
Critical revision for important intellectual content: S. Perez, C.D. Smith, L. Colello, W. Nickel.
Final approval of the article: S.L. Perez, A. Weissman, S. Read, C.D. Smith, L. Colello, D. Peter, W. Nickel.
Provision of study materials or patients: S.L. Perez, L. Colello, W. Nickel.
Statistical expertise: A. Weissman, S. Read.
Obtaining of funding: S.L. Perez, D. Peter.
Administrative, technical, or logistic support: S. Read, L. Colello, D. Peter.
Collection and assembly of data: S.L. Perez, A. Weissman, L. Colello, D. Peter, W. Nickel.
Rising out-of-pocket costs are creating a need for cost conversations between patients and physicians.
To understand the factors that influence physicians to discuss and consider cost during a patient encounter.
Mixed-methods study using semistructured interviews and a survey.
20 internal medicine physicians were interviewed; 621 internal medicine physician members of the American College of Physicians completed the survey.
Interviews were analyzed by using thematic analysis, and surveys were analyzed by using descriptive statistics.
From the interviews, 4 themes were identified: Physicians are 1) aware that patients are struggling to afford medical care; 2) relying on clues from patients that hint at their cost sensitivity; 3) relying on experience to anticipate potentially high-cost treatments; and 4) aware that patients are making financial trade-offs to afford their care. Three quarters (n = 466) of survey respondents stated that they consider out-of-pocket costs when making most clinical decisions. For 31% (n = 191) of participants, there were times in the past year that they wanted to discuss out-of-pocket prescription drug costs with patients but did not. The most influential factors for ordering a test are the desire to be as thorough as possible (71% [n = 422]) and insurance coverage for the test (68% [n = 422]).
Findings are self-reported, the sample is limited to a single specialty, the survey response rate was low, information on the patient population was limited, and the survey instrument is not validated.
Physicians are attuned to the burden of health care costs and are willing to consider alternative options based on a patient's cost sensitivity.
Robert Wood Johnson Foundation.
Table 1. Themes and Participant Quotes*
Table 2. Demographic Characteristics of Survey Participants
Table 3. Factors Related to Prescribing Drugs*
Table 4. Factors Related to Ordering Medical Tests*
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Perez SL, Weissman A, Read S, et al. U.S. Internists' Perspectives on Discussing Cost of Care With Patients: Structured Interviews and a Survey. Ann Intern Med. 2019;170:S39–S45. doi: 10.7326/M18-2136
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Published: Ann Intern Med. 2019;170(9_Supplement):S39-S45.
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