In an era of increasing deductibles and other out-of-pocket costs, physicians should be prepared to engage patients about financial issues.

Patients’ growing concern about the cost of medical care no longer is breaking news. Patients want to know how much their treatment is likely to cost—and increasingly, they expect their doctors to have the answer.

“Historically, patients weren’t as interested as they are now, because through medical insurance they were very often protected from the cost of treatment,” says Ronan Kelly, MD, assistant professor of oncology at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore.

The days when insurance paid for the lion’s share of medical expenses are over. The Kaiser Family Foundation’s 2015 Employer Health Benefits Survey found that more than eight in 10 workers in large firms with job-based health insurance are covered by plans with a general annual deductible, the average amount of which is $1,318. That sum represents a $400 increase since 2010.

Among people who buy Silver-tier health insurance plans through the Affordable Care Act marketplaces, average deductibles are more than $2,900 this year, according to an analysis by HealthPocket.

It’s no surprise, then, that data released this year by the National Health Interview Survey show 18 percent of people under age 65 are in families struggling to pay for health care, including more than 36 percent of people with some form of health insurance.

Hesitant to Talk Money

Surveys consistently show that patients want financial information from their physicians, but are hesitant to broach the topic.

“More than 50 percent report that cost is an issue for them, but they report bringing it up less than half the time,” says Minal R. Patel, PhD, MPH, assistant professor at the University of Michigan School of Public Health, Ann Arbor, Mich.

One possible reason is limited time. “There are a lot of competing demands” during the average 15-minute doctor’s office visit, Patel says.

Social stigma also plays a role. Often, the patients with the largest out-of-pocket costs are those with private health insurance that includes a high deductible.

“The individuals who have those types of plans are in a higher income bracket—so there is an expectation to pay, but they are burdened with that high out-of-pocket situation,” Patel says. Patients often are embarrassed to talk about financial strain.

Finally, Patel says, patients often believe there is no point in discussing the high cost of care because nothing can be done about it.

Differing Perspectives

Kelly is the lead author of a study, recently published in the Journal of Oncology Practice, that assesses the perceptions of patients and oncologists about cost-of-care discussions.

Oncologists were asked to show patients with cancer the costs associated with their various treatment options.

“Out of the 18 oncologists, only five felt somewhat comfortable discussing cost and only one regularly asked patients [about cost],” Kelly says. “So, the take-home is that doctors really don’t feel comfortable discussing cost.”

The study also found that patients see the issue differently from their physicians. When asked before an office visit whether they would be interested in talking about the cost of care with their oncologist, 80 percent of patients said they would—yet 72 percent said they had never had such discussions.

Why do physicians avoid the money talk? Rivka Friedman, practice manager with the Advisory Board’s Medical Group Strategy Council, says one reason may be that physicians often don’t have the information patients are seeking. Without all the answers, some physicians might rather offer none at all.

“Patients want something, physicians don’t have a comprehensive answer, so physicians don’t offer any information,” Friedman says.

Offering Help

There is growing recognition that financial burden can have a negative impact on a patient's health, and that physicians and their staff can help relieve that burden.

“For the same reason that oncologists will always make sure to discuss chemo side effects with patients, they should also think of the cost of care as another thing to discuss because cost of care can have a bigger impact on patient quality of life than more traditional side effects,” says Peter Ubel, MD, associate director, health sector management, Fuqua School of Business, Duke University.

In fact, a recent report by Families USA, a healthcare advocacy organization, found that one in four adults with non-group insurance policies last year went without needed medical care because they could not afford tests, treatments, follow-up care, or prescription drugs.

There are no easy solutions, but there are ways for physicians to help.

To start, Ubel says, simply begin the conversation. “Don’t wait for the patient to bring it up,” he says. “And don’t miss when your patients do bring it up. If your patient comments on their insurance coverage not being as great as they thought—or the treatment, intervention, or testing is more expensive than they thought—that might be their way of asking for help.”

If the cost of medication is a concern, the physician could write two prescriptions and explain to the patient that if he or she finds the first drug to be too expensive at the pharmacy, the second one is a viable alternative. “So, you don’t have to know the cost, but you’re making a plan for it,” Ubel says.

Bringing up money at the right time and being sensitive to the patient’s emotional state is also critical, Kelly says: “You can’t just go in and the first thing you talk about with a patient [diagnosed] with cancer is the cost of treatment.”

Physicians also should ask patients whom they would like to speak with about costs. Kelly’s research found that while most patients want to discuss costs, roughly half prefer to do so with a financial adviser rather than with their physician.

Therefore, staff should be trained to discuss finances and also to make referrals to a social worker who can direct patients to resources such as copay and prescription assistance programs or clinical trials.

“The expectation isn’t for the physician to know all the resources inside and out, but to acknowledge them and be available to sign off,” Patel says.

Finally, both Kelly and Ubel say that although good resources are lacking, technology-based tools that give physicians access to accurate prices, including the cost per regimen and patients’ insurance details, ultimately will make the cost-related information that both patients and physicians need more readily available.

But, Ubel acknowledges, “That is down the road.”


Lisa Zamosky is a healthcare journalist specializing in health and finance concerns, health insurance, healthcare policy, and the Affordable Care Act. 

Interviewed for this article: Ronan Kelly, MD, assistant professor of oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore; Minal R. Patel, PhD, MPH, assistant professor, University of Michigan School of Public Health, Ann Arbor, Mich.; Rivka Friedman, practice manager, Medical Group Strategy Council, Advisory Board; Peter Ubel, MD, associate director, health sector management, Fuqua School of Business, Duke University.

Publication Date: Monday, November 09, 2015