Cost-of-Care Conversations During Clinical Visits in Federally Qualified Health Centers: An Observational Study

Abstract

Background: 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.

Objective: To describe cost-of-care conversations with financially vulnerable (<400% federal poverty level) adult patients during clinical encounters.

Design: Five observers shadowed a convenience sample of patients during encounters and then interviewed patients and clinicians after the encounter.

Setting: Federally Qualified Health Centers in Texas (n = 2) and Pennsylvania (n = 2).

Participants: 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).

Measurements: Self-reported characteristics of patients, and frequency and characteristics of interviewer-observed cost-of-care conversations.

Results: 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.

Limitations: 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.

Conclusion: 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.

Primary funding source: Robert Wood Johnson Foundation.