Talking to a wall? Patients push back on cost-effectiveness

Physicians who introduce the topic of cost into discussions with their patients may find it resembles talking to the proverbial wall. Focus group findings show that public attitudes about healthcare costs must shift significantly for cost to be an explicit factor in clinical decisions, according to an article published in the February issue of Health Affairs.

When discussing cost-effective care with patients, physicians have an ethical duty to be transparent and explain the justification for cost-conscious decisions to patients, who can then be more active in thinking through treatment choices, according to authors Marion Danis, MD, of the National Institutes of Health Clinical Center in Bethesda, Md., and colleagues.

However, it may be a difficult conversation. “We found that the majority of participants were unwilling to consider costs when deciding between nearly comparable options and generally resisted the less expensive, marginally inferior option,” they wrote.

Findings were based on a series of 22 focus group discussions featuring a total of 211 participants. All participants were recruited from the Santa Monica, Calif., and Washington, D.C., metro areas and had health insurance, but the population represented a range of ages, races or ethnicities and income levels.

Danis and colleagues also found that participants made four times as many negative comments as positive ones on the theme of willingness to discuss costs. There were three times as many comments indicating unwillingness to accept a less expensive option as there were comments expressing willingness.

The authors outlined four barriers to patients taking cost into account:

• Preference for what is perceived to be the best care, regardless of cost;
• Inexperience weighing health against money;
• Disinterest in costs borne by insurers or society as a whole; and
• Behavior characteristic of the “commons dilemma,” where people act out of self-interest even though it depletes limited common resources.

“Surmounting these barriers will require new research in patient education, comprehensive efforts to shift public attitudes about health care costs, and training to prepare clinicians to discuss costs with their patients,” wrote Danis et al.

Better education can help bridge the gap to educating patients and providers on the ramifications of high-cost care, according to the authors. Widespread efforts by the media can shift public consciousness on the discussion of healthcare costs, and professional medical societies can endorse and support cost-consciousness on the part of individual clinicians.

“If patients and clinicians do not discuss and consider costs during the clinical encounter, the alternatives are problematic,” wrote the authors, who added that cost-conscious healthcare decision making is necessary “given the limited resources and unsustainably rising health care costs.”