Association of Diabetes Care & Education Specialists

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Having Healthcare Cost Conversations to Improve Patient Outcomes: A Practical Guide

Feb 07, 2022

This guide was created in partnership with Beyond Type 1 and was originally published at BeyondType1.org. If you know someone struggling to afford or access insulin, you can build custom plans based on their personal circumstances through our tool, GetInsulin.org.


Healthcare Cost Conversation Guide Thumbnail PreviewBeyond Type 1’s 2021 advocacy survey further confirmed findings from other studies that have shown that cost of care is a frequent barrier for the diabetes community. In the survey, a majority of respondents (56%) ranked access to affordable insulin and diabetes drugs as their most important access issue, while almost half of respondents (40%) ranked access to diabetes supplies as the second most important access issue.

40.4% of respondents indicated they incur a deductible of more than $1,500 per person for their insurance coverage, 55% of respondents stated they have paid more than $100 out-of-pocket in any month for any diabetes medication and 64% of respondents paid more than $100 out-of-pocket in any month for diabetes supplies.

Additionally, 21.6% ran out of medications or rationed due to cost, 15.0% skipped specialist visits or other healthcare to pay for diabetes care or supplies, 16.8% did not see a medical professional due to cost, 14.1% “borrowed” insulin or other diabetes supplies because of cost, 20.1% utilized a copay card for any diabetes medication and 22.8% made a decision between bills and diabetes supplies

As a healthcare provider (HCP), you may not be familiar with these limitations of access that present significant barriers to diabetes care. By having a conversation with patients about their out-of-pocket healthcare costs, you can take a vital step toward providing equitable and actionable care that meets the individual’s needs. HCP’s must be knowledgeable, not only about the indications, risks and benefits of prescribed medications, but also about suitable alternatives when those medications are not accessible for the person with diabetes.

While conversations that address the cost of diabetes care can reduce financial distress and improve patient outcomes, research has shown that conversations around the cost of care are rarely taking place—even though both patients and HCPs think they should be. This article helps healthcare professionals identify potential barriers to these conversations and shares tips to overcome them.

Consider and Address Barriers to Healthcare Cost Conversations

A person with diabetes without affordable access to a medication, treatment or care faces the same risk of poor outcomes as if the HCP did not prescribe it at all. By talking to the individual about the affordability of medication or treatment, you can identify barriers and might even uncover other issues in the social determinants of health that limit access to health care.

Non-judgmental inquiries about cost as a barrier give HCPs the opportunity to connect patients with social services and non-medical assistance programs, such as housing, food, etc. that free up resources for medications and out-of-pocket healthcare costs.

Screening tools for social determinants of health are available to help you identify a patient’s needs beyond the practice setting, but before you embark on these conversations consider the potential barriers and address them.

Barriers to having a cost conversation

Suggested Solution

Your personal values, behaviors, and thoughts (i.e. biases, generalizations, stereotypes, etc.) about the situation are getting in the way. Focus on the situation at hand and not personal emotions. Commit to listening, understanding the individual’s situation, and being empathetic.
You work with clients in a group setting that is not appropriate for sensitive conversations. Schedule a time and place to have the discussion in a private location.
You have insufficient time and/or knowledge about cost. Request and share available faculty and resources, including benefits coordinators, social workers, and community-based organizations. Work with the pharmacists and other members of the diabetes care team to identify resources that lower cost of medications.
Patients do not know they can bring up the cost of care conversation or believe that the HCP will start the conversation. Consider incorporating SDOH questions in the check-in or intake process that indicate and open conversations around cost of care concerns.
Patients fear that discussions about affordability will impact their care. Reassure patients that the cost of care conversation will not negatively impact the quality of their appointment, treatment, and such.
Patients are often embarrassed or ashamed to initiate discussions of affordability. Normalize the issue of cost of care barriers for patients.

Having the Cost of Care Conversation

It is important to create a safe and non-judgmental environment to be able to accurately assess the needs of each patient. As an HCP, you have great control over this by the tone, language, and body language used during the conversation. When bringing up the subject of cost of care, reassure the person with diabetes that your goal is to get them the care they need while minimizing problems, barriers, and the distress of cost. Emphasize that cost of care is a common issue and not a shortcoming of the individual, but of the expensive and difficult to navigate healthcare system. The American College of Physicians have developed some prompts that you may wish to adopt.

  • “Our goal is for you to get the best care with fewer problems and lower costs. This may involve us asking new types of questions.”
  • “I’d like to discuss any worries or concerns you have about the cost of your health care.”
  • “I have heard from many of my patients that the amount they have to pay for medications or tests is becoming hard to manage.”

During your conversation, aim to get an understanding of the patient’s concerns, needs, and possible sources of financial barriers or distress. Select prompts and questions from the following table to help inform your assessment of the resources the patient may need.

Type of Cost

Questions

Medication
  • What are some challenges you’ve had to accessing your medications or taking them as prescribed?
  • What are concerns or issues you’ve brought up with your prescribing doctors or pharmacist about your medications?
Cost of Care
  • Do you know if you have a deductible you must meet before the actual cost of care is covered by your insurance and what the amount of the deductible is?
  • What are some out of pocket healthcare costs you need help with?
  • Are you using any copay cards, discounts, or any other cost lowering resources currently?
Other Determinants of Health and Financial Burdens
  • When was the last time you felt you had to choose between your diabetes care or other personal or family expenses?
  • When was the last time you skipped a healthcare or doctor’s appointment because of cost of care or difficulty with transportation?
  • What challenges do you have accessing healthy food for you and your family?

When determining a treatment plan, it is important that shared-decision making is centered around and includes the patient as well as the HCP and other members of the care team. The patients and their family members are the “experts” of what their day-to-day needs are; it is the role of the healthcare professional to assist as best as they can by providing relatable suggestions. The following table provides some suggested guidance to promote productive conversations and build trust between the patient and the care team. You can find this guidance in this printable handout as well (also available in Spanish).

Do

Reason

Example

Use “I” statements: I believe, I feel, I hear, I think. Using “I” statements helps patients feel that HCPs are not devaluing their perspectives. “I believe there are programs out there that can help you get the medications you need. Would you like to know more about them?”
Talk about “cost of care,” not “money.” Many patients will find it personal to talk about “money” and are more open to discussing “cost of care.” “I am aware that the cost of many medications – even those that are generic – are rather expensive. Are you having any problems with the cost of your medications impacting how often you fill the prescription or your ability to take the medications as frequently as directed?”
Ask if you understood everything correctly. This may help identify gaps between your and the patient’s understanding of their health situation and leads to treatment choices suited to the patient’s expectations and needs. “Let me see if I understood correctly. I think you are saying…”

 

“So what you are saying is… Does that sound right?”

Confirm patient understanding using teach-back method. Confirms that you have explained things in a manner your patients understand. The teach-back method allows you to confirm that patients are able to follow specific instructions. “We covered a lot today and I want to make sure that I explained things clearly. So let’s review what we discussed. Can you please describe the things you agreed to do to help you manage your diabetes?”

 

“Many people have trouble remembering how to take their insulin. Can you show me how you are going to take it?”

Plan for follow up. Timely follow-up is vital to ensure the patient is accessing and progressing with the prescribed treatment plan. “Let’s schedule a time to follow up on what we discussed.”

Don’t

Reason

Example

Dismiss patients’ concerns. Your dismissal can be read as dismissive or disrespectful, break trust, and impact future cost conversations. “Don’t worry about that right now.”
Interrupt. Healthcare professionals wait an average of 11 seconds before interrupting patients. This may prevent you from getting the full picture.

Where Do I Find More Information to Help My Patients?

While it is not expected for the HCP to be an expert on all available resources, it is important to know where that information is available. You may find it especially useful to be familiar with the prescription resources available to support patients who are struggling to afford their medications, including alternative brands, discounts and manufacturer coupons, copay cards, manufacturer patient assistance programs (PAPs), financing plans, and local, state, and federal financial assistance programs. Below are some practical resources to help you become familiar with some of these resources.


References

  1. Alexander GC, Casalino LP, Meltzer DO. Patient-Physician Communication About Out-of-Pocket Costs. JAMA. 2003;290(7):953–958. doi:10.1001/jama.290.7.953
  2. American College of Physicians. Cost Distress Screening and Conversation Guide. March 2019. https://www.acponline.org/system/files/documents/clinical_information/high_value_care/clinician_resources/cost-of-care/1-cost-distress-and-conversation-guide_.pdf
  3. Phillips, K. A., Ospina, N. S., & Montori, V. M. (2019). Physicians Interrupting Patients. Journal of general internal medicine, 34(10), 1965. https://doi.org/10.1007/s11606-019-05247-5


ADCES Perspectives on Diabetes Care

The Association of Diabetes Care & Education Specialists Perspectives on Diabetes Care covers diabetes, prediabetes and other cardiometabolic conditions. Not all views expressed reflect the official position of the Association of Diabetes Care & Education Specialists.

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HEALTHCARE DISCLAIMER: This site and its services do not constitute the practice of medical advice, diagnosis or treatment. Always talk to your diabetes care and education specialist or healthcare provider for diagnosis and treatment, including your specific medical needs. If you have or suspect that you have a medical problem or condition, please contact a qualified health care professional immediately. To find a diabetes care and education specialist near you, visit DiabetesEducator.org/Find.

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