What, When & How of Cost Conversations

Susan Perez

Susan Perez


For vulnerable, low-income patients, discussions about the costs of healthcare services can be life changing. While a majority of patients want to discuss out-of-pocket costs during medical visits, they are worried that voicing financial concerns will lead to lower-quality care.  Little is known about how to overcome the many barriers to holding these conversations effectively. A major obstacle is the lack of established best practices: a) to guide providers about when and how to initiate cost conversations; and b) to make it easy for patients to express their preferences and values.


We conducted eight focus groups in five different communities, rural and urban, in two different states—California and New York. Participants were recruited through a Federally Qualified Community Clinic network.


We discovered that participants shared a number of barriers to accessing needed healthcare services. Participants discussed systemic barriers (e.g., not being able to establish care with a primary care provider or get an appointment), economic hardships (e.g., inability to afford medications) and cultural beliefs (e.g., choosing between traditional remedies and a doctor’s treatment plan) that cause them to delay or avoid accessing care. There was a range of in terms of how appropriate patients felt it was to initiate a cost conversation with their provider. Hesitancy to initiate a cost conversation with their provider is a result of a paternalistic perspective of the healthcare system, lack of trust between the patient and provider, concern that their provider will offer “less than care,” and lack of awareness that cost could be discussed with a physician.


When it comes to affordability of healthcare, patients might not be willing to initiate a conversation about cost resulting in unspoken barriers to a patient’s ability to afford necessary services. Embracing patient’s economic realities in the context of a treatment plan will improve an individual’s likelihood for continuity of care, decrease the likelihood that patients will make sacrifices to afford treatment, and build trust with their provider. This could be achieved through transitioning practice policies toward normalizing cost conversations as a part of the patient provider interaction, such as screening for cost sensitivity and integrating cost into treatment plans (e.g., treating cost as a “side effect”).