Table 1.

Published estimates of physician-patient cost conversation incidence with accompanying definitions

First author, year, (N)	Clinical setting and population characteristics	Cost conversation definition or criteria	Estimated cost conversation incidence
Analyses of recorded dialogue from clinic visits
Hunter, 2016 [18] N = 1,755	Outpatient visits taking place in community-based practices nationwide from 2010–2014 for routine management of breast cancer, rheumatoid arthritis, and major depressive disorder. Encounters featured specialist physicians and patients >18 years old.	• Any mention of the patient’s financial costs or insurance coverage related to a specific intervention.	Overall, 30 % of clinic visits contained cost conversation. Cost conversations were observed in 22 % of breast oncology visits, 33 % of rheumatoid arthritis visits, and 38 % of depression visits.
Tarn, 2013 [38] N = 1,477	Outpatient visits with primary care providers occurring in a variety of locations around the U.S. from 1998–2010.	• Discussion of themes concerning cost and/or affordability discussed.	Cost and/or affordability was mentioned for 4.2 % of dietary supplements discussed.
Beard, 2010 [33] N = 200	Rheumatoid arthritis patients visiting rheumatologists from 2003–2005 as part of randomized controlled trial to improve communication about quality of life and medication concerns in rheumatology visits.	• Discussion of medication-related costs; could be ‘explicit’ (e.g. price of intervention) or ‘implicit’ (e.g. copay assistance, insurance coverage).	34 % of visits included discussion of medication-related costs.
Tarn, 2006 [32] N = 185	Outpatient visits to family physicians, internists, and cardiologists as part of the Physician Patient Communication Project (1999).	• Discussion of themes concerning medication cost and insurance.	15 % of visits with newly prescribed medications contained discussion of cost or insurance coverage.
Survey studies in non-subspecialty settings
Alexander, 2003 [13] N = 484	General internists and their patients residing in the Greater Chicago area.	• Discussion of out-of-pocket (OoP) costs.	15 % of patients discussed OoP costs with their physicians.
			35 % of physicians discussed OoP costs with these patients.
Piette, 2004 [16] N = 660	Elderly adults with chronic illnesses who reported underusing medication in the prior year because of cost.	• Any conversation about problems paying for prescription medications.	65 % of patients with cost-related medication underuse discussed the cost problem with their physician in the prior year.
Shrank, 2006 [30] N = 509	Random sample of physician members of the California Medical Association. Participating physicians practiced in a variety of primary care and specialty settings.	• Discussion of OoP costs (defined as what the patient pays) or total costs with patients.	15 % of physicians reported discussing OoP costs most or all the time; 5 % reported total costs most or all the time. 45 % reported discussing OoP cost seldom or never.
Shrank, 2006 [44] N = 1707	Nationwide sample of patients managed by family medicine or general practitioners.	• Discussion of OoP costs.	33 % of patients with incentive-based pharmacy benefit designs discussed OoP costs with their physicians.
Wilson, 2007 [39] N = 17,569	Nationwide sample of Medicare beneficiaries aged 65 years or older.	• Talking with any doctor about the cost of prescription medicines in the previous 12 months.	Overall, 31 % of seniors talked with at least one of their physicians about medication costs. 61 % of those reporting cost-related non-adherence discussed cost with at least one of their physicians.
Beran, 2007 [31] N = 678	Internal medicine and family physicians caring for senior patients, practicing clinical medicine, and residing in California.	• Discussion of OoP cost of medications.	43 % of physicians reported discussing medication costs with at least half of their senior patients in the previous 30 days.
Tseng, 2007 [47] N = 1,116	Seniors enrolled in a Medicare managed care plan, surveyed in 2002. Half exceeded caps on their drug benefits the previous year, and all had total drug expenditures in the top quartile of members in their cap level.	• ‘Has your provider ever asked you whether you can afford the cost of your medications?	Overall, 17 % said providers asked about affordability; 19 % said providers usually or always discussed prices when he or she writes a prescription.
		• “How often do you and your provider talk about the price of a medication when he or she writes you a prescription?”
Tseng, 2010 [28] N = 5,085	Patients with diabetes mellitus enrolled in multi-center study of diabetes care in managed care settings.	• Discussion of medication costs.	19 % of patients who reported being open to discussing cost trade-offs (discussing lower cost drugs with higher chance of adverse effects, lower effectiveness, or higher dosing frequency) said their physician usually or always discussed drug costs when prescribing.
Schmittdiel, 2010 [15] N = 1,458	Patients with diabetes mellitus enrolled in multi-center study of diabetes care in managed care settings.	• Talking about the amount paid for prescription drugs during 2006.	44 % of patients discussed prescription drug costs with any doctor during 2006.
Survey studies in subspecialty settings
Schrag, 2007 [27] N = 167	Random, nationwide sample of medical oncologists practicing in the U.S.	• Discussion of the costs of cancer treatment.	42 % of oncologists reported discussing cost always or most of the time, 32 % reported sometimes discussing cost with their patients.
Patel, 2009 [45] N = 343	Random, nationwide sample of pediatricians and family physicians who care for children with asthma in the U.S.	• Asking the child’s family about OoP costs a newly prescribed asthma medication.	50 % of physicians reported asking about cost regularly when prescribing new asthma medications for children.
Neumann, 2010 [26] N = 787	Random sample of U.S. based oncologists with an oversample from California.	• Discussion of cancer treatment costs.	43 % always or frequently discussed cancer treatment costs with their patients, while 37 % said they did so occasionally.
Irwin, 2014 [14] N = 134	Breast cancer patients at a single academic cancer center.	• Discussion of costs of care.	14 % discussed costs with their doctor.
Patel, 2014 [46] N = 422	African-American adult women with persistent asthma recruited from a single academic center.	• Did you talk with your doctor about out-of-pocket healthcare costs?	39 % have discussed costs with their doctors.
Bestvina, 2014 [29] N = 300	Cancer patients in quaternary referral cancer center and affiliated rural oncology practices.	• Discussion of OoP costs of cancer care with oncologist.	19 % discussed the cost of cancer care with their oncologists.

We searched PubMed, EMbase, Cochrane Database, and the Social Science Research Network using terms synonymous with ‘out-of-pocket costs’ and ‘cost discussion’. We reviewed titles and abstracts from resultant articles, retaining those that reported on the frequency of physician-patient communication about healthcare costs. We further investigated all pertinent references in these articles to identify additional studies not included in the above databases. This analysis focused on cost conversation incidence in the United States; thus, studies with international sample populations were excluded. Abbreviations: OoP indicates out-of-pocket