Discussing Out-Of-Pocket Expenses during Clinical Appointments – Observational Study of Patient/Psychiatrist Interactions

Abstract

Objective

High out-of-pocket expenses have been associated with worse quality of life, decreased adherence, and increased risk of adverse health outcomes. Treatment of depression has high potential out-of-pocket expenses. There are limited data characterizing psychiatrist-patient conversations about healthcare costs.

Methods

Content analysis of dialogue from 422 outpatient psychiatrist-patient visits for medication management of major depressive disorder in community-based private practices nationwide from 2010-2014.

Results

Patients’ healthcare expenses were discussed in 38% of clinic visits (95% confidence interval [CI], 33% to 43%). Uninsured patients were significantly more likely to discuss expenses than patients enrolled in private or public plans (64%, 44%, 30%, respectively; P=0.0003). Sixty-nine percent of cost conversations lasted less than one minute (median: 36 seconds; interquartile range [IQR]: 16 to 81 seconds). Cost conversations most frequently addressed psychotropic medications (52%). Physicians initiated 50% of cost conversations and brought up costs for psychotropic medications more often than patients (62% vs. 40%; P=0.009). Conversely, a greater percentage of patient-initiated cost conversations addressed costs for provider visits (26% vs. 10%; P=0.008). Overall, 45% of cost conversations mentioned cost reducing strategies (95% CI, 37% to 53%). The most frequently discussed cost reducing strategies were 1) lowering cost by changing the source or timing of an intervention (e.g. changing pharmacies), 2) providing free samples, 3) switching to a lower cost therapy or diagnostic.

Conclusions

Psychiatrists and patients regularly discuss patients’ healthcare costs in visits for depression. These discussions address a wide variety of clinical topics and frequently include strategies to lower patients’ costs.

INTRODUCTION

Out-of-pocket expenses, in the form of co-payments, coinsurance, deductibles and/or uncovered services, are growing for many Americans with increases in patient cost sharing, the prevalence of high-deductible healthcare plans, and the use of high-cost pharmaceutical drugs (1-5). High out-of-pocket costs have been associated with non-adherence to care and may negatively affect quality of life and various healthcare outcomes (6-14). Out-of-pocket expenses may be particularly problematic for patients with depression, who already face higher costs at multiple components of care (15). Despite the Mental Health Parity Act, determination of equivalent coverage is imperfect, and the use of carve-outs for mental health benefits may lead to fragmentation of care thereby leading to higher costs (16). In addition, depression is more common among the poor, with over 15% of persons below the federal poverty level suffering from depression compared to 6.2% of patients at or above the poverty level (17). Discussion of costs during psychiatry appointments offers important opportunities to ensure that financial burden does not add to disability.

In previous survey studies, almost 2/3 of patients have indicated a desire to discuss out-of-pocket expenses with their physicians, but only approximately 15% reported ever doing so (18, 19). Physicians regularly cite insufficient time, lack of habit, lack of perceived solution, their own as well as perceived-patient discomfort, as barriers to discussion of out-of-pocket expenses (20-22). However, in our analysis of physician-patient interactions, we discovered that healthcare expense conversations were more common than previously thought, occurring in 30 to 43% of psychiatry appointments depending on how cost conversation was defined (23).

In this article, we explore outpatient psychiatric interactions in more depth, to characterize the content of healthcare expense conversations that took place during visits between psychiatrists and patients with major depression. We analyze naturally occurring dialogue from private-practice, community-based, outpatient psychiatric clinic visits taking place between 2010 and 2014. By exploring the frequency and duration of healthcare cost discussions in these encounters, as well as the cost reducing strategies therein, we provide novel insights about the out-of-pocket cost management efforts discussed by psychiatrists and patients. By doing so, we hope to help psychiatrists recognize the many ways in which they can help patients reduce out-of-pocket expenses.

METHODS

Sample Description

Patient visits were sampled from the Verilogue Point-of-Practice™ database of audio-recorded and transcribed clinical encounters (www.verilogue.com). Visits took place from May 2010 to January 2014 for medication management in outpatient, private-practice offices across the United States. Details of the sample have been discussed in previous publications (23, 24). Briefly, Verilogue recruits physicians randomly from available lists of active, board certified physicians, and pays them to record patient visits for the purpose of marketing or health services research. No other specific inclusion or exclusion for the physicians exist; the recruitment rate is 1:1200. Physicians and patients are unaware of the research questions for which their recorded visits will be used. Patients are approached and consented prior to initiation of the visit, with approximately 80% of patients agreeing to participate. In the sample, only 1 visit per patient existed though multiple visits per provider may exist. The visits can occur at any time within the patient-physician relationship. All protected health information is removed during the transcription process; no other information is censored. This study was approved by the Duke University Institutional Review Board.

Cost Related Measurements and Analytic Approach

We defined “cost conversation” as any mention of the patient’s out-of-pocket expenses or insurance coverage for a past, present, or potential healthcare service. The development and validity of this definition has been discussed in detail elsewhere (23). To mitigate individual coder biases and errors, encounters were analyzed independently by at least two team members. The following cost-related measures were evaluated: (1) Presence or absence of cost conversation; if a cost conversation was present, then (2) to which intervention(s) the cost conversation was related; (3) duration of the cost conversation; and (4) discussion of cost-saving strategies. The cost conversation duration was calculated by multiplying the total number of cost-related words by the average rate of words spoken, as described elsewhere (23). A team member experienced in conversation analysis assessed coder agreement on each of the above measures. In cases of agreement, the corresponding decision was assigned as ‘final’. When discrepant, the final coding decision was decided by group consensus. Team members with clinical experience (Dr. H., Dr. B.) supervised coder training and discrepancy resolution to ensure proper interpretation of clinical matters. All coding was applied using NVivo software (QSR International Pty Ltd. Version 10, 2014).

Statistical Analysis

We compared cost discussion code frequencies using Pearson’s chi-square tests and Fisher’s exact test, and calculated 95% confidence intervals using Clopper and Pearson’s exact method (25). We used Kruskal-Wallis and Mann-Whitney U tests to compare cost discussion durations, since their distributions were non-normal; Statistical analyses were conducted using R software (R Core Team [2013], Version 3.0.1, http://www.R-project.org/). All authors had full access to the data and take responsibility for its integrity.

RESULTS

Study Population

Our final sample included 422 clinic visits. Patient, psychiatrist, and visit characteristics are provided in Table 1. A total of 422 patients with major depressive disorder were included in our study; they were predominantly female (66%), 35-54 years of age (44%), and white (83%). Eight percent of patients were uninsured, which is similar to the national average for patients with depression at 9.8% (26). A total of 36 psychiatrists were included in this study; they recorded a median of 13 visits each (interquartile range [IQR], 4 to 17 visits), were all male, and most commonly had 21-30 years of experience in practice (44%). Data on physicians’ race are not available. The clinic visits occurred in 20 states: Arizona, Georgia, Hawaii, Illinois, Indiana, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, Mississippi, North Carolina, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Texas, Virginia, and Wisconsin.

TABLE 1.

Demographics of patients and psychiatrists^a

Patients	N=422
Age, years	%
19-34	23
35-54	44
55-74	33
75+	1
Gender	%
Female	66
Race	%
White	83
Black	7
Hispanic	5
Other	4
Insurance status	%
Private	49
Public	43
Uninsured	8
Psychiatrists	N = 36
Gender	%
Male	100
Years in practice	%
0-10	16
11-20	34
21-30	44
31+	6

^aPercentage totals do not all sum to 100 due to rounding.

Cost Conversation Incidence

Thirty-eight percent of visits contained a cost conversation (95% confidence interval [CI]; 33% to 43%). Cost conversation incidence varied significantly by patients’ insurance status and was highest among uninsured patients (64%), followed by patients enrolled in private insurance plans (e.g. Aetna, Blue Cross Blue Shield; 44%), and then patients enrolled in public insurance plans (i.e. Medicare, Medicaid; 30%; P=0.0003 for comparison across groups). Additionally, cost conversation incidence was higher in visits with white, non-Hispanic patients compared with visits featuring non-white and/or Hispanic patients (40% vs 27%, respectively; P=0.05). Lastly, cost conversations were more common in visits with middle-aged patients (35-54 years old; 43%), than with younger patients (19-34 years old; 39%), or older patients (≥55 years old; 31%; P=0.06 for comparison across age groups).

Topics and Initiators of Cost Conversations

Cost conversations most commonly addressed medications (66% of all cost conversation topics), and over half dealt with costs for psychotropic drugs (52%). The most frequently discussed classes of psychotropic medications were serotonin norepinephrine reuptake inhibitors (SNRIs; 11% of all cost conversation topics) and antipsychotics (also 11%). Selective serotonin reuptake inhibitors (SSRIs), sleep aids, and stimulants were discussed less frequently, constituting 7%, 7%, and 5% of cost conversation topics, respectively. The costs of over 50 different medications were discussed in our sample; the most frequently mentioned were: 1) duloxetine (Cymbalta), 2) aripiprazole (Abilify), 3) quetiapine (Seroquel), 4) zolpidem (Ambien), 5) bupropion (Wellbutrin, Aplenzin), and 6) escitalopram (Lexapro). Examples of medications among the different classes as well as an example for the seven conversations that discussed cost of medications in general are provided in Supplemental Table 1.

Non-pharmacologic therapies and services accounted for 34% of cost conversation topics and most commonly addressed costs for psychotherapy (9%), provider visits (9%), procedures (4%), and medical equipment (3%). Four (<1%) cost conversations discussed the cost of neuropsychiatric testing. Of the conversations pertaining to procedures, five involved electroconvulsive therapy (ECT) and/or transcranial magnetic stimulation (TMS) and one discussed a vagus nerve stimulator. Twenty-four percent of cost conversations addressed costs for more than one clinical topic: 18% addressed 2 different topics and 6% addressed 3 different topics.

Nearly equal percentages of cost conversations were initiated by physicians and patients (50.3% vs. 48.4%, respectively). Rarely, cost conversations were initiated by patients’ caregivers or companions (1.2%). The break-down of initial cost topics and who initiated them is presented in Figure 1. A significantly greater percentage of physician-initiated cost conversations addressed costs for psychotropic medications when compared with those initiated by patients (62% vs. 40% of initial cost topics, respectively; P=0.009). By contrast, a significantly greater percentage of patient-initiated cost conversations addressed costs for provider visits (26% vs. 10% P=0.008).

FIGURE 1. Initiators and topics of patient-psychiatrist cost conversations^a.

^aCost conversation topics stratified by initiator. ^b‘N’ represents the total number of times each cost topic appeared as initial cost topic.

Discussion of Cost Reducing Strategies

Overall, 45% of cost conversations contained discussion of at least one cost reducing strategy (95% CI, 37% to 53%). When cost reducing strategies were discussed, they most commonly dealt with costs for psychotropic medications (78% of cost reducing strategies; Table 2). Specifically, psychiatrists and patients most often mentioned cost reducing strategies for antipsychotics and SNRIs (19% and 17% of all cost reducing strategies, respectively). Fifteen percent of cost reducing strategies pertained to non-pharmacologic topics such as provider visits (6%), or procedures, diagnostic testing, and medical equipment (‘Other’; 8%).

TABLE 2.

Types and frequencies of cost reducing strategies

Cost Topic
	Psychotropic medications		Non-psychotropic medications		Provider visit		Other		All topics
Cost-Reducing Strategy	N=107		N=29		N = 38		N=34		N=208a
	N	%	N	%	N	%	N	%	Nb	%
	Switching to a lower cost alternative	18	16%	1	1%	2	2%	3	3%	24	22%
Changing dose or frequency	9	8%	1	1%	0		1	1%	11	10%
Changing source or timingc	18	16%	1	1%	5	4%	1	1%	25	23%
Using free samples to reduce costs	21	19%	4	4%	0		0		25	23%
Facilitating use of copay assistance or coupons	19	17%	1	1%	0		2	2%	22	20%
Other	1	1%	0		0		2	2%	3	3%
Total	86	78%	8	7%	7	6%	9	8%	N=110

^a‘N’ in the first row represents the total number of times each cost topic was discussed. Total number of cost topics discussed (N=208) is greater than the total number of cost conversations (N=161), since 38 cost conversations mentioned more than one cost topic, i.e. had a second or third cost topic.

^b‘N’ within the table correspond to the first cost topic and respective cost-reducing strategy. Percentages also correspond to only first cost topic and conversation.

^cChanging source or timing of an intervention could include changing pharmacies, changing office location or changing follow-up timing due to cost.

The majority of cost reducing strategies did not require changes to the care plan (68% of all cost reducing strategies); these included discussions of lowering cost by changing the source or timing of an intervention (23%), providing free samples for the purpose of lowering the patient’s costs (23%), or facilitating use of copay assistance programs (CAPs) or cost-saving coupons (20%). Conversely, 32% of cost reducing strategies required changes to the care plan; these included switching to a lower cost therapy or diagnostic (22%), and changing the dose and/or frequency of an intervention (10%).

Frequently, psychiatrists and patients sought to lower costs for psychotropic medications by providing free samples or facilitating use of CAPs or coupons. These often involved a variety of interrelated scenarios where the doctor offers a medication option because he has samples, offers a trial of the medication before a prescription, or offers to start with a sample then move to using coupons (Table 3). Sometimes psychiatrists discussed coupon programs for nonmedication expenses, e.g. a conversation around steps—including surgery—towards transitioning sex that utilized a grant program.

TABLE 3.

Transcript examples for strategies discussed to reduce patient out-of-pocket costs^a

Cost Reducing Strategy	Medication example(s)	Non-medication example(s)
Switching to a lower cost alternative	DR: In terms of the Wellbutrin, if we go up to 450 by giving you three of the 150s that would be 50% higher than where you’re at right now or we could go up to 400 by using, and it may be cheaper, the Wellbutrin SR. They come in 200. You could take that twice a day and be up from 300 to 400.	DR: I don’t know if your insurance will cover [neuropsychiatric testing] because it’s a few thousand dollars sometimes. […] So, what you could do instead then is an adult self report skill [questionnaire]. […] I’ve had pretty good results working over 20 years doing this with these checklists.
	PT: That I might rather try first then going all the way up to the 450.
	DR: Plus, it may be cheaper.
	DR: The one I’m giving you is Seroquel XR.
	PT: Yeah.
	DR: But the generic Seroquel is much cheaper.
	DR: You even responded to the Lexapro […]. I think the Effexor is an excellent choice because it covers the panic and the generalized anxiety that you have as well as depression […] and the generic is inexpensive.
Changing dose or frequency	PT: Now also they didn’t give me the Effexor right.	PT: I know I’m going to lose interest [in therapy books]. I’m not going to pay for that because like in a week I’ll probably toss it aside.
	DR: Okay, so we’ll look at that then. Because you do a 150 and a 75, right?
	PT: Yeah, and they gave me, 2 sets of 75s, 90 days each but they didn’t give me the third.
	DR: All right. I’ll see now, because I’m going to change that. Yeah, it might be cheaper if we do 3 of the 75s, right?
Changing source or timing	DR: But, where are you getting it? What pharmacy do you use?	PT: You’ll accept Medicare, Medicaid do you?
	PT: Uh, [DEIDENTIFIED].	DR: No, but I could see you at my other place if that were the case.
	DR: You need to go away from [DEIDENTIFIED] and go to [DEIDENTIFIED]. It is way less expensive.
		DR: How about therapy wise are you seeing a counselor?
		PT: No. I can’t afford $145 a visit. I don’t have that.
		DR: How about someone through a church?
Using free samples to reduce costs and/or facilitating use of copay assistance or cost-saving coupons	DR: The two agents that have recently been approved, one is called Abilify. […] Its downside is it’s expensive. […] With that medicine. I like it in that they have given us samples and coupons, so you could at least try it.	DR: This is the CTS steps program here. […] And, so there’s no charge or anything. It’s just free as long as you put in that little code.
	DR: So the Effexor worked good for you, but you’re not sure if you’ll be able to get it or not? [What] comes closest to the Effexor is the Pristiq. And for the time being, I don’t really have an issue being able to provide you with samples until we settle the issue.
	DR: [Abilify] is by far the most expensive medicine I prescribe. But I like it in a situation like yours. If you wanted to try it I have some samples, and they have a coupon program to help you with your insurance if your insurance won’t cover it.
	DR: “Didn’t you try Cymbalta at one time?”
	PT: “Yeah but then that ended up being the same thing. I couldn’t really afford.”
	DR: “I have samples of that though.”

^aRepresentative excerpts demonstrating different cost reduction strategies. Fillers (e.g. “um”, “oh”) have been removed from dialogue for brevity and punctuation has been added to improve readability.

Sometimes psychiatrists recommended reducing expenses by switching to a different formulation of the same medication. This was particularly true with bupropion (example in Table 3). Other times, psychiatrists lowered patients’ expenses by prescribing generic medications that were not the equivalent of the brand name medication patients were previously taking (Table 3).

Sometimes psychiatrists lowered patients’ expenses by changing the source or timing of medications, e.g. discussing an alternative location for obtaining the medication, such as using a different pharmacy to obtain a lower price. Other times, psychiatrists lowered patients’ medication expenses by prescribing a different quantity of medications, e.g. 90-day versus 30-day.

Psychiatrists also reduced patients’ expenses by addressing the source or timing around nonmedication expenses, e.g. by having a patient come to the physician’s other office location that accepted the new insurance, or by spacing out the intervention, such as the appointment follow-up time. Psychiatrists also suggested logistical changes to reduce therapy expenses, e.g by recommending that patients seek counselors through churches (Table 3). Discussions around ECT and/or TMS often focused on obtaining insurance approval.

Duration of Cost Conversations

The median visit duration in our sample was 12 minutes and 15 seconds (IQR: 9 minutes and 13 seconds, 18 minutes and 36 seconds). In visits containing cost conversations, the median time spent discussing patients’ healthcare costs was 36 seconds (IQR, 16 to 81 seconds). The majority of cost conversations lasted less than 1 minute (69%), and 8% lasted 3 minutes or longer (Figure 2). There was no significant difference in the duration of cost conversations initiated by physicians versus patients (P=0.91). However, cost conversations containing discussion of cost reducing strategies lasted significantly longer than those without discussion of such strategies: median durations of 71 seconds and 22 seconds, respectively (P<0.0001).

FIGURE 2.

Duration of discussion of costs

DISCUSSION

We analyzed the content of outpatient encounters between patients being treated for depression and their psychiatrists and discovered that discussion of healthcare costs was common, typically brief, and frequently focused on ways of reducing patients’ out-of-pocket expenses. Cost conversations occurred in more than 1 in 3 visits and focused mainly on costs for psychotropic medications. Notably, psychiatrists and patients differed with respect to the costs they brought up; psychiatrists were more likely to bring up costs for psychotropic medications, whereas patients were more likely to bring up costs for provider visits.

Why are psychiatrist-initiated conversations disproportionately focused on medication costs? The combined cost reducing strategies around free samples and the use of CAPs or coupons accounted for almost 50% of the cost reducing strategies discussed. Previous survey data have indicated that physicians will change prescribing habits, deviating from their preferred drug, if samples are present (27). The availability of samples and coupon programs in the clinics is unknown though familiarity with these strategies may explain the high rates of discussion. A prior study indicated that physicians with high perceived knowledge on medication costs are more likely to discuss costs (28). Physicians may be more likely to initiate cost discussions on the topics in which they perceive greater knowledge and comfort. Patients, conversely, may have greater motivation to initiate conversations with greater immediate out-of-pocket expenses, whether high co-pays, co-insurance, or deductibles.

Our study also highlights that out-of-pocket expenses can be reduced without necessarily changing the course of clinical care. While a variety of cost reducing strategies were utilized, the majority of strategies did not alter the plan of care. However, the long-term effects of these cost reducing strategies on clinical care are unclear. Although providing free samples or facilitating the use of CAPs or coupons can provide patients significant short-term cost saving (29, 30), the long-term effect on patients’ out-of-pocket expenses is possibly detrimental (31, 32). After the sample or program runs out, patients may be faced with co-pays for brand name drugs or even the full cost of the drugs out-of-pocket. In some cost conversations, for example, patients complained about the cost of medications, pointing out that even with coupons and other assistance programs, their out-of-pocket expenses remained high.

Our study also suggests demographic variation in the kind of patients likely to discuss healthcare costs with their psychiatrists. For example, the rate of discussions in patients over 55 years was lower than for younger populations. Further studies are needed to better assess the relationship among race, age, and insurance status with regards to cost discussions. Still, not surprisingly, the highest incidence of cost discussions were among uninsured patients. In this group, psychiatrists, not patients, were more likely—at almost twice the rate—to initiate the cost conversation. Knowing that the patient is uninsured may have made psychiatrists more cognizant of discussing costs. It is not known if the uninsured patients had chosen not to use their insurance to avoid insurer or employer awareness of mental health treatment. Another point of emphasis concerning demographics is that all physicians in the study were men despite the majority of psychiatrists nationally being women. While there is high likelihood of bias in the sample from having only male physicians, the overall impact is not known.

Almost one-half of the cost conversations in this study included discussion of a cost reducing strategy. One often-cited barrier to communication around costs is the perception of insufficient time (20, 33). Yet, psychiatrists commonly engaged in cost conversations with their patients. This concern over time has not been borne out in our study. These conversations are and can be succinct. Almost 70% of the cost conversations lasted less than 1 minute, and the plurality of cost conversations lasted less than 30 seconds, meaning that the vast majority of cost conversations took less than 10% of the visit.

Our study shows that cost conversations occur more often than survey data has previously described and that cost reducing strategies are included in these discussions. However, the study does not establish the effect these discussions had on out-of-pocket expenses nor does it establish that the cost conversations are as effective as they could be. Discussions around strategies to reduce cost do not necessarily lead to lowered expenses for the patient (e.g. substitution of Pristiq for Effexor in one encounter). Further research is required to characterize strategies that improve the efficiency, quality, and patient-centeredness of cost discussions. This would include evaluation of strategies that can reliably lead to changes in out-of-pocket expenses. In some encounters, neither psychiatrists nor patients were able to assign costs to specific interventions accurately. Indeed, frustration around the complexities in healthcare reimbursement was a common theme with psychiatrists and patients at times aligning against such perceived barriers. Greater price transparency could help alleviate some of difficulties in determining out-of-pocket expenses and facilitate the discussion around cost reducing strategies (20, 34).

There are some additional limitations to the study. Generalizability of the findings may be further limited as the sample did not include academic settings, hospital-based clinics, or community mental health clinics. However, the relatively large sample size, geographic diversity, and variety of insurance coverage speaks to broader generalizability than previous studies. Because we had access to only 1 visit per patient, we could not determine if cost conversations occurred during preceding encounters limiting the need for discussion in the current one. Furthermore, other psychiatric conditions may have different rates of cost conversations.

CONCLUSIONS

In clinic visits for depression management, we found that patients and psychiatrists discuss costs regularly, in more than 1 in 3 visits. Interestingly, patients and psychiatrists initiated cost conversations with nearly equal frequencies, although they differed with respect to the costs they brought up more often: psychotropic medications for psychiatrists opposed to provider visits for patients. Importantly, almost half of cost conversations mentioned a cost reducing strategy, which most often pertained to the use of free samples or facilitation of copay assistance programs or coupons. Cost conversations were usually brief, with the majority less than one-minute in length. This study provides novel insights into the topics and cost reducing strategies discussed in outpatient psychiatrist-patient visits for management of major depressive disorder.