Barriers to Patient-physician Communication About Out-of-pocket Costs


  • Received from the Robert Wood Johnson Clinical Scholars Program (GCA, LPC, DOM), MacLean Center for Clinical Medical Ethics (GCA), Department of Health Studies (LPC), Biological Sciences Collegiate Division (DM), and Harris School of Public Policy (DOM), University of Chicago, Chicago, Ill; Pacific Health Research Institute (CWT); and Department of Family Practice and Community Health (CWT), John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii.

Address correspondence and requests for reprints to Dr. Alexander: RWJ Clinical Scholars Program, The University of Chicago, 5841 S. Maryland, MC 2007, Chicago, IL 60637 (e-mail:


BACKGROUND:  Though many patients and physicians believe that they should discuss out-of-pocket costs, research suggests that they infrequently do.

OBJECTIVE:  To examine barriers preventing patient-physician communication about out-of-pocket costs among study subjects recalling a time when they wanted to discuss these costs but did not do so.

DESIGN, SETTING, AND PARTICIPANTS:  Cross-sectional surveys of 133 general internists and 484 of their patients from 3 academic and 18 community practices in a large midwestern metropolitan region.

MEASUREMENTS:  Patient- and physician-reported barriers to discussing out-of-pocket costs.

MAIN RESULTS:  Overall, 54 patients (11%) and 27 physicians (20%) were able to recall a specific time when they wanted to discuss out-of-pocket costs but did not do so. Among patients, a wide variety of barriers were reported including their own discomfort (19%), insufficient time (13%), a belief that their physician did not have a viable solution (11%), and concerns about the impact of discussions on quality of care (9%). Among physicians, the most common barriers reported were insufficient time (67%) and a belief that they did not have a solution to offer (19%).

CONCLUSIONS:  Efforts to promote discussions of out-of-pocket costs should emphasize the legitimacy of patients’ concerns and brief actionable alternatives that physicians can take to address them.