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Keywords:

  • physician-patient communication;
  • health care costs;
  • empathy.

Abstract

  1. Top of page
  2. Abstract
  3. EMPATHIC COMMUNICATION
  4. “WE” STATEMENTS
  5. “I WISH …” STATEMENTS
  6. IT's OKAY TO ASK
  7. WHAT NEXT? KNOWLEDGE OF RESOURCES
  8. CONCLUSION
  9. References

Escalating health care costs are affecting patients across the country. As employers and insurance companies face higher expenses, they may move to a cost-sharing strategy, which potentially increases financial burdens on patients. In this situation, physicians may find themselves serving as both medical and financial advisors for their patients. Clinical encounters in which patients experience financial hardship can be awkward and frustrating for both parties. Physicians must learn to discuss issues of affordability in a manner that builds, rather than detracts, from a therapeutic alliance. This article describes our experiences using several communication skills that can help in the discussion of health care costs with patients. The primary skill, empathic communication, which includes “we” statements and “I wish …” statements, serves to create a platform for shared decision-making, negotiation, and a search for alternatives. In addition, it is helpful if physician offices have resource materials available and strategies identified to assist patients facing financial hardship.

Steadily increasing health care costs over the past decade affect nearly all patients. Since 2002, health care premiums have increased at 4 times the rate of inflation.1 The uninsured face prohibitive medical costs and may be unable to finance their care. Even those with excellent insurance experience accelerating premiums and higher out-of-pocket expenses. Employers face surging health insurance expenses and employee cost-sharing increases.2 Cost sharing is a strategy designed to reduce overall premiums through the addition of deductibles, copayments, and coinsurance paid by the patient at the time of service. In the past, these charges were frequently nominal, but now even well-insured patients are being asked to pay significantly more for office and emergency care, hospitalizations, ambulance transportation, prescriptions, diagnostic procedures, and other health-related services. While the relative merits of cost-sharing are being debated, it appears that this economic strategy is here to stay.3

As patients ask that the financial context of their lives be considered as part of their medical and social histories, physicians find themselves caught in the uncomfortable position of serving as both medical and financial advisors for those in their care. These circumstances present opportunities for exam room conversations about medical care cost, options, and alternatives. According to Trude (a senior health researcher with the Center for Studying Health System Change in Washington, DC), “cost has never been a major focus of the patient-physician relationship, but in the future, it will have to become part of that dynamic.”4 Trude may be inaccurate about the patients' view of medical costs in the past, and yet may be correct in foreseeing a need for more dialogue in the future. A survey study by Alexander revealed that although both patients and physicians believed that discussions about out-of-pocket costs were important, such discussions occurred infrequently.5 Although nearly 2/3 of patients surveyed desired to speak with their physician about out-of-pocket costs, only 15% reported having done so. Reasons cited for not having cost conversations include discomfort in discussing financial issues, insufficient time, a belief that there were no viable solutions to the patients' concerns, and lack of knowledge about costs.6

Financial discussions may add to the complexity of a physician-patient relationship, especially when cost concerns conflict with a medically indicated treatment plan. As noted by Gallagher and Levinson,7 interactions between anxious patients and frustrated doctors can be a prescription for conflict and disagreement. However, open and honest communication about out-of-pocket expenses need not interfere with the therapeutic relationship. Indeed, exploring financial barriers with patients can strengthen the doctor-patient relationship and build trust. Ignoring patients' concerns, delaying the conversation, or blaming external entities may detract from the partnership. The disclosure of financial hardship on the part of the patient also provides critical information for the physician. Uncovering financial concerns has clinical relevance because lack of resources is a common source of noncompliance with prescribed diagnostic and treatment plans.

EMPATHIC COMMUNICATION

  1. Top of page
  2. Abstract
  3. EMPATHIC COMMUNICATION
  4. “WE” STATEMENTS
  5. “I WISH …” STATEMENTS
  6. IT's OKAY TO ASK
  7. WHAT NEXT? KNOWLEDGE OF RESOURCES
  8. CONCLUSION
  9. References

It has been our experience that the use of several communication skills, based on empathic communication, help create the framework for a respectful exam room conversation about cost of care. Empathic communication facilitates the physician's expression of understanding and partnership and allows for more effective use of shared decision-making and negotiation around medical options and alternatives.8 Many physicians have been trained in the world of “Find it and Fix it” medicine, where empathic communication was an afterthought, if considered at all. Empathy was seen as a part of “bedside manner” and it seemed “you were either born with it or you weren't.”9 More recently, a greater emphasis has been placed on empathy as a communication tool, and many experts now agree that empathy and empathic communication are teachable, learnable skills.10 Empathy is the cornerstone of several communication models, including “The Four Habits” model (Invest in the Beginning, Elicit the Patient's Perspective, Demonstrate Empathy, Invest in the End) used within Kaiser Permanente11; the “E-4” model (Engage, Empathize, Educate, Enlist) developed by the Bayer Institute for Health Care Communication12; and others.13,14

Empathy has been described as an emotional attunement that facilitates patient trust and disclosure.15 Empathic communication is a response that demonstrates an understanding and acceptance of another's feelings, values, and ideas, serves to fortify the doctor-patient relationship, and is especially important in difficult clinical encounters, including those that involve financial hardship. Empathic communication requires an afferent limb—the physician's careful listening and understanding of the patient's values, feelings, and ideas (including those about finance), and an efferent limb—the way we demonstrate our understanding so that the patient feels understood. It is important to remember that empathy incorporates nonverbal (pausing, listening, nodding, and maintaining eye contact) as well as verbal behaviors.16 Statements that facilitate empathy have been categorized as queries, clarifications, and responses.17

Queries:

What has it been like for you dealing with the copays and drug costs?

Are you worried about the cost of your care?

Clarifications:

Tells me more about how you've been dealing with the expenses.

Responses:

I can imagine that all these medical expenses might make you feel …

It sounds like you are finding the costs to be …

An example of an office encounter involving cost concerns where a physician uses empathic communication to negotiate a treatment plan follows:

A 46-year-old man presents for evaluation of 2 weeks of increasing chest pain. The pain is somewhat exertional, but sharp and fleeting. He smokes 1 pack of cigarettes daily. The EKG shows “nonspecific changes.” After performing a history and exam, the physician thinks that the patient should go by ambulance to the Emergency Department for further evaluation.

Patient: Are you sure I have to go to the ED, doc? I mean if you're not totally convinced that this is my heart, I'd rather not pay for an ambulance ride that I don't need. The last time I checked, my ambulance transportation deductible was 250 dollars. That comes right out of my pocket. Besides, I really can't afford to miss work right now.

Physician: It sounds to me like you're really concerned about the cost of this trip to the ED, especially the ambulance charge.

Patient: That's right.

Physician: Is there a particular concern you have about cost?

Patient: Yes, I need to pay for my wife's new diabetes medication and I'm not sure I can afford both.

Physician: Of course that's a worry, and on top of that, you're uneasy about losing more time at work.

Patient: Exactly.

Physician: I can see why you might be hesitant to pursue an aggressive and potentially expensive course of action, especially when we're not sure whether your pain is due to something serious or not. [PAUSE] Frankly, I'm concerned about your health and I'm worried about delaying this evaluation. You and I both want to get this figured out as soon as possible so we can get you safely back to work.

Patient: Well, now that you put it like that, I can see that this really is the best option. I definitely don't want anything bad to happen. Thanks for your concern.

In this brief exchange, the physician does not ignore the patient's concerns, but rather, empathetically acknowledges the issues of ambulance copay cost, other pressing economic concerns, and time missed from work. Using empathic communication, the physician builds trust, strengthens the relationship, and genuinely responds to the patient's plight, without having to take responsibility for it. The physician avoids potentially harmful statements such as: “Well, this is the insurance plan you chose and you'll have to address your complaints with the business office,” or “If you decide not to follow my directions, I'll need you to sign this Against Medical Advice form.”

“WE” STATEMENTS

  1. Top of page
  2. Abstract
  3. EMPATHIC COMMUNICATION
  4. “WE” STATEMENTS
  5. “I WISH …” STATEMENTS
  6. IT's OKAY TO ASK
  7. WHAT NEXT? KNOWLEDGE OF RESOURCES
  8. CONCLUSION
  9. References

The use of “we” statements is a simple communication skill that is useful to express partnership around cost concerns. This can be especially important when there are competing interests such as expense, medical necessity, and patient hesitance. Words such as “we,”“us,”“let's,” and “together” help convey collaboration and teamwork.18 One must be careful that the use of “we” does not communicate condescension or a pretense of togetherness. In some situations, use of “you and I” may be preferable to “we.”19 In either case, by communicating a sense of understanding and collaboration, the physician may prevent the patient from feeling alone and isolated. The following is a simple example of a physician's use of “we” statements to express understanding and partnership:

Patient: I'm afraid that I can't afford that blood pressure pill anymore. My insurance coverage has changed and I now have to pay double what I used to for name-brand drugs. That pill alone will run me 200 dollars a year!

Physician: It must have been quite a shock to see the cost of the prescriptions increase so much.

Patient: You bet it did.

Physician: Let's see if we can find an alternative medication that will work as well, but not be so expensive for you.

Patient: That would be great!

With this empathic response, the physician acknowledges the cost concern and uses “we” statements to reassure the patient that they will work together to find a reasonable solution. The physician avoids blaming external entities over which he and the patient have little control. A physician response of “Yeah, between the pharmaceutical companies and insurance companies, you're really getting a raw deal here” or the like would have provided no value to the patient. Such replies serve only to vent frustration and may ultimately weaken the therapeutic alliance. In this context, voicing displeasure with current medical economic realities does little to build strong therapeutic relationships.

“I WISH …” STATEMENTS

  1. Top of page
  2. Abstract
  3. EMPATHIC COMMUNICATION
  4. “WE” STATEMENTS
  5. “I WISH …” STATEMENTS
  6. IT's OKAY TO ASK
  7. WHAT NEXT? KNOWLEDGE OF RESOURCES
  8. CONCLUSION
  9. References

Quill, Arnold, and Platt have advocated the use of “I wish …” statements to allow clinicians to enter a patient's world and diminish potential conflict in areas of futility and unrealistic hopes.20 When caring for patients who are experiencing worry and concern about the affordability of medical care, “I wish …” statements can be powerful expressions of empathy. By expressing wishes, physicians temporarily suspend their role as scientists and respond as human beings. The physician “wishes” that the circumstances were different and at the same time acknowledges the emotional impact of the financial difficulty. The following is an example of a physician using “I wish …” to demonstrate empathy and support:

Patient: Doc, are you sure I have to go to the hospital and get intravenous antibiotics? I have a 500-dollar copay when I am admitted and even though I feel terrible, I'd rather just go home and take my chances.

Physician: I understand that it costs more for hospital care. I wish there was a less expensive alternative in terms of treating your pneumonia. However, given the severity of the x-ray findings, I really don't think that sending you home with oral antibiotics is a safe option. I'm hopeful that with the powerful intravenous antibiotics and close observation, we can get you better more quickly.

Patient: Well, I definitely don't want to put myself in any unnecessary danger. Knowing your reasoning makes it easier for me to see that the best option is to go to the hospital for the antibiotics.

In this example, the physician does not “bully” the patient or take the opportunity to “bash” the current economics of health care. Rather, the physician uses an “I wish” statement to empathetically acknowledge the patient's concern about the expensive copay, build upon the relationship, and restate her position that hospitalization is warranted. Empathic communication facilitates the negotiation.

IT's OKAY TO ASK

  1. Top of page
  2. Abstract
  3. EMPATHIC COMMUNICATION
  4. “WE” STATEMENTS
  5. “I WISH …” STATEMENTS
  6. IT's OKAY TO ASK
  7. WHAT NEXT? KNOWLEDGE OF RESOURCES
  8. CONCLUSION
  9. References

Research indicates that patients want to discuss cost of care and expect and prefer that their physician initiate the conversation.5 While a few patients will directly and overtly raise cost concerns (“I'm on a fixed income and there's no way I can afford that”), others may voice their concerns more indirectly (“That sounds expensive”). Still others may feel such shame or embarrassment with their financial plight and the inability to afford prescribed tests and medications that they simply never follow through with what is ordered. It is important that the physician have a low threshold for inquiring about potential cost concerns. Just as with other “sensitive” areas of medical history taking, such as a sexual or spiritual history, this should be done with sensitivity and respect. The following example illustrates:

Physician: So, Mr. Jones, I think the most prudent course of action is to treat you with an antibiotic today and then follow up with a CT scan of your lungs in about 4 weeks. I realize that copays for certain imaging procedures have been increasing. Do you foresee any difficulties in proceeding with this plan?

Patient: Well, now that you mention it, I know I have to pay twice as much for non-generic drugs and the copay for a CT scan will cost me a bundle. Are you sure I need all this?

Physician: I imagine that those increased charges are a real annoyance. They would be to anyone. So we're caught in a tough squeeze; less optimal, less expensive treatment or a better and safer treatment at higher cost. Sometimes we need to utilize more costly tests in order to assure we get the best outcome. What do you think we should do?

Patient: Now that you put it that way, let's do as you suggest. Thanks for looking out for me.

In this example, the physician anticipates potential financial concerns, mentions an awareness of the high cost of certain drugs and procedures, and explores whether potential barriers exist. The patient notes that the cost will be substantial for him, but after an empathetic response and explanation of necessity, the patient agrees to proceed. Had this exchange not occurred, it is possible that the patient may not have picked up the prescription or followed through with the CT scan.

WHAT NEXT? KNOWLEDGE OF RESOURCES

  1. Top of page
  2. Abstract
  3. EMPATHIC COMMUNICATION
  4. “WE” STATEMENTS
  5. “I WISH …” STATEMENTS
  6. IT's OKAY TO ASK
  7. WHAT NEXT? KNOWLEDGE OF RESOURCES
  8. CONCLUSION
  9. References

There is likely to be considerable variation in individual patients' insurance and financial situations, and it may be difficult to ascertain the actual cost of referrals, consultations, and procedures provided by other professionals. For some patients, national and local programs may provide financial assistance. Government and private programs are available for low-income patients who qualify.21 Most pharmaceutical companies have medication assistance programs.22 There are numerous internet sites detailing resources for discount medications (including http://www.TogetherRxAccess.com, http://www.rxassist.org, http://www.rxoutreach.com, and http://www.drugstore.com), although scrutiny and caution are advised when dealing with any online organization. Alexander and Tseng have outlined 6 strategies to assist patients who are burdened by out-of-pocket prescription costs, including switching to less expensive/generic medications, stopping nonessential medications, and splitting pills.23 The following is an example of offering help to manage a patient's financial concerns:

Patient: I am really worried about this winter. My medications have gotten so expensive that I can barely afford my heating bill.

Physician: It sounds like you're concerned that you might have a tough time making ends meet before too long.

Patient: You can say that again.

Physician: How about if we take another look at your medications and see if there are any less expensive alternatives. Let's also get you a list of some financial resources that my staff has researched and put together that might be of help to you. What you're experiencing is increasingly common, so let's work together to see what you and I can come up with. Does that sound ok?

Patient: That would be great.

CONCLUSION

  1. Top of page
  2. Abstract
  3. EMPATHIC COMMUNICATION
  4. “WE” STATEMENTS
  5. “I WISH …” STATEMENTS
  6. IT's OKAY TO ASK
  7. WHAT NEXT? KNOWLEDGE OF RESOURCES
  8. CONCLUSION
  9. References

We are practicing our calling during a crisis in health care affordability. Many of our patients, even those with excellent insurance, feel the pinch of increasing health care costs. There are no easy answers to this crisis and many patients are suffering as a result. Like other sensitive issues, including delivering bad news, end of life care, and HIV/AIDS, for which there may be no simple solution, physicians' willingness to talk about and support patients' expression of emotion, fear, and concern is arguably the most powerful therapeutic tool available to the clinician. Use of empathic communication to talk about costs strengthens the physician-patient relationship and facilitates negotiation and shared decision-making around care options. Using “we” statements and “I wish …” statements, inquiring about cost concerns, and providing financial resources serve to reassure that the physician and patient remain partners in care.

References

  1. Top of page
  2. Abstract
  3. EMPATHIC COMMUNICATION
  4. “WE” STATEMENTS
  5. “I WISH …” STATEMENTS
  6. IT's OKAY TO ASK
  7. WHAT NEXT? KNOWLEDGE OF RESOURCES
  8. CONCLUSION
  9. References
  • 1
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  • 2
    Gabel J, Claxton G, Holve E, Pickreign J, Whitmore H, et al. Health benefits in 2003: premiums reach thirteen-year high as employers adopt new forms of cost sharing. Health Affairs. 2003;22: 11726.
  • 3
    Milstein A, Chassin M. Pro & Con: does patient cost sharing lead to better care? (Opinion). Intern Med News. 2004;37: 13.
  • 4
    Finkelstein JB. Firms embrace cost sharing; sick pay most. Am Med News. 2004;47: 10.
  • 5
    Alexander GC, Casalino LP, Meltzer DO. Patient–physician communication about out-of-pocket costs. JAMA. 2003;290: 9538.
  • 6
    Alexander GC, Casalino LP, Tseng CW, McFadden D, Meltzer DO. Barriers to patient–physician communication about out-of-pocket costs. J Gen Intern Med. 2004;19: 85660.
  • 7
    Gallagher TH, Levinson W. A prescription for protecting the doctor–patient relationship. Am J Manage Care. 2004;10: 618.
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    Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA. 2004;291: 235966.
  • 9
    Hardee JT. An overview of empathy. Perman J. 2003;7: 2932.
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    Platt FW, Keller VF. Empathic communication: a teachable and learnable skill. J Gen Intern Med. 1994;9: 2226.
  • 11
    Frankel RM, Stein T. Getting the most out of the clinical encounter: the Four Habits model. Perman J. 1999;3: 7988.
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    Keller VF, Carroll JG. A new model for physician–patient communication. Patient Educ Couns. 1994;23: 13140.
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    Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001;76: 3903.
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    Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997;277: 67882.
  • 15
    Halpern J. What is clinical empathy? J Gen Intern Med. 2003;18: 6704.
  • 16
    Platt F, Gordon GH. Field Guide to the Difficult Patient Interview. 2nd ed. Philidelphia: Lippincott Williams & Wilkins; 2004.
  • 17
    Coulehan JL, Platt FW, Enger B, Frankel R, Lin CT, et al. Let me see if I have this right …: words that help build empathy. Ann Intern Med. 2001;135: 2217.
  • 18
    Skelton JR, Wearn AM, Hobbs R. “I” and “we”: a concordancing analysis of how doctors and patients use first person pronouns in primary care consultations. Fam Prac. 2002;19: 4848.
  • 19
    Dobson R. We are definitely not amused. BMJ. 2002;325: 919.
  • 20
    Quill TE, Arnold RM, Platt FW. “I wish things were different”: expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med. 2001;135: 5515.
  • 21
    Montemayor K. How to help your low-income patients get prescription drugs. Fam Prac Manage. 2002;9: 516.
  • 22
    Chisholm MA, DiPiro JT. Pharmaceutical manufacturer assistance programs. Arch Int Med. 2002;162: 7804.
  • 23
    Alexander GC, Tseng CW. Six strategies to identify and assist patients burdened by out-of-pocket prescription costs. Cleve Clin J Med. 2004;71: 4338.