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Complex Conversations on Cost

Pill bottle with money pouring out


How many clinicians hold a conversation with patients around the potential costs of the proposed care devised for the patient? For low-income patients, who have little to no savings, the fear of paying for a health crisis increases the anxiety and stress around the diagnosis itself, including a chronic condition like diabetes. And yet, according to a paper published this week in the Annals of Internal Medicine, discussion around cost of care occurred during less than half of observed patient encounters, and only 11.9 percent of physician-patient encounters included a discussion of the cost of treatment plans. The Robert Wood Johnson Foundation-funded research was conducted by Douglas D. Bradham, DrPH, MA, MPH, a health economist and policy expert, and Principal Investigator of Migrant Clinicians Network’s “Clear on the Cost” study; Deliana Garcia, MA, MCN’s Director of International Projects and Emerging Issues; Alma Galván, MCH, MCN’s Senior Program Manager; and Corey Erb, MCN’s former Research Assistant and Executive Associate.

This new MCN publication joins a growing body of research and popular press articles detailing the complexity around having a cost-of-care conversation. A recent New York Times article, entitled, “They Want It to Be Secret: How a Common Blood Test Can Cost $11 or Almost $1,000,” dove into the complexity of medical costs, using the routine metabolic blood panel as the example: “Some insurance companies provide consumers with tools to help steer them away from the $450 test, but in many cases you won’t know the price your insurance company agreed to until you get the bill.” Patient costs may be surprising to both patient and clinician.

Discrepancies in health care costs can change over time, tangling an already intricate picture of health coverage and patient responsibility differences, options in procedures and prescriptions, and in and out-of-network care. Most patients who need to have cost-of-care conversations are not well and may be adjusting to the realities of new prescription regimens, long-term care needs, and procedures, and their impacts on day-to-day living, or the “indirect” costs of care, like loss of work or transportation costs. Additionally, clinicians and clinic staff have a limited patient encounter window, during which diagnosis and treatment must be fully discussed, in addition to the related cost of care.

In their study, MCN researchers observed clinical encounters, from check-in through discharge, and then conducted patient interviews and provided the clinicians with post-visit surveys, at two multi-site health centers in Texas and Pennsylvania. Of the 67 encounters with complete data, 38 of them (or 56.7 percent) had no mention of cost by clinic staff, clinicians, or patients. Indirect costs of care were mentioned in just 2.9 percent of visits.

“The nation’s largest network of primary care providers could serve as a fulcrum to enhance transparency and clarity about all costs of care,” concluded Bradham. “There are implications that these costs may reduce patients’ compliance with recommended care and lower providers’ positive outcomes, although these connections were not part of this current study.” 

In response to the research findings, Migrant Clinicians Network developed a policy template for use by health centers to implement and change policy and practice around cost-of-care conversations; it is currently being tested with two health center sites. Additionally, MCN is developing patient education materials, on issues including co-pay, out-of-pocket, annual deductible, and lifetime maximum. Such concepts can easily cause confusion among patients whose insurance coverage may change frequently, and with it, the cost of coverage.

Watch MCN’s blog for updates on the release of those materials and other initiatives to improve cost-of-care conversations:

Read the full research article on cost-of-care conversations at the Annals of Internal Medicine website:



Health Network and PRAPARE
In 2016, just as PRAPARE was set to launch, Migrant Clinicians Network was beginning to develop its new database to better serve patients enrolled in Health Network, MCN’s bridge case management program. Over the course of the following year, MCN configured the new database to allow for the integration of PRAPARE data, in which one health center’s PRAPARE data can be transferred to the next health center, as a mobile patient moves.
“When we started thinking about that data and [Health Network] case management work, so much of case management isn’t just ‘are you taking your medication every day?’ It’s more about, ‘How can I help you access care and manage your health in general?’” explained Anna Gard, RN, who assisted MCN in the development of the new database. “One piece of this is: ‘Let me help you find a health center.’ But the larger pieces around effective case management are, ‘How are you going to get there? Is there public transportation? How are you going to pick up your medications if you live in a hostile community and you’re afraid of leaving the house?’ PRAPARE gives a structured format to capture [these] data, in a form that’s been tested and validated.”
As more health centers provide case management and chronic care management to address the social determinants of health, Gard noted, integration of the PRAPARE data with Health Network, a virtual case management, seemed to make sense. Now, the Health Network team is working to fit PRAPARE into their own workflow.
Saul Delgado, Health Network Data Specialist, who has been integral in building and launching Health Network’s new case management system, notes that asking such personal questions over the phone, when a patient doesn’t have transferrable PRAPARE data from a previous health center, can be challenging. “When we call, the patient doesn’t know you. They’re very scared to answer these kinds of personal questions, whereas when you go the clinic, you at least see the nurse or case worker face-to-face,” he explained. But he recognizes the utility of the data, and has developed the PRAPARE data screens within the database to be easily accessed from the main patient information screen. With drop-down menus, Health Network Associates can populate the information they hear from patients, like how many people live with them in their household, or if they’re worried about losing their home. The information, either attained from a previous health center or inputted by a Health Network Associate, will be transferred when the mobile patient gets to his or her next destination, just as the basic medical records do.
“Health centers are doing more to integrate social and behavioral determinants of health, and we’re recognizing that all of those things have to be integrated with care management. So we’re on the forefront,” Gard concluded.

MCN Streamline Summer 2019

Read this article in the Summer 2019 issue of Streamline here!

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Associate Director of Communications