Shared Decision-Making Tool Aids Out-of-Pocket Patient Cost Talks

July 20, 2021 - Three out of four patient-provider encounters included discussions about out-of-pocket patient costs when a shared decision-making (SDM) tool was used, a study published in JAMA Network Open revealed.

Researchers studied 830 audiovisual recordings of conversations between physicians and patients with atrial fibrillation (AFib). They analyzed conversations with and without the use of SDM tools to determine how often cost conversations came when discussing anticoagulation treatment.

Five medical centers took part in the study with representation from academic, community, and safety-net practices. Settings included primary care, cardiology clinics, emergency departments, outpatient safety-net facilities, and inpatient hospital services.

An estimated 12.1 million people in the US alone will develop atrial fibrillation by 2030, the Centers for Disease Control and Prevention says. AFib increases stroke risk and incurs over $25 billion per year in healthcare costs.

However, oral anticoagulants, non-vitamin K antagonists, direct oral anticoagulants (DOACs), and warfarin can successfully prevent strokes for AFib patients. Despite the multitude of treatment options, almost half of AFib patients do not take oral anticoagulants, and 30 to 50 percent of those who do end up discontinuing treatment within the first 12 months, the study explained.

“Treatment costs burden patients directly, whether through out-of-pocket costs such as deductibles, copayments, and coinsurance for those who are insured, or the total cost of medications for those that are not insured,” the study stated.

“With 1 in 3 patients having trouble paying their medical bills, delays, avoidance of care, and nonadherence expose patients to the risk of preventable strokes.”

Despite concerns over the financial burden of starting a new treatment, only one in three clinicians reported regularly having anticoagulation cost conversations with patients. Researchers hypothesized that use of an SDM conversation tool that included information on annual costs of each treatment option would encourage cost conversations.

The Anticoagulation Choice SDM encounter tool provides a patient’s stroke risk with and without anticoagulation, then compares treatment options based on a patient’s medication use, risk of bleeding, need for periodic monitoring, and estimated out-of-pocket patient costs.

Cost conversations occurred during 90 percent of encounters with the SDM group, compared to only 63 percent in the standard case cohort. In addition, middle-income individuals earning between $40,000 and $100,000 per year were more likely to have cost conversations with their providers.

Female clinicians, family medicine clinicians, and internal medicine clinicians were also more likely to engage in cost conversations compared to cardiology providers. Female clinicians were three times more likely than male clinicians to discuss out-of-pocket patient costs.

While the conversations did play a role in patients’ decision-making processes, researchers found that they did not make a significant impact on final treatment choice.

“Even if medication choices were unaffected, there is still enormous value in normalizing cost conversations. These conversations continue to carry stigma, especially for historically marginalized populations,” an accompanying article suggested. 

“Developing more shared decision-making tools with cost information and offering them at the point of care may lower the activation energy to have these conversations, especially for clinicians who cite lack of knowledge about costs as a barrier or are otherwise less likely to offer them organically.”

Researchers also suggested that the SDM tool may have simply prompted clinicians to ask more about patient preferences and cost just happened to be a major concern for many. In addition, the incidence of cost conversations even without the tool were significantly higher than previous research suggested.