Discussing out-of-pocket expenses during clinical appointments: An observational study of patient-psychiatrist interactions

Abstract

Objective: High out-of-pocket expenses for medical treatment have been associated with worse quality of life, decreased treatment adherence, and increased risk of adverse health outcomes. Treatment of depression potentially has high out-of-pocket expenses. Limited data characterize psychiatrist-patient conversations about health care costs. Methods: The authors conducted content analysis from 422 outpatient psychiatrist-patient visits for medication management of major depressive disorder in communitybased private practices nationwide from 2010 to 2014. Results: Patients' health care expenses were discussed in 38% of clinic visits (95% confidence interval [CI]= 33%-43%). Uninsured patients were significantly more likely to discuss expenses than were patients enrolled in private or public plans (64%, 44%, and 30%, respectively; p,.001). Sixty-nine percent of cost conversations lasted less than one minute (median=36 seconds; interquartile range [IQR]=16-81 seconds). Cost conversations most frequently addressed psychotropic medications (51%). Physicians initiated 50% of cost conversations and brought up costs for psychotropic medications more often than did patients (62% versus 38%, p=.009). Conversely, a greater percentage of patient-initiated cost conversations addressed provider visit costs (27% versus 10%, p=.008). Overall, 45% of cost conversations mentioned cost-reducing strategies (CI=37%-53%). Themost frequently discussed costreducing strategies were lowering cost by changing the source or timing of an intervention (for example, changing pharmacies), providing free samples, and switching to a lower-cost therapy or diagnostic test. Conclusions: Psychiatrists and patients regularly discuss patients' health care costs in visits for depression. These discussions cover a variety of clinical topics and frequently include strategies to lower patients' costs.