A Touchy Subject: Can Physicians Improve Value by Discussing Costs and Clinical Benefits With Patients?

Over the last decade, the cost of health care—and cancer care in particular—has risen dramatically [1, 2]. Increasingly, these costs are being passed on to patients in the form of cost sharing, which can have a catastrophic effect on the financial well-being of patients and their families [3, 4]. This “financial toxicity” of cancer treatment has been shown to impact patients’ finances, leading to nonadherence to prescribed treatment, dose adjustments, and skipping appointments [5]. As a result, the Institute of Medicine, the American Society of ClinicalOncology,andothershaverecommendedthatpatients be clearly informed of costs as part of delivering high-quality cancer care [6, 7]. Although a growing body of evidence suggests that some patients struggle with treatment-related financial burden, until recently, little work has been done to identify effective ways of introducing cost into physician-patient discussions, or to place this information within the overall context of value. Value is now a topic of intense interest among patients, clinicians, payers, and policy makers, and it has been defined as a measure of outcomes relative to costs [8]. The patient perspective, however, is of critical importance in defining value. Because perception of value is so individualized, discussionswithpatientsmust includeanassessmentofpatient needs, goals, and preferences. Including cost-benefit discussion in the decision-making process has the potential to both improve outcomes and decrease costs, thereby increasing the value of care delivered. As prices continue to rise in the setting of greater costsharing, continuing with the model of prescribing treatment without discussing value is unsustainable. Policy interventions like price transparency legislation and reimbursement reform are important, but they take time to implement. A more immediate solution might be to focus on the patientprovider interaction as a means to improve value in cancer care. To determine whether the patient-provider interaction around cost is a reasonable area on which to focus for intervention development, we must first define a cost discussion, determine the benefit of those discussions, and describe the path forward in terms of research and intervention development. DEFINING THE COST DISCUSSION Beforedeterminingwhetheracostdiscussionbetweenpatient and provider is beneficial, we should first determine what composes a discussion of health-care costs. The definition of the term “health-care costs” varies by perspective when used by policy makers, the media, or patients. Policy makers often refer to costs in terms of governmental spending on health care, whereas health-care providers or payers are usually referring to the costs of providing care to patients. In considering what costs matter to patients, out-of-pocket expenses are likely to be top of mind for the individual. These costs include not only the direct costs of receiving medical care, but also thenonmedical costs involvedduring treatment, such as transportation, childcare expenses, and time off work. However, when costs escalate, the burden is experienced by society as a whole, and when health-care premiums rise in response, the individual’s pocketbook is affected as well. Hence, some have called for physicians to practice better financial stewardship of our limited resources when making medicaldecisions [9, 10]. Studies suggestmostpatientsarenot interested in discussing societal valuewhenmaking treatment decisions [11].With respect to individual patients’ perception of value from treatment, although many patients want to discuss costs, not all do [12]. Furthermore, the evidence suggests that some patients who want to discuss costs might still prioritize clinical benefit over cost [13]. Limited evidence exists as to the extent or quality of cost discussions between oncologists and patients. The incidence and quality of discussions have been studied in three ways: survey-based studies that query patients and/or providers about their desire to have cost discussions; survey-based studies that ask patients and/or providers to recall whether they have discussed costs with their oncologist; and studies of audio-recorded conversations between patients and providers. A great deal of variation exists in the degree to which patients report desire to have cost discussions, ranging from approximately 50% to nearly 100% of surveyed patients with cancer [11, 12, 14]. Similarly, studies based on recall suggest variation in theextent towhichpatients reportdiscussing their costs with oncologists. Those estimates of cost discussion