Measuring the Effectiveness of Cost-of-Care Conversations


With support from the Robert Wood Johnson Foundation, Avalere assesses opportunities to normalize cost-of-care conversations through measurement.

Cost continues to pose a barrier to accessing healthcare for millions of Americans. Research has shown that conversations addressing costs among patients, caregivers, and the clinical team can help build a more trusted relationship between patients and clinicians.

Avalere has partnered with Robert Wood Johnson Foundation (RWJF) since 2015 to work toward normalizing cost-of-care (CoC) conversations in clinical settings, including identifying barriers and facilitators to engaging in conversations about cost. CoC conversations can be defined as discussions that address any costs patients and families might face, from out-of-pocket (OOP) to non-medical costs (e.g., transportation, childcare, lost wages). To that end, Avalere collaborated with the National Patient Advocate Foundation to explore the feasibility of patient-centered measure concepts to support quality improvement, increase satisfaction, and improve outcomes. This issue brief highlights the challenges associated with measurement in this space alongside alternative solutions to encourage CoC conversations in practice.

Avalere thoroughly evaluated clinician and patient needs and developed a set of measure concepts and improvement activities to improve the frequency and quality of CoC conversations. Based on the gaps identified, Avalere assessed the following individual concepts and improvement activities:

  • Concept 1: Discussion of a CoC with patient during a clinic visit
  • Concept 2: Assignment of a case worker to address financial concerns
  • Concept 3: Documentation of treatment plan modification based on a CoC conversation
  • Concept 4: Patient-reported assessment of a CoC conversation during a clinic visit
  • Activity 1: Use of a patient-facing tool to prepare patients for CoC conversations
  • Activity 2: Use of a discharge-planning tool to outline costs of prescriptions post-discharge

Concepts identified through this work can move the needle toward normalizing these conversations. However, more research is needed to transform them into quality measures that could be used for accountability and improvement purposes. Our findings indicate the following research opportunities for consideration:

  • Accessibility of Data: Many clinicians are doing the best they can to address cost concerns in the absence of OOP cost information. To optimize conversations, clinicians need access to more data to feel comfortable engaging in meaningful and productive CoC conversations. There are opportunities to collaborate with public and private payers to determine the operations and functionality of accessing this data in a timely manner.
  • Roles and Responsibilities: CoC conversations are a newer concept to healthcare; thus, there is no clear role within the care team as to who should lead these conversations—and the right role may depend on the type of cost concern and on who is capable of working to address the concern. Team-based care is about meeting patients where they are by aligning the appropriate clinical team member to varying patient needs during the care episode. Having the right conversation at the right time could have a significant impact on how the patient engages with the care team and their long-term outcomes.
  • Validating the Needs of Patients: Patients—particularly low-income and vulnerable patients—may feel they are subject to unintended consequences as a result of CoC conversations (this includes lack of access to treatments as a result of a patients’ financial status). A patient’s assessment of the quality of a conversation and whether they have the information they need to make a decision about their care signals the need for more patient-reported outcome measures to ensure patients’ needs are met and that they are being heard throughout their care journey.

Thoughtful, sensitive CoC conversations can facilitate a more trusted partnership between clinicians and patients and prevent missed opportunities to address cost concerns that may have not been raised otherwise. Normalizing these conversations has the potential to reduce stigma and help to reduce disparities in outcomes. This issue brief highlights specific strategies for encouraging clinicians to talk to their patients about costs of care. Future testing and validation should ensure the measures introduced in this Issue Brief are feasible in practice to facilitate integration into existing or novel payment models. In addition, CoC measure development efforts should address the varied priorities and needs of all patients, including financial issues and barriers to equitable outcomes.

Download the issue brief.

Nelly Ganesan, MPH, is a Principal at Avalere Health. Josh Seidman, PhD, is a Managing Director at Avalere Health. Morenike AyoVaughan, MPH, is a Consultant II at Avalere Health. Rina Bardin is a Senior Associate at Avalere Health.

This post originally appeared on Avalere here.

The Need for Measuring Clinician-Patient Cost-of-Care Conversations


It is no surprise that beyond COVID-19 health risks, the pandemic has also caused significant disruption to the lives of everyone in America. It has caused exacerbating financial pressures and ongoing job losses. An estimated 42 million people have lost their job since March 2020, which has increased the number of uninsured. The loss of coverage has the potential to yield catastrophic healthcare costs for those seeking care during the period.

While the pandemic has exacerbated coverage challenges, it also highlights gaps that existed long before the outbreak. Prior to COVID-19, average out-of-pocket costs were on the rise with an estimated 24% of Americans spending over $1,000 per year on direct medical care and surprise medical billing. The pandemic-induced economic disruption reinforces the need for physicians and patients to embrace conversations regarding cost in the clinical setting; avoiding such discussion may result in patients foregoing care and not realizing their options.

Patients should be able to rely on their clinicians to help them understand the costs of their care, including losses associated with the time away from work and transportation expenses for visits. Our past research, and the research of others, has demonstrated that these conversations are valued and can be impactful in helping patients understand their options to address concerns upfront. And yet, the concept of having a Cost-of-Care (CoC) conversation is merely optional. These conversations are not typically supported with access to price information, nor are they consistently viewed as a routine part of practice. Cost conversations are not consistently documented, lack standardization, and structure. Furthermore, physicians have not adequality been trained to address CoC conversations with their patients.  

Our work to date as shown that patients feel supported by clinicians and care teams when the clinical staff addresses cost concerns and can connect patients to financial resources to help them make decisions regarding their care. Measurement is one mechanism to encourage these conversations. In partnership with patients and clinicians, Avalere Health, the National Patient Advocate Foundation and Robert Wood Johnson Foundation are exploring the feasibility of quality measures to normalize and improve the quality of CoC conversations in the clinical setting.

Implementation of meaningful quality measures allows health care system leaders and policymakers assess whether clinicians are engaging in respectful conversations about costs with patients, and whether patients’ concerns about costs are being addressed. We also know measurement alone will not drive improvement. Measures can be used to support quality improvement and systems change.

Based on our research and a growing body of literature, we are exploring measure concepts to facilitate CoC conversations between patients/caregivers and their care teams and to assess their impact. We need to ensure these measure concepts meet three main goals. First, they need to resonate with patients; the measures need to address issues that really matter to individuals who are trying to make decisions about their care. Second, the measures should have some impact on holding clinicians accountable; normalizing CoC conversations – asking clinicians to do something patients want but is only happening a quarter of the time – requires accountability for their actions. Third, we want these measures to drive improvement; the measures need to provide information that guide clinicians and the organizations they work in on what steps they can take to make conversations respectful, responsive, and effective. Based on existing gaps and our knowledge of the clinical workflow, the concepts we are exploring address: discussion of CoC during a clinic visit, documentation of CoC concerns and a patient-reported assessment of the CoC conversation.

Having a CoC conversation requires a shift in how a clinician prioritizes how to use their time with patients. This shift will need to be addressed and implemented by clinicians, care teams, payers, and policymakers. Only then will patients see a meaningful change to their experiences in care delivery. Our partners are very excited to test, implement and evaluate these measures in a real-world setting, we’re hopeful that introducing quality improvement in this space will enhance cost transparency and put more pressure on policymakers and regulators to advance the use of measures to address barriers to CoC conversations.

Morenike AyoVaughan, MPH, is a Consultant II at Avalere Health, Nelly Ganesan, MPH, is a Principal at Avalere Health, Emmy Ganos, PhD, is a Senior Program Officer at the Robert Wood Johnson Foundation, and Josh Seidman, PhD, is a Managing Director at Avalere Health.