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G. Caleb Alexander, MD; Lawrence P. Casalino, MD, PhD; David O. Meltzer, MD, PhD

JAMA. 2003;290:953-958.

Context  Out-of-pocket costs account for approximately one fifth of health care expenditures and are increasing. Previous research suggests that these costs are associated with medication nonadherence and considerable economic burden among some patients. Little is known about patient-physician communication regarding these costs.

Objective  To identify patients' and physicians' beliefs and practices regarding discussions of out-of-pocket costs.

Design, Setting, and Participants  Cross-sectional paired surveys of 133 general internists and 484 of their outpatients, aged 18 years or older, in 3 academic and 18 community general medicine practices in the Chicago metropolitan area, March-November 2002.

Main Outcome Measures  Patient and physician beliefs regarding discussions of out-of-pocket costs, frequency and predictors of discussions, and physician recognition of patient burden from out-of-pocket costs.

Results  Sixty-three percent of patients reported a desire to talk with their physician about their out-of-pocket costs, and 79% of physicians believed that patients in general want to discuss these costs. By contrast, only 35% of physicians and 15% of patients reported ever having discussed the study patient's out-of-pocket costs. Multivariate analysis indicated that discussions were significantly more likely to occur with patients burdened by their out-of-pocket costs (prevalence ratio [PR], 2.55; 95% confidence intervals [CI], 1.62-3.76) and with those patients seen in a community practice (PR, 5.19; CI, 1.86-8.93). Among patients burdened by out-of-pocket costs, physicians were substantially more likely to recognize this burden when a prior discussion regarding out-of-pocket costs had taken place (80% vs 51%).

Conclusions  Among respondents, both patients and physicians believed that discussions of out-of-pocket costs were important, yet these discussions occurred infrequently. Physician communication with patients about out-of-pocket costs may be an important yet neglected aspect of current clinical practice. Further research should identify the prevalence of this problem in broader populations, investigate its causes, and evaluate the impact of enhanced communication about out-of-pocket costs on patient satisfaction, utilization of care, and outcomes.

Author Affiliations: Robert Wood Johnson Clinical Scholars Program (Drs Alexander and Meltzer), MacLean Center for Clinical Medical Ethics (Dr Alexander), Department of Health Studies (Dr Casalino), and Harris School of Public Policy (Dr Meltzer), University of Chicago, Chicago, Ill.

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