title: Patient costs as a barrier to intensive health behavior counseling.
abstract: BACKGROUND
  Although intensive health behavior counseling has been demonstrated to help patients lose weight and quit smoking, many payers offer limited coverage for such counseling.
  
  
  OBJECTIVE
  This mixed-methods case study examined how coverage affected utilization of an electronic linkage system (eLinkS) to help adult patients obtain intensive health behavior counseling, provided through a collaboration of primary care practices and community programs.
  
  
  METHODS
  Grant support enabled patients to obtain counseling at no cost, but funds were exhausted within 5 weeks as a result of an overwhelming response. To study the influence of cost as a barrier, referrals were resumed for an additional 3 weeks, but patients were required to pay for them. Use of eLinkS, level of clinician counseling and referrals, and patient interest in referrals were measured using electronic medical record data and patient and clinician interviews.
  
  
  RESULTS
  When counseling was free, approximately one in five patients with an unhealthy behavior and an eLinkS prompt was referred for intensive counseling. However, when patient charges were instituted, referrals decreased by 97% (from 21.8% to 0.7%, p<0.001); clinicians asked fewer patients about health behaviors (37% vs 29%, p<0.001); clinicians offered fewer patients referrals (29% vs 6%, p<0.001); and patients were less interested in accepting referrals (76% vs 14%, p<0.001). In interviews, patients and clinicians cited cost as a major barrier.
  
  
  CONCLUSIONS
  Coverage for intensive health behavior counseling is important to utilization, particularly for interventions that involve clinician-community partnerships. The potential public health benefits of such collaborations to reduce unhealthy behaviors justify the elimination of financial barriers (e.g., copayments) by payers.
authors.affiliation: Department of Family Medicine, Virginia Commonwealth University, Richmond, VA 23298-0251, USA. ahkrist@vcu.edu
authors.forename: Alex H
authors.initials: AH
authors.lastname: Krist
authors.forename: Steven H
authors.initials: SH
authors.lastname: Woolf
authors.forename: Robert E
authors.initials: RE
authors.lastname: Johnson
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Rothemich
authors.forename: Tina D
authors.initials: TD
authors.lastname: Cunningham
authors.forename: Resa M
authors.initials: RM
authors.lastname: Jones
authors.forename: Diane B
authors.initials: DB
authors.lastname: Wilson
authors.forename: Kelly J
authors.initials: KJ
authors.lastname: Devers
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003153:Community Health Services / Q000191:economics / Q000379:methods; D037001:Directive Counseling / Q000191:economics* / Q000379:methods; D005260:Female; D015438:Health Behavior; D006801:Humans; D019458:Insurance Coverage / Q000191:economics*; D008297:Male; D008498:Medical Record Linkage / Q000379:methods*; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D011320:Primary Health Care / Q000191:economics / Q000379:methods; D012017:Referral and Consultation / Q000706:statistics & numerical data; D016540:Smoking Cessation / Q000191:economics / Q000379:methods; D015431:Weight Loss; D055815:Young Adult