title: 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 community-based 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%). The most frequently discussed cost-reducing 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.
authors.affiliation: Dr. Brown is with the Department of Psychiatry and Behavioral Health and with the Department of Medicine, Duke University School of Medicine, Durham, North Carolina ( gregory.brown@duke.edu ), where Dr. Hunter is affiliated. Dr. Hesson is with the College of Human Medicine, Michigan State University, East Lansing. Mr. Davis, Ms. Kirby, and Dr. Ubel are with the Duke-Margolis Health Policy Center and with the Fuqua School of Business, Duke University, both in Durham. Mr. Barnett and Mr. Byelmac are with Verilogue Inc., Horsham, Pennsylvania.
authors.forename: Gregory D
authors.initials: GD
authors.lastname: Brown
authors.affiliation: Dr. Brown is with the Department of Psychiatry and Behavioral Health and with the Department of Medicine, Duke University School of Medicine, Durham, North Carolina ( gregory.brown@duke.edu ), where Dr. Hunter is affiliated. Dr. Hesson is with the College of Human Medicine, Michigan State University, East Lansing. Mr. Davis, Ms. Kirby, and Dr. Ubel are with the Duke-Margolis Health Policy Center and with the Fuqua School of Business, Duke University, both in Durham. Mr. Barnett and Mr. Byelmac are with Verilogue Inc., Horsham, Pennsylvania.
authors.forename: Wynn G
authors.initials: WG
authors.lastname: Hunter
authors.affiliation: Dr. Brown is with the Department of Psychiatry and Behavioral Health and with the Department of Medicine, Duke University School of Medicine, Durham, North Carolina ( gregory.brown@duke.edu ), where Dr. Hunter is affiliated. Dr. Hesson is with the College of Human Medicine, Michigan State University, East Lansing. Mr. Davis, Ms. Kirby, and Dr. Ubel are with the Duke-Margolis Health Policy Center and with the Fuqua School of Business, Duke University, both in Durham. Mr. Barnett and Mr. Byelmac are with Verilogue Inc., Horsham, Pennsylvania.
authors.forename: Ashley
authors.initials: A
authors.lastname: Hesson
authors.affiliation: Dr. Brown is with the Department of Psychiatry and Behavioral Health and with the Department of Medicine, Duke University School of Medicine, Durham, North Carolina ( gregory.brown@duke.edu ), where Dr. Hunter is affiliated. Dr. Hesson is with the College of Human Medicine, Michigan State University, East Lansing. Mr. Davis, Ms. Kirby, and Dr. Ubel are with the Duke-Margolis Health Policy Center and with the Fuqua School of Business, Duke University, both in Durham. Mr. Barnett and Mr. Byelmac are with Verilogue Inc., Horsham, Pennsylvania.
authors.forename: J Kelly
authors.initials: JK
authors.lastname: Davis
authors.affiliation: Dr. Brown is with the Department of Psychiatry and Behavioral Health and with the Department of Medicine, Duke University School of Medicine, Durham, North Carolina ( gregory.brown@duke.edu ), where Dr. Hunter is affiliated. Dr. Hesson is with the College of Human Medicine, Michigan State University, East Lansing. Mr. Davis, Ms. Kirby, and Dr. Ubel are with the Duke-Margolis Health Policy Center and with the Fuqua School of Business, Duke University, both in Durham. Mr. Barnett and Mr. Byelmac are with Verilogue Inc., Horsham, Pennsylvania.
authors.forename: Christine
authors.initials: C
authors.lastname: Kirby
authors.affiliation: Dr. Brown is with the Department of Psychiatry and Behavioral Health and with the Department of Medicine, Duke University School of Medicine, Durham, North Carolina ( gregory.brown@duke.edu ), where Dr. Hunter is affiliated. Dr. Hesson is with the College of Human Medicine, Michigan State University, East Lansing. Mr. Davis, Ms. Kirby, and Dr. Ubel are with the Duke-Margolis Health Policy Center and with the Fuqua School of Business, Duke University, both in Durham. Mr. Barnett and Mr. Byelmac are with Verilogue Inc., Horsham, Pennsylvania.
authors.forename: Jamison A
authors.initials: JA
authors.lastname: Barnett
authors.affiliation: Dr. Brown is with the Department of Psychiatry and Behavioral Health and with the Department of Medicine, Duke University School of Medicine, Durham, North Carolina ( gregory.brown@duke.edu ), where Dr. Hunter is affiliated. Dr. Hesson is with the College of Human Medicine, Michigan State University, East Lansing. Mr. Davis, Ms. Kirby, and Dr. Ubel are with the Duke-Margolis Health Policy Center and with the Fuqua School of Business, Duke University, both in Durham. Mr. Barnett and Mr. Byelmac are with Verilogue Inc., Horsham, Pennsylvania.
authors.forename: Dmytro
authors.initials: D
authors.lastname: Byelmac
authors.affiliation: Dr. Brown is with the Department of Psychiatry and Behavioral Health and with the Department of Medicine, Duke University School of Medicine, Durham, North Carolina ( gregory.brown@duke.edu ), where Dr. Hunter is affiliated. Dr. Hesson is with the College of Human Medicine, Michigan State University, East Lansing. Mr. Davis, Ms. Kirby, and Dr. Ubel are with the Duke-Margolis Health Policy Center and with the Fuqua School of Business, Duke University, both in Durham. Mr. Barnett and Mr. Byelmac are with Verilogue Inc., Horsham, Pennsylvania.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Ubel
mesh_terms: D000328:Adult; D000368:Aged; D001071:Appointments and Schedules; D003142:Communication; D003865:Major Depressive Disorder / Q000191:economics* / Q000628:therapy; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D011788:Quality of Life; D014481:United States; D055815:Young Adult
keywords: Depression; Economics; Medical decision making; Out-of-pocket costs; Outpatient treatment; Patient-physician Communication