Examining the Relationship Between the Quality of Cost Conversations and Patient Satisfaction in the Oral Health Setting

Abstract

When implemented, provider–patient cost conversations have been touted as an effective strategy for reducing patients’ costs. However, the impact of quality cost conversations on patients’ satisfaction with dental visits remains unknown. By addressing this gap in the literature, this study contributes to the existing body of research on the factors influencing dental patient experience. The data used for this study were from an online, self-administered survey of US residents aged 18 years and older who had visited a dentist within the past 24 months. Adjusted binary logistic regression analysis was performed to evaluate the relationship between the quality of cost conversations and satisfaction with dental visits. Most respondents identified as non-Hispanic White (65.9%), aged 18 to 34 years (45.7%), and had dental insurance coverage (73.7%). In the adjusted logistic regression analysis, the quality of cost conversations was positively and statistically significantly associated with reported satisfaction with the dental visit (odds ratio = 4.371; 95% confidence interval 2.598-7.355). The study suggests aligning cost conversations with treatment planning and incorporating best practice elements, such as routinely discussing care costs as part of the clinical encounter and developing treatment plans responsive to cost concerns, may enhance patients’ experience in dental care settings.

Keywords

cost conversations patient satisfaction dental visits oral health quality

Introduction

Dental costs continue to be a significant concern for many Americans. In 2022, it was estimated that over a quarter of adults in the United States did not receive necessary dental care due to cost.¹ The financial burden of dental care can be quite substantial for individuals, largely due to high out-of-pocket expenses.² Cost discussions between providers and patients create an opportunity to alleviate potential financial difficulties and enhance overall patient satisfaction.³

While cost conversations are seen as an essential tool for whole-person care, there have been documented challenges in implementation, such as patient hesitation and provider unpreparedness to engage in these discussions.^4,5 According to Erwin and Fitzpatrick,⁶ individuals—especially those with low or fixed incomes—often worry about the stigma associated with conversations about healthcare costs and the possibility of receiving low-quality care as a result of these discussions. Providers experience similar discomfort, including concerns about potentially harming the provider–patient relationship.⁴ However, existing evidence, primarily in medicine, indicates that standardizing and integrating cost conversations into clinical workflows can enhance shared decision-making and improve patient satisfaction while minimizing the discomfort associated with these discussions.^3,5

There is limited evidence in the oral health literature regarding cost conversations and their impact on dental outcomes and patient experience. A previous study suggested that these conversations may occur more frequently in oral health than in medical settings.⁷ In that study, about two-thirds of participants reported discussing costs with their dental provider during their last dental visit. In contrast, rates in medical settings were reported to be less than 50%.⁸ However, an evidence gap remains regarding how such discussions with dentists and other oral health providers influence patients’ satisfaction with their care. Therefore, this research aimed to bridge this knowledge gap by examining the relationship between the quality of cost conversations and patient satisfaction during dental visits. The study's findings can inform efforts to enhance patient-centered dental care.

Methods

Sample, Recruitment, and Data Collection

Data for this study were obtained from an online cross-sectional survey of US adults who had received dental care within the past 24 months at the time of the survey. Survey data collection occurred in August 2021. The study adopted a quota sampling approach to recruit a sample whose distribution on gender, race, and ethnicity matched that of the population of adult oral care users in the United States.⁹ Study participants were recruited from the Qualtrics online opt-in market panel, which includes a large pool of participants who have agreed to participate in research studies administered by Qualtrics, one of the world's largest market and academic research firms.

Due to the limited literature on this topic, particularly in the oral health domain, a survey instrument was developed for this study following a review of the existing cost conversations literature. The instrument was brief (average completion time of 6 min) to facilitate the high-quality data collection.

Participants consented to participate in the study, which was reviewed by the Institutional Review Board at the authors’ institution.

Measures

The outcome variable for this study was satisfaction with the dental visit, measured using the following question: “Overall, how satisfied were you with the care you received during your last dental visit?” Participants responded on a 5-point Likert scale ranging from strongly dissatisfied (1) to strongly satisfied (5). For ease of interpretation, this was recoded into a binary satisfaction indicator: satisfied or strongly satisfied versus other.

The primary independent variable assessed in this study was the quality of cost conversations. Previous studies^3,6 have identified best practices for effective cost conversations to include integrating such conversations into clinical practice and routinizing them, providing patients with resources on healthcare costs, addressing cost concerns, and tailoring treatment plans to minimize patients’ cost concerns. Accordingly, the quality of cost conversations was evaluated in this study based on a composite score derived from 4 binary indicators (yes/no) of whether the following best practices processes occurred during the visit: (1) a dentist or staff member had a conversation with them about treatment options and their costs; (2) resources were provided to address their cost concerns; (3) a treatment plan was developed mutually by the dental provider and patient; and (4) the plan was responsive to the patient's cost concerns.

This 4-item scale was validated within the context of this study using exploratory factor analysis. The Kaiser-Meyer-Olkin measure of sampling adequacy was .79, above the recommended threshold of 0.6, and Bartlett's test of sphericity was statistically significant (P < .001), thus supporting the factorability of these items.

A factor analysis was performed on a tetrachoric correlation matrix—ideal for non-normal distributions—to obtain the composite score. The Stata user-written package “polychoric” was used for the analysis, which involves a 2-stage process that includes an estimation of the polychoric/tetrachoric correlation matrix, followed by a factor analysis using the estimated correlation matrix.¹⁰ The principal component factor method, with oblique oblimin rotation, was used for the factor analysis. Using an eigenvalue cutoff of 1 and examining scree plots, one factor was retained, which explained 78.3% of the variance in the data—all 4 items loaded above 0.80. Reliability was assessed using the Kuder-Richardson Formula 20 (KR-20 = 0.79), suitable for binary indicators and the Cronbach's alpha (0.79), both values were above the 0.70 threshold.¹¹ The predicted factor score represented the composite measure of the quality of cost conversations.

The regression model controlled for patient and provider characteristics. Patient-level control factors included gender (female/male/nonbinary); age (18-24 years/25-34 years/35-54 years; 55 years and older); race/ethnicity (Non-Hispanic White/Non-Hispanic Black/Non-Hispanic Other/Hispanic); location of residence (county population under 50,0000/county population above 50,000); region of residence (Northeast/Midwest/South/West); and personal income (under $25,000/$25,000-$49,999/$50,000-$74,999/$75,000 or more). The study also controlled for dental insurance coverage (yes/no). Provider and visit characteristics included the type of provider seen (general dentist/specialist dentist/dental hygienist or other), type of practice visited (public/private), and when the dental visit occurred (within the last 6 months, 7-12 months ago and 13-24 months ago).

Data Analysis

Five hundred and eleven eligible adults aged 18 years or older participated in the study. This included 50 surveys obtained during the “soft launch” or pilot phase of the survey data collection stage, 2 days before the actual launch of data collection. Data collected during the piloting phase was deleted in subsequent data analysis. An additional 11 observations were deleted due to data quality issues, such as extremely short completion times, straightlining in matrix-style questions, and inaccurate responses to attention-check questions. This resulted in a sample size of 450 participants.

After excluding visits occurring at free dental clinics (N = 28) and observations missing data on the study's variables (N = 61), the analytical sample included 361 observations. Data were described using descriptive statistics, including frequencies, percentages, means, and standard deviation. Adjusted binary logistic regression analysis was conducted to assess the relationship between the quality of cost conversations and dental visit satisfaction. Statistical significance was evaluated at the P < .05 level. Robust standard errors were obtained and clustered at the state level. All analyses were performed using STATA.v.18.

Results

Sample Characteristics

The characteristics of the survey respondents are summarized in Table 1. About half the sample were female (49.0%). Most respondents were non-Hispanic White (65.9%) and between 18 and 34 years old (45.7%). Most reported a personal income above $50,000 (50.4%) and had dental insurance coverage (73.7%). Over a third (37.4%) lived in counties with less than 50,000 population and the South (35.2%). Regarding their most recent dental visit, the majority of participants reported being seen at a private dental clinic (58.7%), by a general dentist (69.3%), and within the last 6 months (54.3%) at the time of the survey (Table 1). The mean composite quality of cost conversation score within the study sample was 0.705 (standard deviation = 0.426; range: 0-1.132).

Table 1.

Sample Characteristics (N = 361)

	n	%
Gender
Female	181	49.0
Male	177	50.1
Non-Binary	3	0.8
Age
18–34 years	165	45.7
35–54 years	130	36.0
55 and older	66	18.3
Race
Non-Hispanic White	238	65.9
Non-Hispanic Black/African Americans	39	10.8
Non-Hispanic Other	33	9.1
Hispanic	51	14.1
Personal Income
Under $25,000	65	18.0
$25,000 – $49,999	114	31.6
$50,000 – $74,999	82	22.7
$75,000 and above	100	27.7
Insured for Dental Care
Yes	266	73.7
No	95	26.3
County of Residence
Less than 50,000 population	135	37.4
50,000 population or greater population	226	62.6
Region of Residence
Midwest	85	23.6
Northeast	78	21.6
South	127	35.2
West	71	19.7
Practice Type
Private Dental Practice	212	58.7
Public Dental Clinic	149	41.3
Provider Seen
General Dentist	250	69.3
Specialty Dentist	70	19.4
Dental Hygienist or Other	41	11.4
When Visit Occurred
Within the last 6 months	196	54.3
7–12 months ago	88	24.4
13–24 months ago	77	21.3

The Relationship Between the Quality of Cost Conversations and Patients’ Satisfaction With Their Most Recent Dental Visit

In adjusted logistic regression analysis, the quality of cost conversations was positively and statistically significantly associated with reported satisfaction with the dental visit odds ratio [OR] = 4.371; 95% confidence interval [CI] = 2.598-7.355) (Table 2).

Table 2.

The relationship between the quality of cost conversations and dental visit satisfaction

	Odds ratio	Robust std. err.	z	P > z	[95% conf.	interval]
Quality of Cost Conversation Score	4.371	1.160	5.56	<0.001	2.598	7.355
Female (Ref: Other)	0.720	0.204	−1.16	0.246	0.413	1.254
Age (Ref: 18–34 years)
35–54 years	0.661	0.236	−1.16	0.246	0.329	1.330
55 years and above	0.564	0.251	−1.29	0.198	0.236	1.349
Race/Ethnicity (Ref: Non-Hispanic White)
Non-Hispanic Black	1.084	0.538	0.16	0.872	0.409	2.869
Non-Hispanic Other	0.866	0.382	−0.33	0.744	0.365	2.054
Hispanic	1.421	0.826	0.6	0.546	0.455	4.440
Personal Income (Ref: Under $25,000)
$25,000 –$49,999	2.353	0.975	2.06	0.039	1.044	5.300
$50,000 – $74,999	1.143	0.499	0.31	0.760	0.486	2.689
$75,000 and above	3.382	1.850	2.23	0.026	1.158	9.881
Has Dental Insurance (Ref: No)	1.918	1.157	1.08	0.280	0.588	6.256
County Population < 50,000 (Ref: Population >/=50,000)	1.714	0.564	1.64	0.101	0.900	3.265
Region (Ref: Northeast)
Midwest	1.561	0.597	1.16	0.245	0.737	3.305
South	1.197	0.601	0.36	0.720	0.447	3.204
West	0.970	0.449	−0.07	0.947	0.392	2.402
Public Dental Clinic (Ref: Private)	0.558	0.127	−2.56	0.010	0.358	0.872
Provider Seen (Ref: General Dentist)
Specialist Dentist	0.451	0.191	−1.88	0.060	0.196	1.035
Dental Hygienist or Other	3.799	1.686	3.01	0.003	1.592	9.065
When Visit Occurred (Ref: Within the Last 6 months)
7–12 months ago	0.854	0.382	–0.35	0.724	0.356	2.050
13–24 months ago	0.646	0.193	−1.46	0.144	0.360	1.160

Other factors associated with visit satisfaction included personal income, setting of care, and the type of provider seen. Specifically, compared to individuals earning less than $25,000, those earning between $25,000 and $49,999 (OR=2.353; 95% CI = 1.044 - 5.300), and those earning over $75,000 (OR=3.382; 95% CI = 1.158 - 9.881) were more likely to report visit satisfaction. Participants receiving dental care at public clinics were less likely to report being satisfied with their visit compared with those receiving care at private clinics (OR=0.558; 95% CI = 0.358 - 0.872), while those seeing dental hygienists, compared with general dentists, were more likely to report being satisfied with their visit (OR=3.799; 95% CI = 1.592 - 9.065) (Table 2).

Discussion

This study examined the relationship between the quality of provider–patient cost conversations and dental visit satisfaction. The findings suggest that the quality of cost conversations positively correlates with patient satisfaction in the dental setting. In line with this study's findings, Brick et al⁴ found that regardless of illness severity, patients generally favored physicians who provided cost information as part of treatment discussions. In general, the outcomes associated with cost conversations have yet to be explored comprehensively in the literature, as noted in a recent systematic review by Barrera et al.¹² The few existing studies that have explored cost conversation outcomes have been conducted primarily in medical oncology settings and provided mixed results. Some studies have identified positive outcomes, including acceptance, satisfaction, and lower out-of-pocket costs,^13–15 while others have reported less favorable outcomes, such as medication nonadherence.¹⁶ Undoubtedly, additional research using robust randomized or quasi-experimental approaches is needed to characterize the outcomes associated with cost conversations.¹² However, our findings suggest a need to go beyond simply discussing costs and ensuring that best practice elements are incorporated, such as routinely screening for financial distress, providing resources to address cost concerns, and ensuring that the developed treatment plan is responsive to those concerns.

In addition to the quality of cost conversations, personal income, care setting, and the type of provider seen were independently associated with dental visit satisfaction. Higher-income earners, those receiving care in private practices and from dental hygienists, were more likely to report being satisfied with their visit. Previous research has demonstrated a high level of patient satisfaction with the care provided by dental hygienists.¹⁷ Similar to this study's finding, Rozier et al,¹⁸ in their study of pediatric dental visit satisfaction, documented lower satisfaction with preventative dental services for visits occurring in public dental clinics, a finding consistent with what was reported by Milgrom et al.¹⁹ In line with our findings, higher-income earners have been previously shown to report higher levels of satisfaction with their dental care.²⁰ Previous research has established that patients’ perception of the cost of care influences their satisfaction with the care they receive.²¹ Higher-income earners may have less cost-related anxiety about their care, which may enhance their overall clinical experience.

Limitations

This study represents one of the first to examine the relationship between cost conversations and patient outcomes within the oral healthcare setting. However, it has some limitations that are worth noting. First, due to its cross-sectional design, causal relationships cannot be inferred. Second, the nonprobability sampling approach adopted in this study limits the extent to which the findings can be generalized beyond the study population. A quota sampling approach was adopted to minimize this limitation. Additionally, the regression model may not have adjusted for all potential confounders, resulting in potentially biased parameter estimates. Fourth, given its use of a self-reported survey, the study may be subject to recall bias.

Future research can address these limitations through probability-based samples or randomized trials. Additional translational research is also needed to confirm best practices for incorporating cost conversations into clinical workflow and determine if such elements vary by care setting (eg, dental vs medical settings).

Practical Implications

These findings have implications for efforts to integrate cost conversations into oral health settings. The findings suggest that strategies to integrate quality cost conversations into clinical workflows may be beneficial in enhancing patient satisfaction and experience.

Relative to medical care, patients may be less dissociated from the cost of dental care as the coverage scope of dental plans is narrower and cost-sharing options are less complicated. Accordingly, dental settings are well-suited for defining effective strategies for addressing cost concerns. To enhance the dental patient experience, dental practices may consider strategies such as screening for financial need as part of patient registration processes, routinizing treatment cost conversations between patients and the dentist or a dental staff member during the clinical encounter, and providing or linking patients to resources to help address their cost concerns. A dedicated patient navigator to assist with these functions can help streamline processes and enhance the overall patient experience.

Conclusion

This study sought to explore the association between the quality of cost conversations and patient satisfaction with dental visits. The findings suggest that patient–provider cost conversations aligned with treatment planning can improve patient satisfaction in dental care settings.

Footnotes

Acknowledgements

The authors would like to thank Tawanna Brown for her assistance in conducting this study. All authors made substantial contributions to the conception and design of the study, interpretation of data, drafting of the article, and approving the final approval of the version to be published. Authors 4 and 5 were also involved in data acquisition.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval

The Institutional Review Board at the authors’ institution approved this study. Participants consented to the study.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The original study was conducted with funding support from the Georgia Southern University McNair Scholars Program and the Department of Health Policy and Community Health at the Jiann-Ping Hsu College of Public Health, Georgia Southern University. Institutional Review: The Georgia Southern Institutional Review Board reviewed and approved the study. Participants consented to the study.

ORCID iD

Bettye A. Apenteng

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