Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs

Abstract

Background:

Out-of-pocket costs are a serious barrier to care and drive suboptimal medical therapy. Understanding of these costs can lead to care oriented around the limits they generate. Despite this, there is minimal attention paid to these costs in post-graduate education.

Objective:

To define a potential knowledge gap regarding costs experienced by patients by surveying Internal Medicine residents at our large academic institution.

Methods:

We surveyed Internal Medicine residents in spring 2019 about knowledge and practices surrounding patient out-of-pocket costs. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into “Poor” and “Moderate or Better.” Non-parametric analysis was used to test differences between outpatients and inpatients and by year of training.

Results:

Of 159 residents, 109 (67%) responded. Familiarity with patient insurance status was moderate or better in 85%. Reported understanding of costs associated with medications, testing, and clinic visits was less common. Respondents had higher familiarity with out-of-pocket costs for clinic patients compared with inpatients. Knowledge of cost of care was not an often-considered factor in decision making. There was no significant difference in response by year of training.

Conclusion:

Patient out-of-pocket costs are an important dimension of patient care which Internal Medicine Trainees at our institution do not confidently understand or utilize. Improvements in education around this topic may enable more patient-centered care.

Introduction

Patient out-of-pocket costs are an identified barrier to care and can drive suboptimal adherence to medical therapy.^1,2 Post-graduate education is a time when physicians first become responsible for the longitudinal care of patients, including understanding and helping to overcome their financial barriers to care. A national survey of residency program directors demonstrated awareness of the importance of trainee understanding of providing cost-conscious care. ³ Educational programs related to the awareness of out-of-pocket costs have a demonstrated positive impact, in one example increasing knowledge of costs and willingness to consider them during patient care. ⁴ However, few residency programs have a formal curriculum dedicated to this. ³ We sought to define this knowledge gap at our large academic medical center through a survey of all current Internal Medicine trainees.

Methods

We surveyed all Internal Medicine residents in spring 2019 at a large academic internal medicine residency program, which provides care in 3 settings: a county safety-net hospital, a Veteran’s Affairs hospital, and a tertiary-care university hospital. Residents rotate on services at all sites and the vast majority have their primary care clinic at the county or Veteran’s Affairs hospital. The survey was developed in an iterative process with a Resident focus group discussing and giving suggestions on initial drafts. The members of this group were not asked to respond to the survey. We inquired about resident knowledge and practice patterns surrounding patient out-of-pocket costs (survey available in Supplemental Information). Participants answered questions related to their practice, questions considering their most recent inpatient panel, and questions considering their clinic patient panel. Familiarity was ranked on a 5-point Likert scale: (Not at All Aware, Slightly, Moderately, Extremely). Non-parametric analyses were used to test differences between responses by setting (inpatient compared with outpatient) and year of training. The University of Texas Southwestern Medical Center Institutional Review Board deemed this project non-regulated research, no identifying information other than year of training and primary clinic site was collected from respondents.

Results

Of 159 residents, 106 (67%) responded to the survey. Familiarity with patient insurance status was rated as was moderate or better by most respondents (85%). Moderate or better understanding of costs associated with medications (52%), testing (19%) and clinic visits (30%) was less common. Respondents had significantly higher familiarity with out-of-pocket costs for their clinic patients compared with their most recent inpatient panel: clinic visits (39% vs 21% P < .005), testing (26% vs 12% P = .002), and medications (62% vs 42% P < .005). Knowledge of cost of care was not a commonly considered factor in decision making (27% “Often” or “Always”). There was no significant difference in response by year of training among all categories noted above and in a composite score of familiarity among all categories.

Discussion

Our survey responses demonstrate that most trainees readily understood patient insurance status, likely partly because it is reported clearly in the electronic health record. In contrast, self-reported familiarity with the various patient out-of-pocket costs was low, albeit modestly higher when trainees considered their clinic patient panel than their most recent inpatient panel. This may reflect longitudinal clinical experience trainees have with patients in their clinic or the relative heterogeneity of admitted patients’ insurance statuses given that patients seen in these primary care clinics have relatively homogenous coverage. Familiarity with out-of-pocket costs was not a commonly considered factor in medical decision making and understanding of these costs did not significantly improve with subsequent years of training. These data suggest that trainees learn all they will meaningfully incorporate into care decisions by the end of their first year of training. The lack of additional improvement beyond the first postgraduate year represents an important gap in trainee education at our institution that likely exists elsewhere. Strengths of our study include a high response rate across all years of training and various sites of clinical practice. Our study has important limitations as well. These include self-reported outcomes, involvement of a single center, and administration of the survey at the end of the academic year. We are a 3-hospital system with a comprehensive county assistance program for our county clinic patients as well as Veteran’s Affairs coverage for our VA patients. Though these factors are present at other training institutions, they are far from universal, limiting the generalizability of our results. While survey data are inherently affected by the respondent, self-reported familiarity with information likely has implications for patterns of practice. The specific costs an individual faces are impacted by a number of factors which may make them difficult to report systematically to providers. Nevertheless, teaching about the impact of patient out-of-pocket costs during residency can increase awareness of these costs as a barrier to care, enabling more effective and patient-centered care of both current and future patients. We hope these data spark discussion on this important topic.

Conclusion

Patient out-of-pocket costs are an important dimension of patient care which Internal Medicine Trainees at our institution do not confidently understand or utilize. Improvements in education around this topic may enable more patient-centered care.

Supplemental Material

sj-docx-1-mde-10.1177_2382120521996368 – Supplemental material for Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs

Supplemental material, sj-docx-1-mde-10.1177_2382120521996368 for Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs by Jeffrey Chidester, Rebecca Vigen and Sandeep R Das in Journal of Medical Education and Curricular Development