Original Research

Journal of General Internal Medicine

, Volume 29, Issue 1, pp 223-229

First online:

Exploring Public Attitudes Towards Approaches to Discussing Costs in the Clinical Encounter

  • Marion DanisAffiliated withDepartment of Bioethics, National Institutes of Health Clinical Center Email author 
  • , Roseanna SommersAffiliated withDepartment of Bioethics, National Institutes of Health Clinical Center
  • , Jean LoganAffiliated withDepartment of Bioethics, National Institutes of Health Clinical Center
  • , Beverly WeidmerAffiliated withRAND
  • , Shirley ChenAffiliated withUniversity of Michigan
  • , Susan GooldAffiliated withUniversity of Michigan
  • , Steven PearsonAffiliated withDepartment of Bioethics, National Institutes of Health Clinical Center
  • , Elizabeth McGlynnAffiliated withKaiser Permanente



Patients’ willingness to discuss costs of treatment alternatives with their physicians is uncertain.


To explore public attitudes toward doctor–patient discussions of insurer and out-of-pocket costs and to examine whether several possible communication strategies might enhance patient receptivity to discussing costs with their physicians.


Focus group discussions and pre-discussion and post-discussion questionnaires.


Two hundred and eleven insured individuals with mean age of 48 years, 51 % female, 34 % African American, 27 % Latino, and 50 % with incomes below 300 % of the federal poverty threshold, participated in 22 focus groups in Santa Monica, CA and in the Washington, DC metro area.


Attitudes toward discussing out-of-pocket and insurer costs with physicians, and towards physicians’ role in controlling costs; receptivity toward recommended communication strategies regarding costs.


Participants expressed more willingness to talk to doctors about personal costs than insurer costs. Older participants and sicker participants were more willing to talk to the doctor about all costs than younger and healthier participants (OR = 1.8, p = 0.004; OR = 1.6, p = 0.027 respectively). Participants who face cost-related barriers to accessing health care were in greater agreement than others that doctors should play a role in reducing out-of-pocket costs (OR = 2.4, p = 0.011). Participants did not endorse recommended communication strategies for discussing costs in the clinical encounter. In contrast, participants stated that trust in one’s physician would enhance their willingness to discuss costs. Perceived impediments to discussing costs included rushed, impersonal visits, and clinicians who are insufficiently informed about costs.


This study suggests that trusting relationships may be more conducive than any particular discussion strategy to facilitating doctor–patient discussions of health care costs. Better public understanding of how medical decisions affect insurer costs and how such costs ultimately affect patients personally will be necessary if discussions about insurer costs are to occur in the clinical encounter.


communication decision making health care costs patient engagement