Do financial considerations about treatment occur during the ICU stay? A study of electronic medical records found that 4% had at least one narrative clinical note linked to finance.

The study, led by Deborah D. Gordon, MBA,  Mossavar-Rahmani Centre for Business and Government, Harvard Kennedy School, examined over 46,000 narrative clinical notes from the electronic health records of patients treated in the Beth Israel Deaconess Medical Center, Boston between 1 June 2001 and 31 October 2012. The analysis included only the index admission, and used machine learning to develop classifiers to identify these discussions.

Longer hospital stays were significantly associated with the presence of financial notes. Of the 1936/46,146 patients with at least one note, 1936 were male (58.6%) mean age was 38.8 and mean length of stay was 21.7 days. Discussion of change of medication or association of financial barriers with previous medication non adherence occurred in 303 (0.7%) of the discussions and 142 (0.3%) each for change in treatment or discharge plan.

The authors suggest that while their findings may underestimate the occurrence of financial considerations, they highlight “the need to develop better systematic approaches to understanding how financial constraints may alter care decision in US health systems.” They suggest further research to understand the nature of financial considerations and the extent to which patients and families take part in financial conversations.

Deborah Gordon explained the background to the research in an email interview with ICU Management & Practice.

“Americans face increasing — and sometimes crushing — financial burdens resulting from rising health costs and greater cost-shifting onto consumers. Studies suggest people would like to engage with their doctors about these costs, but few have such opportunities. The tools and individual competencies for finding, understanding, and discussing health care costs are under-developed. Given consumer interest in better understanding healthcare costs, and specific evidence that people seek it from clinicians and their staff, we wanted to understand to what extent — if at all — cost conversations or considerations occur in clinical encounters. Analyzing how often such considerations were documented in electronic health records would no doubt undercount how often the conversations actually occurred, yet provide an initial view into the prevalence of these discussions.”

Gordon went on to explain the key takeaways from the study:

"First, conventional wisdom holds that in emergencies and high-acuity health situations, people are simply too vulnerable to focus on the cost of care. However, our findings call those assumptions into question. We found cost considerations documented in a small but meaningful proportion of records, suggesting that cost is a critical factor for patients and clinicians even in the ICU. These findings suggest both need and opportunity for providers and staff to proactively acknowledge patient cost concerns and develop competencies for discussing and navigating financial issues, even in the most acute care settings."

"Second, our study suggests clinicians may be able to play a role in helping patients manage costs. The medical records showed that cost could be a barrier to patients accessing needed treatment prior to arriving at the hospital, and/or a consideration in treatment plans during or after discharge from the hospital. At times, these notes also showed that clinicians were able to find lower-cost options when necessitated by patient constraints, suggesting the potential for patient-provider partnership in cost management."

"Finally, we found concrete evidence of unintended consequence of financing mechanisms (e.g., insurance), on overall costs. For example, we saw documented cases of patients being kept longer in the ICU than clinically necessary pending insurance approval for step-down levels of care. An extra night in the ICU may not cause the patient to incur any incremental cost but it certainly increases the overall cost of the episode. Thus, our study revealed potential misalignment between direct patient costs and overall system costs, a conflict which ought to be further examined and addressed as one strategy to mitigate rising health care costs."

Gordon confirmed that the researchers are pursuing similar questions and methods in other data sets using the same data mining methodology to determine whether documented cost considerations are more prevalent in settings such as outpatient clinics, where we might expect cost to be more commonly considered.

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Gordon DD, Patel I, Pellegrini AM, Perlis RH (2018) Prevalence and nature of financial considerations documented in narrative clinical records in intensive care units. JAMA Network Open, 1(7):e184178.

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healthcare costs, finance, USA Do financial considerations about treatment occur during the ICU stay? A study of electronic medical records found that 4% had at least one narrative clinical note linked to finance.