Table 3 Major domains identified on physician perceptions of patients’ financial burden with managing chronic disease

Patient financial burden with chronic care is visible to physicians

Physicians see issues of financial burden often in their chronic disease patients, especially with COPD and diabetes. They notice that these burdens go beyond the out-of-pocket costs with medicines. Physicians feel worried about behaviors patients engage in to manage their financial burden.

“One of my patients will stretch out their Lantus and they will make it last like 45 days or 2 months. Then they wonder why they’re like poorly controlled and have to keep raising their dose.” (male second year internal medicine resident)

Patient’s financial burden with chronic care and discussing these issues is important to physicians

Physicians view patients’ financial burden as important because it impacts compliance, and believe these issues will continue and magnify with the Affordable Care Act.

“I think if you assess that it’s gonna affect whether or not they actually take the med, then it’s probably one of the most important things because you can tell them all of these recommendations but they’re not gonna do em.” (male third year internal medicine resident)

Ability to identify patients who perceive financial burden is imperfect

Physicians have a hard time identifying patients who may be at risk for forgoing care due to cost, they have never been trained to address these issues, and they make assumptions based on limited information.

“I had a couple of admissions, COPD exacerbations…they had not been taking their maintenance inhalers or something like that and it turns out that it was ‘cause they couldn’t afford it.” (male second year internal medicine resident)

Communication of financial burden with patients is complex and difficult to navigate

Physicians experience discomfort in having conversations with patients about affordability and financial burden. Social distance, perception of no solution, lack of training and cognitive burden preclude them from initiating these conversations.

“It’s a disaster, there’s not formalized training about how to navigate that conversation or how to set a follow-up conversation to happen in the future with their primary care physician or whatever. That is totally lost to me.” (male second year internal medicine resident)

Strategies utilized to address concerns are not always generalizable

Physicians utilize $4 and $10 generic lists, recommend low cost pharmacies in the area, and recommend splitting higher dose pills to reduce financial burden. Physicians acknowledge that these strategies may not be generalizable.

“For the most part, I feel like it’s easy to find a lot of alternatives on the list. And that is the main place that I go at least when someone brings up cost issues is the $4 or the $10 lists ‘cause usually that’s hopefully not an issue, and you can usually find an acceptable alternative.” (female second year internal medicine resident)

Physicians have ideas for widespread change to make these conversations easier for them

Physicians recommend utilizing ancillary care staff, incorporating questions into screening forms, and leveraging the electronic health record to better identify and address patients’ financial burden.

“And I think those screening tools are super helpful for us physicians to flag the social issues that we maybe don’t see and don’t talk about.” (female second year family medicine resident)