Deciding Whether to Take Sacubitril/Valsartan: How Cardiologists and Patients Discuss Out-of-Pocket Costs.

Background Out-of-pocket costs have significant implications for patients with heart failure and should ideally be incorporated into shared decision-making for clinical care. High out-of-pocket cost is one potential reason for the slow uptake of newer guideline-directed medical therapies for heart failure with reduced ejection fraction. This study aims to characterize patient-cardiologist discussions involving out-of-pocket costs associated with sacubitril/valsartan during the early postapproval period. Methods and Results We conducted content analysis on 222 deidentified transcripts of audio-recorded outpatient encounters taking place between 2015 and 2018 in which cardiologists (n=16) and their patients discussed whether to initiate, continue, or discontinue sacubitril/valsartan. In the 222 included encounters, 100 (45%) contained discussions about cost. Cost was discussed in a variety of contexts: when sacubitril/valsartan was initiated, not initiated, continued, and discontinued. Of the 97 cost conversations analyzed, the majority involved isolated discussions about insurance coverage (64/97 encounters; 66%) and few addressed specific out-of-pocket costs or affordability (28/97 encounters; 29%). Discussion of free samples of sacubitril/valsartan was common (52/97 encounters; 54%), often with no discussion of a longer-term plan for addressing cost. Conclusions Although cost conversations were somewhat common in patient-cardiologist encounters in which sacubitril/valsartan was discussed, these conversations were generally superficial, rarely addressing affordability or cost-value judgments. Cardiologists frequently provided patients with a course of free sacubitril/valsartan samples without a plan to address the cost after the samples ran out.

Adolescent and Young Adult Perspectives on Quality and Value in Health Care.

OBJECTIVE: To describe adolescent and young adult (AYA) perspectives on defining quality and value in health care and to gain understanding of their knowledge of value-based payment. METHODS: A text message-based survey was sent to a convenience sample of AYAs aged 14 to 24 in 2019. Participants were asked 4 open-ended questions: 1) how they would define "good health care," 2) what factors to consider in rating doctors, 3) whose opinions should matter most when rating doctors, and 4) the best ways to collect AYA opinions on doctors, and one yes/no question on their awareness of value-based payment. Analyses included descriptive demographic statistics and an inductive thematic approach with multivariable models comparing adolescent (14-18) and young adult (19-24) responses. RESULTS: Response rate was 61.0% (782/1283). Most participants were White (63.3%), female (53.3%), and adolescents (55.6%). Common themes from the first 2 questions included accessibility (specifically affordability), coverage benefits, and care experience (including compassion, respect, and clinical competence). Young adults more commonly mentioned affordability than adolescents (54.4% vs 43.3%, P = .001) and more commonly felt their opinion should matter more than their parents when rating doctors (80.6% vs 62.0%, P < .001). Only 21.0% of AYAs were familiar with the potential value-based link between physician payment and care quality. CONCLUSIONS: When considering quality and value in health care, AYAs expressed their desired agency in rating the quality of their care and clinicians. AYAs' perspectives on health care quality, including the importance of care accessibility and affordability, should be considered when designing youth-centered care delivery and value-based payment models.

How can healthcare organizations improve cost-of-care conversations? A qualitative exploration of clinicians' perspectives.

OBJECTIVES: Clinicians increasingly believe they should discuss costs with their patients. We aimed to learn what strategies clinicians, clinic leaders, and health systems can use to facilitate vital cost-of-care conversations. METHODS: We conducted focus groups and semi-structured interviews with outpatient clinicians at two US academic medical centers. Clinicians recalled previous cost conversations and described strategies that they, their clinic, or their health system could use to facilitate cost conversations. Independent coders recorded, transcribed, and coded focus groups and interviews. RESULTS: Twenty-six clinicians participated between December 2019 and July 2020: general internists (23%), neurologists (27%), oncologists (15%), and rheumatologists (35%). Clinicians proposed the following strategies: teach clinicians to initiate cost conversations; systematically collect financial distress information; partner with patients to identify costs; provide accurate insurance coverage and/or out-of-pocket cost information via the electronic health record; develop local lists of lowest-cost pharmacies, laboratories, and subspecialists; hire financial counselors; and reduce indirect costs (e.g., parking). CONCLUSIONS: Despite considerable barriers to discussing, identifying, and reducing patient costs, clinicians described a variety of strategies for improving cost communication in the clinic. PRACTICE IMPLICATIONS: Health systems and clinic leadership can and should implement these strategies to improve the financial health of the patients they serve.

Applying Behavioral Economics to Improve Adolescent and Young Adult Health: A Developmentally-Sensitive Approach.

Each day, adolescents and young adults (AYAs) choose to engage in behaviors that impact their current and future health. Behavioral economics represents an innovative lens through which to explore decision-making among AYAs. Behavioral economics outlines a diverse set of phenomena that influence decision-making and can be leveraged to develop interventions that may support behavior change. Up to this point, behavioral economic interventions have predominantly been studied in adults. This article provides an integrative review of how behavioral economic phenomena can be leveraged to motivate health-related behavior change among AYAs. We contextualize these phenomena in the physical and social environments unique to AYAs and the neurodevelopmental changes they undergo, highlighting opportunities to intervene in AYA-specific contexts. Our review of the literature suggests behavioral economic phenomena leveraging social choice are particularly promising for AYA health. Behavioral economic interventions that take advantage of AYA learning and development have the potential to positively impact youth health and well-being over the lifespan.

Pediatric accountable health communities: Insights on needed capabilities and potential solutions.

BACKGROUND: Pediatric accountable health communities (AHCs) are emerging collaborative models that integrate care across health and social service sectors. We aimed to identify needed capabilities and potential solutions for implementing pediatric AHCs. METHODS: We conducted a directed content analysis of responses to a Request for Information (RFI) from the Center for Medicare & Medicaid Innovation on the Integrated Care for Kids Model (n = 1550 pages from 202 respondents). We then interviewed pediatric health policy stakeholders (n = 18) to further investigate responses from the RFI. All responses were coded using a consensual qualitative research approach in 2019. RESULTS: To facilitate service integration, respondents emphasized the need for cross-sector organizational alignment and data sharing. Recommended solutions included designating "Bridge Organizations" to operationalize service integration across sectors and developing integrated data sharing systems. Respondents called for improved validation and collection methods for data relating to school performance, social drivers of health, family well-being, and patient experience. Recommended solutions included aligning health and education data privacy regulations and utilizing metrics with cross-sector relevance. Respondents identified that mechanisms are needed to blend health and social service funding in alternative payment models (APMs). Recommended solutions included guidance on cross-sector care coordination payments, shared savings arrangements, and capitation to maximize spending flexibility. CONCLUSIONS: Pediatric AHCs could provide more integrated, high-value care for children. Respondents highlighted the need for shared infrastructure and cross-sector alignment of measures and financing. IMPLICATIONS: Insights and solutions from this study can inform policymakers planning or implementing innovative, child-centered AHC models. LEVEL OF EVIDENCE: Level V.