Begin Your Journey
A guide for physicians, nurses, community health workers, and frontline clinicians
The medical debt crisis has reached a fever pitch. It will only continue to grow if we cannot marshal a collective effort for change.
We know trust is critical to the patient-clinician relationship, and that trust is increasingly fragile in the wake of the COVID-19 pandemic. Things are further undermined by a broken healthcare financing system that leaves patients confused and uncertain as to whether they can afford their healthcare at all. Clinicians have two options—either bypass the hard conversations with their patients about affordability or engage with patients while having few options to support them.
Everyone touched by the system—physicians, nurses, community healthcare workers, and other frontline staff—has an important role to play in supporting patients and elevating the affordability crisis to a wider audience.
About Our Research
We know medical debt is a barrier to care on the patient side, but what we know less about is how concerns and conversations about medical debt manifest on the clinician side. How do physicians feel about the affordability of care and the way it impacts their patients? What tools, if any, are available to help them guide patients through the maze of financial hurdles that can come with medical care?
Our research explores these questions while laying the groundwork for helping clinicians feel more engaged and empowered to help tackle the medical debt crisis.
We held a series of four focus groups with 30 clinicians.
We wanted to know in their words: what makes a clinician a champion for ending medical debt? How can a clinician champion advocate for and embody the practice, policy, and system changes that must happen to end medical debt?
We learned more about how physicians and other frontline healthcare workers view the medical debt crisis and how they address it with patients.
Nearly everyone agreed the current trajectory is untenable, but there was less agreement on how these problems can be fixed. Learn more about these focus groups by reading our analysis.
We heard from 89 respondents that benefited from medical debt relief.
We invited patients to share their experiences discussing medical expenses or debt with doctors and or hospital staff, how it made them feel, and whether they had ever asked a doctor to change a treatment or prescription due to concerns about cost. 52% reported feeling uncomfortable talking with their doctors or hospital staff about worries around paying for medical care.
What Patients and Clinicians Had To Say
Medical debt is a barrier to care.
Clinicians are afraid they may scare patients away if they prescribe a medication or service they can’t afford. They also shared that they have seen an increase in patients delaying or avoiding care altogether, including patients who stop taking medications or following treatment protocols due to concerns about cost or inability to pay.
“They’re rationing their medication, especially diabetic medication. They’re not taking it as prescribed. They’re making it last longer. They’re avoiding hospital care. I get pushed-back on a regular basis about ambulance transportation. So, I think that could be summarized as, they’re avoiding care.”
— Family physician, West Virginia
Cost-of-care conversations are common—and welcome.
Patients are less afraid to talk about medical debt with their doctors than anticipated. However, clinicians feel they have very limited training and few resources to offer. Most did not receive training on helping patients manage the cost of care, sharing that they cobble together what they can find through word of mouth and some institutional supports—i.e., online discount pharmacies and connecting with financial counselors or social workers. They feel these resources are lacking or overburdened and would like to see more formalized, robust supports for clinicians and patients.
“I would say I’m usually the one initiating it. As soon as I’m meeting with the patient on my screen, I’ll see what kind of healthcare they have, what their health insurance coverage is…if I see they do have a private insurance, I ask them, especially if we’re going to be ordering a CT or an MRI or something like that, and I’ll say if you don’t mind, let’s talk about your healthcare coverage and where you’re at in your deductible and those conversations.”
— Physician assistant, Montana
Health insurance is not enough.
There is deep frustration with things like prior authorization, confusing denials, and high out-of-pocket costs— but also an appreciation that without insurance medical debt could be worse.
“You can have insurance, but if you don’t understand the type of insurance that you have it can be pretty useless and even harmful. Some of my patients have gotten private insurance off the Marketplace that had enormous deductibles, and they didn’t realize and then they get stuck with these huge bills that they didn’t anticipate because they thought they had insurance. And it was partly because they didn’t understand the type of insurance they were getting.”
— CJA-affiliated (Communities Joined in Action) physician, North Carolina
The business of medicine forces clinicians to become financial counselors on top of other work.
On balance, focus group participants accept financial health is part of the patient encounter and were comfortable having medical debt conversations with their patients. Most viewed debt conversations positively, as they allow clinicians to work with patients to find ways to help manage care and costs; it is not the content or context of these conversations that stress providers, rather it is the lack of immediately accessible, easily understandable resources available to their patients that leaves them frustrated.
“With patients, they trust me, and they bring me the bill personally because they can’t get through anywhere else. It’s a 45-minute wait with the billing office. They get conflicting information, there’s nothing else, the insurance company they wait on the phone for two hours and get nowhere. So, they trust me because I’m their physician, and there’s no other option except bring it up with me, which is kind of depressing.”
— Family physician, Pennsylvania
Clinicians feel overburdened and know changing the system cannot be done alone.
Many feel they can sometimes help on an individual level, but there was limited belief in their ability to create systems-level change. Most acknowledged the need for greater change, but felt it was out of their hands and must be tackled at the state and federal level. Some acknowledge their role in creating medical debt for patients but also feel stuck in a dysfunctional system they cannot control.
“I’m not sure how much power I have. I’m sure there’s something that I can do more of, maybe from a top level. I guess sit on a board, talk to some of our administrators. But in general, healthcare has just unfortunately become such a machine. You know, it’s just such a machine. Again, we’re just trying to give people the absolute best care that we can, in a very tiny window of time we’re trying to address unbelievable amounts of problems, five and six different comorbid problems that are really, really serious and trying to prioritize, and we do that for probably, some of us, myself, 14 to 19 people a day, in some cases sometimes more. So, if there’s something I can do, I’d love to know about it.”
— Nurse practitioner, South Carolina
Racism in health care is a well-known issue; it manifests in disparities in access to care, the quality of care received, and overall health outcomes. People of color are more likely to be uninsured, experience higher rates of chronic illness, and have less access to preventative care. In the context of this guide, racial bias among the healthcare workforce can result in unequal treatment, poor communication, assumptions about the ability to pay, and misdiagnoses. Specifically, research shows that Black patients are more likely than white patients to report that race negatively affected their care.
Racism, attitudes towards people with physical and intellectual disabilities, sexual orientation or gender identity, age, and class are all barriers to be aware of; much like with medical debt, clinicians can fulfill a role in reducing these burdens by first acknowledging their existence. While this guide is focused on ways to discuss and get involved with ending medical debt, it is important for readers to remain aware of other intersecting biases and identities that may impact a patient’s experience and access to care.
Resources: Confronting Racism in Healthcare (Commonwealth); Anti-racism Resources (Association of American Medical Colleges)
Learn More About the Research
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This work was made possible with support from the Robert Wood Johnson Foundation.
The views expressed here do not necessarily reflect the views of the Foundation.
