The COST Study: Promoting Cost-of-Care Conversations with Low-Income Pregnant Patients

How might we promote cost-of-care conversations between low-income pregnant women and their providers?

Patient-provider communication about costs of care is viewed as an integral part of delivering high-quality, high-value care. But scant research exists about how to do this in the context of time-and information-constrained appointments.

Using a multistakeholder approach, we engaged 20 pregnant or postpartum women — 15 “near poor” (within 400% of the federal poverty line) and 5 “control” patients with higher incomes — seeking prenatal care on Chicago’s south side. We interviewed 24 nurses, OBs, medical support staff and executive administrators. Using drawing activities, projective exercises and prototype reviews, we identified stakeholder goals and common ground for cost-of-care conversations.

This input generated 13 prototypes of a communication tool for use by providers and patients. These prototypes explored how to promote conversations so as to fit into clinical workflows and short appointment times. An iterative development process evolved the content, language and positioning for patients who expressed significant concerns related to sharing information that could generate judgment or lesser care.

The final communication tool was designed to highlight an unexpected driver of patient costs: the frequency (between 13 and 27) and duration (up to four hours if tests are required) of pregnancy appointments. Low-income participants highlighted the need to know this information well in advance.

This would help them activate their social network to help them attend appointments. Word choice and visual language were tailored to make the tool “about me, not about a baby that may never happen” for patients with high-risk pregnancies. Physician time to fill out the tool was less than 90 seconds. Patients and providers also identified 16 benefits of the tool.

Under separate funding, this prenatal tool was pilot-tested in three clinics in a series of 14 week pilots. Research insights and tools can be found on America’s Essential Hospitals website.