AT A GLANCE
  • Most adults feel comfortable talking to their usual health care provider about potentially sensitive issues that are relevant to health care, but providers don’t often ask about these issues.
  • Providers are more likely to ask about potentially sensitive issues with adults who have lower incomes, adults who have health problems, and adults who have difficulty obtaining care because they cannot afford it.
  • Even with patients in vulnerable populations, providers rarely ask about potentially sensitive issues.

Patients Feel Comfortable Talking to Their Providers about Sensitive Issues, but Providers Don’t Often Ask

 

Sharon K. Long and Lea Bart

September 15, 2017

 

The past few years have seen an increasing focus on patient-centered models of health care, such as shared decisionmaking and medical homes. These models, which seek to improve the quality of care while reducing costs, encourage patients to play an active role in their health care by talking with their providers about a wide range of issues.1 Patient-provider communication has been linked to better treatment adherence and improved health status (Haskard-Zolnierek and DiMatteo 2009; Stewart 1995). Conversations between patients and providers may include matters that can affect care, such as concerns about treatment plans, difficulties paying for care, and general struggles in day-to-day life. According to recent data from the Health Reform Monitoring Survey (HRMS), more than half of nonelderly adults (55.3 percent) discussed one or more potentially sensitive issues with their provider in the last year (Bart and Long 2017). These conversations are likely critical to the success of patient-centered care. Building on questions in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys that assess the prevalence of conversations on potentially sensitive issues, we added questions to the HRMS to examine the nature of these conversations in practice. This brief explores how often providers ask about potentially sensitive issues and how often patients feel comfortable discussing those topics with their providers.

 

What We Did

 

This brief draws on data from the September 2016 Health Reform Monitoring Survey,2 which asked respondents about their interactions with the doctor or other health care provider they see most often for their health care on the following potentially sensitive issues:

  1. health and health care challenges: whether there are things that make it hard to take care of their health or whether they have concerns about the health care they receive or their treatment plan
  2. concerns about cost of care: whether they have concerns about the cost of their health care
  3. life challenges and stresses: whether there are things in their life that cause worry or stress or whether they have problems in their day-to-day life or living situation

Because of space constraints in the survey, one group of adults was randomly assigned a question about whether their provider had asked them about potentially sensitive issues, and one group of adults was randomly assigned a question about whether they would feel comfortable talking with their provider about those issues.3 The questions and the topics of conversation build on questions in the CAHPS survey.4 To ensure that respondents had an opportunity to have a conversation, the sample in this analysis is limited to adults who saw their usual provider at any time in the last 12 months.5 More than 1,900 adults were asked each of the questions, for a total sample size of 3,848 nonelderly adults.6 We examine how often providers asked about potentially sensitive issues and how often patients reported feeling comfortable talking with their provider about those issues. The data are self-reported and reflect respondents’ recollections of their interactions with their providers.

 

What We Found

 

Most patients feel comfortable talking to their usual health care provider about potentially sensitive issues that are relevant to health care, but providers don’t often ask about these issues.

 

Patients say they are generally comfortable talking to their usual health care provider about potentially sensitive issues, especially problems or concerns about their health and health care (figure 1). Patients are less comfortable talking with their providers about concerns over health care costs and problems in their day-to-day lives, although over seven in ten say they are comfortable discussing these issues. Nine in ten adults in the sample said they were comfortable talking about at least one of the potentially sensitive issues with their health care provider.

 

 

Despite their reported comfort with these conversations, patients say their providers don’t often ask about these potentially sensitive issues. Their providers ask most frequently about causes of stress and problems with day-to-day life (53.2 percent), less often about challenges taking care of health and concerns with health care (41.6 percent), and much less often about concerns about the cost of health care (15.9 percent). For every topic, adults are significantly more likely to say they are comfortable talking with their provider than to report having been asked about it by their provider.

 

Providers are more likely to ask questions about potentially sensitive issues with adults who have low incomes and adults who have health problems.

 

 

Providers may not ask all patients about potentially sensitive issues, but when they do initiate such conversations, they often do so with patients who are more likely to face potentially sensitive issues. For example, adults with family incomes at or below 138 percent of the federal poverty level (FPL) are more likely to be asked whether they have concerns about the cost of health care than adults with higher incomes; however, such conversations are still relatively infrequent (figure 2). Similarly, adults with a chronic condition or disability are more likely than other adults to be asked about challenges taking care of their health or concerns about their health care (45.0 versus 36.6 percent) and about life challenges and stresses (56.9 versus 47.8 percent) than adults without those problems (figure 3). Across all subgroups, many more adults say they would be comfortable talking with their provider about potentially sensitive issues than report that their provider asked about those issues (data not shown).

 

 

Although providers are more likely to ask about concerns about health care costs with adults who have difficulty obtaining needed care because of affordability problems, such questions from providers are still relatively rare.

 

As in figure 1, providers are less likely to ask about, and patients less likely to say they are comfortable with, conversations about health care costs. Yet more than one-quarter of adults report difficulty affording health care that led to unmet need for care, including unmet need for doctor care (12.0 percent) and unmet need for medical tests, treatment, or follow-up care (14.0 percent; data not shown). When providers do ask about concerns about health care costs, they often do so with patients who are facing cost difficulties (figure 4). Adults with unmet need for care because of affordability problems are twice as likely to be asked about concerns about the cost of care as those without unmet need (26.6 percent versus 11.9 percent). Still, providers are only asking about these issues with roughly one in four adults who report affordability problems, despite relatively high reported comfort with such conversations in this population (71.8 percent; data not shown). As shown in Bart and Long (2017), only 18.7 percent of adults report that they had a conversation about the cost of care with their providers. This suggests that patients are not initiating these conversations either, even when they are going without needed care because they cannot afford it.

 

 

What It Means

 

Nearly all nonelderly adults say they would be comfortable talking about at least one potentially sensitive issue with their usual health care provider, but the share of patients who are asked about these issues by their providers is much lower. Fortunately, providers are more likely to raise these issues with the patients most affected by them; adults with health problems are more likely to be asked about their health care concerns, and low-income adults and adults who have difficulty affording health care are more likely to be asked about cost concerns. Nonetheless, many who struggle with these issues fall through the cracks. Lack of communication about challenges in taking care of health, concerns about treatment plans, and inability to pay for care may hinder treatment effectiveness. Patient-centered care models depend upon patients and providers communicating about sensitive issues, but such conversations may not occur as often as they should. Although we cannot determine why these conversations are not happening, we suspect that short appointment times, provider reluctance to discuss sensitive nonmedical issues, and distrust between patients and providers may contribute to the lack of communication. Increasing the amount of time patients and providers spend together and providing additional guidance to providers on how to approach these conversations are two ideas that could foster more dialogue and lead to improved engagement and health outcomes for patients.

 

 

References

 

AHRQ (Agency for Healthcare Research and Quality). 2015. About the Patient-Centered Medical Home Item Set 3.0. Rockville, MD: AHRQ.

 

Bart, Lea, and Sharon K. Long. 2017. “QuickTake: How Often Do Patients Discuss Sensitive Issues with Their Providers?” Washington, DC: Urban Institute.

 

Epstein, Ronald M., Kevin Fiscella, Cara S. Lesser, and Kurt C. Stange. 2010. “Why the Nation Needs a Policy Push on Patient-Centered Health Care.” Health Affairs 29 (8): 1489–95.

 

Haskard-Zolnierek, Kelly B., and M. Robin DiMatteo. 2009. “Physician Communication and Patient Adherence to Treatment: A Meta-analysis.” Medical Care 47 (8): 826–34.

 

Levinson, Wendy, Cara S. Lesser, and Ronald M. Epstein. 2010. “Developing Physician Communication Skills for Patient-Centered Care.” Health Affairs 29 (7): 1310–18.

 

Stewart, Moira A. 1995. “Effective Physician-Patient Communication and Health Outcomes: A Review.” Canadian Medical Association Journal 152 (9): 1423–33.

 

About the Series

 

This brief is part of a series drawing on the HRMS, a survey of the nonelderly population that explores the value of cutting-edge Internet-based survey methods to monitor the ACA before data from federal government surveys are available. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute.

 

For more information on the HRMS and for other briefs in this series, visit www.urban.org/hrms.

 

About the Authors

 

Sharon K. Long is a senior fellow and Lea Bart is a research assistant with the Urban Institute's Health Policy Center. The authors thank Genevieve Kenney and Stephen Zuckerman for their comments on an earlier draft.

 

Notes


1 James Rickert, “Patient-Centered Care: What It Means and How to Get There,” Health Affairs Blog, January 24, 2012. See also Levinson, Lesser, and Epstein (2010) and Epstein and colleagues (2010). ^

 

2 The data collection period for the September 2016 round of the HRMS extended into October and November for a small share of the sample. ^

 

3 A third group was asked if they had talked to their provider about the potentially sensitive issues; these results are discussed in Bart and Long (2017). ^

 

4 These questions build on the following questions in the CAHPS patient-centered medical home item set: “In the last 6 months, did someone from this provider’s office ask you if there are things that make it hard for you to take care of your health?” and “In the last 6 months, did you and someone from this provider’s office talk about things in your life that worry you or cause you stress?” (AHRQ 2015). ^

 

5 Approximately 30 percent of adults in the survey had not seen their usual provider in the past year. These 2,331 adults were not asked about their conversations with providers. ^

 

6 Forty respondents (only 1 percent of the sample) refused to respond to the question; they are excluded from the analysis. ^

Urban Institute Robert Wood Johnson Foundation