ABLE to support patient financial capacity: A qualitative analysis of cost conversations in clinical encounters

Objective: To explore how costs of care are discussed in real clinical encounters and what humanistic elements support them. Methods: A qualitative thematic analysis of 41 purposively selected transcripts of video-recorded clinical encounters from trials run between 2007 and 2015. Videos were obtained from a corpus of 220 randomly selected videos from 8 practice-based randomized trials and 1 pre–post prospective study comparing care with and without shared decision making (SDM) tools. Results: Our qualitative analysis identified two major themes: the first, Space Needed for Cost Conversations, describes patients’ needs regarding their financial capacity. The second, Caring Responses, describes humanistic elements that patients and clinicians can bring to clinical encounters to include good quality cost conversations. Conclusion: Our findings suggest that strengthening patient-clinician human connections, focusing on imbalances between patient resources and burdens, and providing space to allow potentially unexpected cost discussions to emerge may best support high quality cost conversations and tailored care plans. Practice implications: We recommend clinicians consider 4 aspects of communication, represented by the mnemonic ABLE: Ask questions, Be kind and acknowledge emotions, Listen for indirect signals and (discuss with) Every patient. Future research should evaluate the practicality of these recommendations, along with system-level improvements to support implementation of our recommendations.