Strategies to Work Within a Patient's Financial Constraints

One of the most nuanced challenges faced by clinicians is aligning optimal treatment recommendations with the financial realities of our patients.

Today we're exploring some strategies that may help us navigate working within the potential financial constraints of our patients, without compromising the quality of care.

Last year, I shared an article that built the foundation of this topic; Building Confidence when Discussing Treatment Cost (read here).

This article outlined a number of insights and strategies aimed to help build a clinician's confidence when having these discussions.

Today I want to dive deeper...

Looking at this predominantly through the lens of musculoskeletal pathology management, though much of the information can apply to other practices, I want us to discuss how we should consider the framing of our treatment recommendations, how we can communicate value effectively, and discuss strategies that may outline alternatives that align with both the clinical and financial needs of our patients.

As healthcare providers, our primary objective is to offer the best possible care.

However, this objective often intersects with the practical issue of affordability for our patients.

The dilemma is not straightforward by any means.

On one hand, we are ethically bound to recommend treatments based on clinical efficacy and patient needs, irrespective of cost. On the other hand, we must be cognisant of the financial burdens these recommendations might impose.

This balance is delicate – while communicating the value of our interventions is crucial for patient "buy-in", we must also acknowledge that, in some cases, a patient's financial constraints may limit their ability to follow through with an ideal course of treatment.

Throughout our pursuit to provide value-driven care, it's imperative for us as clinicians to divert away from practices that deliver low-value care – that is, therapeutic interventions that offer little benefit to the patient and may lead to unnecessary healthcare expenses or adverse outcomes.

This topic in itself is nuanced, as what may be deemed as low-value care can vary between individuals, as well as the individual needs of the client. We'll deep-dive this topic another day...

Unbiased Treatment Recommendations: Balancing Ethics and Patient Needs

There are any number of ethical considerations when making treatment recommendations for our clients, and it's these considerations that form the foundation of us delivering effective patient care.

Our treatment recommendations should always, always be free of consideration of our profit margins. That is, recommending one treatment intervention over another simply because it's better for our bottom line.

Moreover, it's vitally important that these recommendations are also grounded in empirical evidence and best-practices, rather than entirely influenced by our personal lens of bias &/or assumptions about a patient’s financial situation.

Ethical Considerations

• Prioritising Clinical Efficacy:
  The cornerstone of ethical healthcare is to prioritise treatments based on their relevance and suitability to the patient's condition & individual goals, as well as their evidence-based efficacy, irrespective of the patient’s financial status.Yes, this article is about navigating financial barriers, however, the first step is to compassionately & transparently deliver all options, associated costs, as well as the risks and benefits of each intervention. This principle ensures that every patient receives the best possible care recommendation as a starting point.

• Avoiding Bias in Recommendations:
  It’s crucial for clinicians to avoid assumptions about what patients can or cannot afford.Decisions should not be preemptively skewed by perceived financial constraints, nor by a clinician's financial gain, as this can inadvertently lead to the delivery of suboptimal care.

For example; a number of years ago I was in an online forum where clinicians were discussing orthoses prescription, and one of the comments that a) stuck out to me, and b) infuriated me, was a practitioner stating that they "always go with customs (orthotic devices), bigger profit margin and less time wasted."

When we look at the evidence pertaining to custom vs prefabricated orthoses in the management of plantar heel pain, the results of collated studies suggest that prefabricated orthoses may be equally as effective as custom orthotic devices in reducing pain for a number of pathologies.

Yes, there are instances in which custom orthotic devices may deliver superior outcomes, however, the decision to recommend that intervention is based on suitability and not financial gain.

The Role of Communicating Value

In recent years there's been a huge up-swing in clinicians talking about the barriers to client's "buying-in" to their treatments simply boil down to a clinician failing to add or communicate the value of the intervention to their client.

When we're communicating value, this is where we are effectively linking our treatment recommendations & management plans to the goals of our client. If we are able to communicate this effectively, then we are successfully communicating the value of the proposed treatment.

However, we must be mindful that even if we are able to communicate the value of a proposed therapeutic intervention financial constraints can remain.

Beyond Financial Constraints

• Value vs Affordability
  While it is important for patients to understand the value and potential benefits of a treatment, this understanding does not automatically equate to affordability. We must recognise that a patient's appreciation of a treatment's value does not eliminate financial barriers.

• Acknowledging Limitations
  Openly acknowledging and discussing financial limitations can facilitate finding a middle ground where the value of the treatment aligns as closely as possible with the patient’s ability to afford it.

How Can We Effectively Communicate Value?

Patient Education and Trust

Health practitioners are often in a unique position where trust is automatically afforded to us, we have an ethical obligation not to abuse this privelage.

Communicating the value of a treatment intervention is not refining a slick sales pitch, it's effectively linking our therapeutic goals to our client's goals.

• Educational Approach
  Provide patients with comprehensive information about their condition and the proposed treatments. This includes discussing how and why a certain treatment works, its benefits, potential risks, and long-term outcomes.

• Building Trust Through Transparency
  Transparency in discussing treatment options, including their pros and cons and cost implications, helps in building trust.Not to mention outlining all associated costs. An example of this is when recommending orthotic therapy. Discussing costs of the device itself, but not mentioning scanning fees, appointment fees, fitting &/or review fees leads to discord.Patients are more likely to feel comfortable discussing their financial concerns if there is a foundation of trust between themselves and their healthcare provider.

• Personalised Explanation
  Tailor your communication to the individual patient’s level of understanding (health literacy, language etc). This personalised approach ensures that the patient fully comprehends the information, fostering better decision-making.

Strategies for Effective Value Communication

As mentioned earlier, effectively communicating value essentially boils down to successfully linking our Therapeutic Goals to our Client's Goals.

What are some ways in which we can improve our success here?

• Use of Analogies and Metaphors
  Simplify complex medical information using analogies and metaphors that make it more relatable to the patient.A future newsletter edition will be unpacking the power of analogies - make sure you subscribe to the newsletter to stay in the loop!

• Visual Aids
  Utilise charts, models, or digital tools to visually convey information about the treatment and its benefits.Utilisation of visual aids is an incredibly valuable and desired method of communication patients want and need (read more here).

• Follow-Up Questions
  Encourage patients to ask questions and express their concerns, and provide clear, concise answers. This two-way communication ensures that the patient feels heard and understood.

Remember, word salads don't belong in healthcare

• Continuity of Care
  Continuity in the patient-provider relationship helps in building a deeper understanding over time, making discussions about treatment value more meaningful and effective.

Now, whilst they are somewhat interrelated, it's important to differentiate between communicating treatment value and providing high & low-value care.

High & Low-Value Care

Defining Low Value Care

Care that confers no benefit or benefit that is disproportionately low compared with its cost, is of low value and potentially wastes limited resources (Scott & Duckett, 2015)

• Minimal Benefit
  Low-value care typically refers to interventions that have been shown to provide minimal or no benefit to patients. These might include outdated practices, overused interventions, or treatments with a poor evidence base.

• Resource Misallocation
  It also encompasses scenarios where the costs, both financial and in terms of potential side effects, outweigh the benefits.

• Patient-Centric Context
  The definition of low-value care can vary depending on the patient's individual presenting pathology, preferences, expectations and needs.

What might be low value in one scenario could be considered high value in another.

Examples of Low Value Care

• Unnecessary Diagnostic Tests/Imaging
  Conducting tests that are not clinically indicated or are unlikely to influence patient management.For example, referring for xray or ultrasound imaging of plantar heel pain at the initial consultation simply for comfirmation of diagnosis, where there are no atypical symptoms and no treatment interventions have been trialled.Read more on recommended musculoskeletal practices here.

• Overuse of Treatments
  Procedures &/or treatments that do not align with evidence, best-practice, or have limited efficacy demonstrated in certain pathologies &/or client groups.This is where manual/passive therapies cop a lot of heat. To be clear, I am not anti-passive therapy, I am anti over-utilisation of passive therapies and lack of clinical reasoning when implementing passive therapies, where; a) there is no plan to utilise the treatments to open the therapeutic window to meaningful movement, and b) patients are booked in for multiple treatment sessions based on a 'protocol' or completely unfounded reasoning.

• Unnecessary Treatment Interventions
  Rarely is any treatment intervention entirely useless, though there are some (I won't open pandoras box on this arguement today). However, again we must consider the individual, their presenting pathology, previous experiences etc and apply our clinical reasoning to identify the utility of a therapeutic intervention.Problems arise when therapies are recommended with little clinical reasoning, based out of clinician habits, protocols and/or financial interests.

• Orthoses Prescription
  Prescribing orthoses as a first-line treatment in many musculoskeletal presentations is often inappropriate, not aligned with evidence, and may create longer-term barriers to helping patients overcome their musculoskeletal pathologies.

• First-Line ESWT (Shockwave) Therapy
  Many clinical practice guidelines recommend utilising ESWT as a second-line treatment, often if other conservative treatments are not providing sufficient therapeutic effect (refer to PHP Guideline link above).

• Surgical Intervention
  When a patient experiences an injury and is recommended surgery prior to trialling conservative measures. Yes, there are certainly instances where surgical intervention as a first-line is warranted.Probably where I have observed the most systemic patterns of inappropriate treatment was when I was working within the Workers' Compensation scheme as a case manager in 2020-21. I'll share more insights into the ins and outs of Workers' Comp another time.

As mentioned, clinical judgement will need to play into your clinical decision-making here, not every patient will follow the timeline or guidelines outlined in literature. For example, Management of Plantar Heel Pain: a best practice guide (Morrissey et al, 2021).

Using the example of plantar heel pain, based on your client's clinical history, clinical presentation, previous treatments etc, there may be instances in which orthoses &/or ESWT come into a treatment plan much earlier that the BPG outlines. Whereas, there may be situations where recalcitrant presentations don't utilise orthoses &/or ESWT.

Remember, not every musculoskeletal pathology is a biomechanical pathology...

Read: Do You Have Biomechanical Tunnel Vision?

Think of the patient that presents to your clinic with 6 pairs of orthoses from 4 different clinicians. Is another pair of orthotic devices really likely going to solve their issue or is there something else that may be a driving factor that's been missed? Prescribing orthoses in this situation may be an example of providing low-value care.

What Does High-Value Care Look Like?

• Evidence-Based Practice
  High-value care is grounded in strong clinical evidence. It involves using the best available evidence to guide decision-making, ensuring treatments are effective and necessary.

• Patient-Centered Approach
  This involves considering the patient's clinical presentation, preferences, values, previous experiences, and overall health goals in the treatment planning process. I will expand on this shortly...

• Cost-Effectiveness
  High-value care also considers the cost implications for the patient and the healthcare system. It focuses on interventions that provide the best outcomes relative to their costs.Remember, this is free of assumptions, but responsive to, and balancing the multiple elements we are considering in this article.

• Proactive Measures
  Often, high-value care includes proactive measures that can mitigate the need for more intensive and costly interventions later on (reactive healthcare). Think of musculoskeletal rehabilitation prior to considering surgical intervention.

Patient-Centered Care

I've mentioned patient-centric care multiple times throughout this article. It's important for us to remember that we're treating people not just pathologies.

In recognising this, often successful management is a result of implementing high-value care (evidence-based practice, patient-centered approach, cost-effective, includes preventative strategies), as well as developing a management approach via collaboration not dictation.

A collaborative, patient-centred approach is often built upon informed and shared decision-making.

Informed Decision Making

Informed decision making is not only about providing information; it's about empowering patients to take an active role in their healthcare journey.

Fundamentally, it involves providing patients with clear, comprehensive information about their health concern and all the available treatment options.

A crucial element of patient-centered care is ensuring we are informing patients about all viable treatment options, including the likely most effective ones, based on quality evidence, as well as your clinical experience, so they can make informed decisions about their care.

Key Elements of Informed Decision Making

1. Full Disclosure of Options
   Patients should be informed about all relevant treatment options, including those that might be more costly or complex. This includes explaining the benefits, risks, potential outcomes, and costs of each option.

2. Clear Communication
   Use language that is easy to understand by patients, avoiding medical jargon. Ensure that the patient fully understands the implications and nuances of different treatment paths.

3. Discussing Alternatives
   Alongside the primary recommendation, it may be beneficial to discuss alternative treatments, including those that may be more cost-effective.This approach helps patients understand the spectrum of available care, and allows them to weigh-up cost, benefit, risks etc and make decisions based on all available information.

4. Respecting Patient Autonomy
   Encourage patients to ask questions and express their concerns. Respect their decisions and preferences, even if they differ from the clinician's recommendation.

Strategies for Enhancing Informed Decision Making

• Educational Materials
  Provide patients with written materials, diagrams, or videos that can help them better understand their condition and the proposed treatments.

• Shared Decision Making
  Engage in shared decision-making processes where the clinician and patient collaborate to reach a decision that aligns with the patient’s values and preferences. Again, encourage your patients to ask questions and faciliate an open dialogue.Shared decision-making builds the foundation of informed decision-making.

• Follow-Up Discussions
  In some instances we can offer follow-up discussions or consultations to give patients time to consider their options and seek additional information or clarification if needed.

Self-Reflection Checklist

1. Clinical Judgment Over Cost
   Have I recommended the best treatment based on clinical need and effectiveness?
   Am I avoiding assumptions about the patient’s ability to afford certain treatments?

2. Patient Communication
   How effectively am I communicating all viable treatment options to my patient?
   Am I providing comprehensive information that helps patients understand the value and potential outcomes of the treatments?
   Remember to include; purpose of treatment (relevant to their pathology), potential risks, potential benefits, costs, alternate options.

3. Bias Awareness
   Am I consciously or unconsciously allowing biases to influence my treatment recommendations?
   How can I ensure equitable care for all patients, regardless of their financial background?

Addressing Financial Barriers Post-Recommendation

After you've delivered your initial treatment recommendations, that are based on your individual assessment and the individual's clinical needs, we may be presented with a situation in which we are required to address financial concerns by our patient.

Navigating these concerns empathetically and effectively is essential for ensuring that patients receive the necessary care within their financial means.

Navigating Financial Concerns

Addressing financial constraints can be a sensitive topic for many patients.

It's not entirely uncommon for a patient to become upset when they raise some financial concerns, it's important to handle these situations with empathy, understanding, and professionalism.

Here are some things to consider:

Try to maintain a calm and compassionare demeanor.

How?

• Empathetic Response
  Acknowledge the patient’s feelings without judgment. Show empathy and understanding, reassuring them that their concerns are valid and heard.

• Stay Calm & Respectful
  Maintain a calm and composed demeanor. A patient's emotional response can be better managed when met with a steady and reassuring presence, not frustration and a dismissive demeanour.

Ensure you are able to provide privacy for the discussion.

Ensure that the conversation takes place in a private setting where the patient feels secure to express their concerns without the fear of being overheard.

ie: Don't have these discussions in the reception area.

Actively listen and validate their concerns.

• Active Listening
  Give the patient your full attention. Let them express their concerns without interruption.

• Validation
  Validate their emotions by acknowledging the stress that financial issues can bring.
  Avoid minimising their feelings or being dismissive.

• Open Dialogue
  As mentioned earlier, encouraging an open and non-judgmental dialogue where patients feel comfortable discussing their financial constraints.

• Understanding Individual Circumstances
  Take the time to understand each patient's unique financial situation.
  This understanding is crucial for tailoring solutions that are realistic and practical for them.

Practical Strategies to Navigate Financial Constraints

Offering Alternatives

In many instances of manging musculoskeletal pathologies, there are multiple treatment options available.

Whilst one approach may be the most "optimal" based on a clinical presentation, the human body is pretty great at healing if we are able to create an environment in which positive adaptation & healing can occur.

Optimal may equate to this process happening faster or with less potential hiccups, however, sub-optimal may yield positive results, just slower and maybe not as good as our ideal. It comes with knowledge & experience, but you can develop flexible treatment plan frameworks.

Where possible, we may be able to offer alternative treatments or options that may be more affordable. This could include altering rehabilitation regimens, alternative therapies (prefabricated vs custom orthoses), or adjusted treatment frequencies.

Flexible Treatment Plans: Developing treatment plans with built-in flexibility.

This may allow for adjusting your treatment based on the various financial situations you may come across when managing pathologies, without compromising, or at least minimising the impact on the quality of care.

Examples

• Example 1
  A podiatrist recommends custom orthotic device ($700) and new footwear ($320) for a patient with plantar heel pain. After presenting this option, they learn about the patient's financial constraints and work together to explore alternative solutions, such as less expensive orthotics (semi-custom or pre-fabricated) and new footwear, or payment plans for the orthotic deivces and a less expensive footwear option, or trialling strapping & progressive loading +/- footwear first (more on plantar fasciopathy management here).

• Example 2
  A physiotherapist recommends a comprehensive rehabilitation program for a post-surgery patient. When cost concerns arise, due to the combination of having to take time off work to get to the appointment, as well as the cost of the extended consultation, they discuss modifying the frequency of sessions and supplementing with home exercises and/or utilising tele-health consults as required, ensuring the patient still receives effective care within their financial means.

Prioritising Treatments
In cases where multiple treatments are recommended, we may be able to help patients prioritise therapeutic interventions based on urgency and importance. This approach can help in managing costs without delaying important care.

Leveraging Technology & Telehealth
As mentioned in the previous example, clinicians may utilise technology, such as telehealth appointments for lower limb musculoskeletal pathology management, which can reduce costs associated with in-person visits without compromising the frequency of professional guidance.

For Australian Podiatrists, here's a link to the Australian Podiatry Association telehealth guide, as well as their telehealth info page.

Please note, some information may not be up-to-date since original publication in 2020.

Whilst there's no single best method in which we can navigate this aspect of clinical practice, I hope this article has provided some useful insights for you.

As always, I'd love to hear your thoughts on this article.

Do you have any other strategies that you've found useful?

Please drop a comment or send a DM, I enjoy the conversations these articles generate.

Also, the best way you can support the newsletter is to a) subscribe, and b) share these articles to your networks.

References

Alfandre, D. Clinical Recommendations in Medical Practice: A Proposed Framework to Reduce Bias and Improve the Quality of Medical Decisions. The Journal of Clinical Ethics. Sep 2016; 27(1).

Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O'Sullivan PPB. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020 Jan;54(2):79-86.

Rennie K, Taylor C, Corriero AC, Chong C, Sewell E, Hadley J, Ardani S. The Current Accuracy, Cost-Effectiveness, and Uses of Musculoskeletal Telehealth and Telerehabilitation Services. Curr Sports Med Rep. 2022 Jul 1;21(7):247-260.

Scott IA, Duckett SJ. In search of professional consensus in defining and reducing low-value care. Med J Aust. 2015 Aug 17;203(4):179-81.

Berenice Wong, Declan Ward, Kirsty Gemmell, Reuben Bright, Roman Blackman, Gisela Sole & Sarah Ward (2020) How is telehealth being utilized in the context of rehabilitation for lower limb musculoskeletal disorders: a scoping review, Physical Therapy Reviews, 25:5-6, 350-360.

References