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of-pocket costs account for approximately one fifth of health care expenditures and are increasing. Previous research suggests that these costs are associated with medication nonadherence and considerable economic burden among some patients. Little is known about patient-physician communication regarding these costs.Objective To identify patients' and physicians' beliefs and practices regarding discussions of out-of-pocket costs.Design, Setting, and Participants Cross-sectional paired surveys of 133 general internists and 484 of their outpatients, aged 18 years or older, in 3 academic and 18 community general medicine practices in the Chicago metropolitan area, March-November 2002. Main Outcome MeasuresPatient and physician beliefs regarding discussions of out-of-pocket costs, frequency and predictors of discussions, and physician recognition of patient burden from out-of-pocket costs.Results Sixty-three percent of patients reported a desire to talk with their physician about their out-of-pocket costs, and 79% of physicians believed that patients in general want to discuss these costs. By contrast, only 35% of physicians and 15% of patients reported ever having discussed the study patient's out-of-pocket costs. Multivariate analysis indicated that discussions were significantly more likely to occur with patients burdened by their out-of-pocket costs (prevalence ratio [PR], 2.55; 95% confidence intervals [CI], 1.62-3.76) and with those patients seen in a community practice (PR, 5.19; CI,). Among patients burdened by out-of-pocket costs, physicians were substantially more likely to recognize this burden when a prior discussion regarding out-of-pocket costs had taken place (80% vs 51%). Conclusions Among respondents, both patients and physicians believed that discussions of out-of-pocket costs were important, yet these discussions occurred infrequently. Physician communication with patients about out-of-pocket costs may be an important yet neglected aspect of current clinical practice. Further research should identify the prevalence of this problem in broader populations, investigate its causes, and evaluate the impact of enhanced communication about out-of-pocket costs on patient satisfaction, utilization of care, and outcomes.

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The patient-centered medical home has become a prominent model for reforming the way health care is delivered to patients. The model offers a robust system of primary care combined with practice innovations and new payment methods. But scant information exists about the extent to which typical US physician practices have implemented this model and its processes of care, or about the factors associated with implementation. In this article we provide the first national data on the use of medical home processes such as chronic disease registries, nurse care managers, and systems to incorporate patient feedback, among 1,325 small and medium-size physician practices. We found that on average, practices used just one-fifth of the patientcentered medical home processes measured as part of this study. We also identify internal capabilities and external incentives associated with the greater use of medical home processes.T he patient-centered medical home model of health care delivery system reform was featured prominently in the Affordable Care Act of 2010. The model was developed by the primary care specialty societies in 2007. It has been endorsed by a broad coalition of purchasers, payers, providers, consumers, and other health care stakeholders. It emphasizes a robust system of primary care combined with practice innovations and new payment models.

Pay-for-performance (P4P) and public quality-reporting programs can increase the quality of health care for the services being measured. However, unless carefully designed, these programs may have the unintended consequence of increasing racial and ethnic disparities. This paper describes ways in which P4P and public reporting programs may increase disparities and suggests ways in which programs might be designed that will make them likely to reduce, or at least not increase, disparities.