The Patient Affordability Framework

The Patient Affordability Framework helps health systems and care teams develop strategies to make care more affordable for patients. Among other things, it calls for measuring patient affordability within one’s practice, providing actionable data about costs to patients, training care teams in delivering more affordable care, and developing care pathways to address the affordability needs of vulnerable populations. How does this build trustworthiness? Patients with high cost burdens report lower levels of trust in their physicians; they receive a message that physicians are not concerned about financial harm or about treating them equitably. This framework elevates the competence of helping patients avoid financial harm.

How It Works

This framework has been published in NEJM Catalyst, with concrete examples from across the country.

The framework includes four components:

  1. Health systems can address the challenge of limited financial transparency for patients by providing actionable out-of-pocket cost data to patients with improved payment information and data management. Out-of-pocket transparency will not solve the affordability issue alone; however, institutional price comparisons, including payer plan specifics, are vital to conversations about treatment options for patients. For health systems to overcome this challenge, they will require further advances in the field such as developing strong relationships with payer entities and potentially further policies supporting these efforts.
  2. Health systems must train clinicians to deliver more affordable care. Engaging clinicians and staff who discuss costs, access data at the point of care, and incorporate it into care plans is critical to patient affordability. For example, care teams can proactively guide patients on what to expect in their care by discussing both the potential clinical and financial impacts of choosing surgery or a nonsurgical intervention prior to, during, and after care is delivered. With this information, care teams can use shared decision-making approaches to help patients make choices that are personal, appropriate, effective, and affordable.
  3. Health systems will need to develop clinical and financial pathways to improve patient affordability for patients (particularly those who lack needed resources and agency). While knowledge and awareness of financial risk will help clinician-patient decision-making, ultimately, there remains an additional challenge to build systems capable of reducing this risk like any other medical or social barrier to care. Health care systems must develop affordability pathways that include affordability screening, committees, and individualized care plans for patients.
  4. Finally, health care systems can address the challenge of system-wide adoption and implementation by focusing on individual care teams and sites of care. Organizations can guide their patients toward more affordable care by developing networks that include care sites with heightened awareness about patient affordability. Network development may include creating systems to identify clinicians and staff (i.e., locally or remotely) trained to deliver more affordable care and creating new relationships or contracts with them.

Skills and Competencies

Skills and competencies include:

  • Begin measuring patient affordability within ones own practice.
  • Develop methods to provide actionable out-of-pocket costs and payment transparency to patients.
  • Train care teams trained in delivering more affordable care.
  • Develop care pathways to address the affordability needs of vulnerable populations.


For example, on January 24, 2019, the news organization Vox published an article titled, “A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills.” The San Francisco hospital has held a venerable and trusted position in the community as it serves the city’s most vulnerable patients. However, the illumination of these balance billing practices rapidly changed how many people in the community viewed the hospital. This example is just one in a string of recent prominent articles that focus on large patient bills, nonsensical billing practices, and, more generally, on healthcare’s lack of attention to patient affordability. The net result is an eroding public trust in the healthcare profession, an effect that extends not just to health systems and institutions, but physicians and health care professionals as well.

In 2016, 34% of adults (63 million) reported having a problem accessing care due to cost-related concerns. Patients with high medical cost burdens have greater odds of lacking trust in their physician to put their needs above all else and to avoid performing unnecessary tests. These patients also had more negative assessments of the thoroughness of care they receive from their physicians. In return, this lack of physician trust is crucial to patient willingness to seek care, adhere to treatment recommendations, achieve positive health outcomes, and use recommended preventive services.

In addition, stories about price gouging, denials of coverage and excessive profit cast doubt over trust among other members of the healthcare system. Frontline clinicians and executive leaders may lose trust when they are asked to see more patients and to cut costs without messaging around preserving quality or patient experience and if savings will be directed back to patients. Healthcare executives also can lose trust when they are incentivized to cut costs by payers that may not consider their unique patient populations.

In light of these risks of patient and public mistrust, we developed this framework for care teams to improve patient affordability and trust in their efforts to improve the delivery of personal, high quality care with patients.


In October 2017, with support from the ABIM Foundation, Costs of Care convened an expert consultation meeting that included primary care and specialty clinicians, patients, case managers, financial managers, public health researchers and advocates. This group helped to define, understand, and establish the responsibility of clinical teams in considering the financial impact of care plans on patient affordability and provide insight into potential proactive solutions. Our practice builds from the on-the-ground insights from this broad stakeholder group providing initial face validity to the framework.

Institutions who focus on improving delivery of affordable care can measure trust and experience within their evaluations moving forward. Currently we have interviewed health systems who have implemented components of the Patient Affordability and Trust Framework. While many of them are measuring affordability in different ways and finding significant success, we are sharing ways for them to integrate patient trust measurement tools as well.

For example, the University of Utah created the Pricing Transparency tool that, with patient inputs about their health plan deductible or co-payments, provides estimates of out-of-pocket costs specific to them for common procedures. Blue Shield Blue Cross are expanding partnerships with providers and behavioral economic benefit design companies to inform patients at the point-of-care. For example, when customers select high-value services such as a lower-cost care site to obtain a $1000 MRI, they are mailed $200. This engages patients in affordable care and shares savings. Both address the underlying causes of mistrust in patient affordability and have seen improvements in out-of-pocket costs to their patients and beneficiaries.


We believe that with further development of affordability measurement, all aspects of this framework can integrate into care team training and workflows that may exist within health systems and practices throughout the nation. This is an emerging field, and we believe that discussion about this important topic will spur the field forward to meet public needs.

There is a need for larger institutions, such as payer entities, to incentivize delivery of more affordable care and the message of this work to engender a national conversation. The Center for Medicare and Medicaid Services has prioritized and is beginning to scale public access to institutional price information and comparisons. Further clarification on actual costs and billing specifics are needed, and policies could be created to ensure that data is provided at the individual patient out-of-pocket cost level. We believe that continued infrastructure development will support further scale.