Higher out-of-pocket medical costs may discourage patients from scheduling recommended procedures by increasing financial discomfort and anxiety.
Across 3 randomized online experiments involving routine blood draws, endoscopies, and nerve conduction procedures, investigators recruited 1,028 English-speaking US adults through Prolific and randomly assigned them to scenarios involving either the full out-of-pocket cost of a procedure or no out-of-pocket expense. Clinical information remained identical between conditions.
The investigators assessed anticipated physical pain, willingness to schedule a recommended procedure, financial discomfort associated with payment—described as the pain of paying—and procedure-related financial anxiety. They examined whether financial discomfort and anxiety mediated the relationship between medical costs and participants' responses, and whether baseline financial stress influenced scheduling intentions.
Study 1 focused on anticipated physical pain associated with a routine blood draw. Among 293 participants, those assigned a $53 out-of-pocket expense reported higher expected pain compared with those assigned no cost, with mean scores of 2.03 vs. 1.84. However, the overall difference was not statistically significant.
The higher-cost group reported greater pain of paying, with mean scores of 3.96 vs. 1.95, and financial anxiety, with mean scores of 3.67 vs. 1.68. A serial mediation analysis identified a significant indirect pathway linking the out-of-pocket expense to greater anticipated physical pain through financial discomfort and subsequent financial anxiety.
In study 2, 344 participants considered a hypothetical endoscopy with a billed price of $787. Those assigned to pay the full amount reported lower willingness to schedule the procedure compared with participants assigned no out-of-pocket cost, with mean scores of 2.87 vs. 4.26 on a 7-point scale.
Participants facing the $787 expense reported greater pain of paying, with mean scores of 5.88 vs. 2.75, and greater financial anxiety, with mean scores of 5.92 vs. 2.31. Although the investigators identified a possible sequential pathway from out-of-pocket costs through financial discomfort and anxiety to scheduling intentions, the overall serial indirect effect did not reach conventional statistical significance.
Study 3 involved a hypothetical nerve conduction procedure costing $1,120. Among 391 participants, those assigned the full out-of-pocket expense reported lower scheduling intentions compared with those assigned no cost, with mean scores of 4.19 vs 5.66.
The higher-cost group reported greater financial discomfort, with mean scores of 5.93 vs. 2.92, and greater financial anxiety, with mean scores of 5.99 vs. 2.32. Anticipated physical pain was numerically higher among participants facing the full expense, with mean scores of 2.51 vs. 2.26, but this difference was not statistically significant.
Serial mediation analyses in study 3 identified significant indirect associations linking higher out-of-pocket costs to both anticipated physical pain and lower scheduling intentions through increased pain of paying followed by financial anxiety. This suggested that emotional responses to medical expenses may contribute to how participants evaluate the prospect of undergoing a procedure.
The investigators examined whether participants' existing financial stress influenced these relationships. In study 3, the association between cost-related financial anxiety and reduced scheduling intentions was stronger among participants reporting greater baseline financial stress.
The studies provided more consistent evidence for an effect of out-of-pocket costs on scheduling intentions than for a direct effect on anticipated physical pain. Although higher-cost conditions produced greater pain expectations in studies 1 and 3, neither overall comparison reached statistical significance. The findings suggested that financial discomfort and anxiety may help explain the relationship between cost information and anticipated pain, but they did not establish that higher expenses directly increase physical pain.
Cost communication, financial counseling, and access to lower-cost alternatives could potentially help address financial anxiety surrounding medical procedures. The investigators raised the possibility that emphasizing high prices without presenting affordable options could unintentionally heighten financial distress. The studies did not evaluate whether these approaches improve appointment attendance, treatment adherence, or clinical outcomes.
Several limitations warrant consideration. The studies relied on hypothetical medical scenarios and self-reported expectations rather than actual health care decisions or experienced physical pain. The online samples may not represent patients facing immediate medical needs, and the findings may not generalize beyond the US health care system. Previous experiences with procedures or physicians, insurance arrangements, and other contextual factors could also influence responses to medical costs. The mediation analyses support proposed psychological pathways but cannot independently establish the causal sequence between financial discomfort, anxiety, and anticipated pain.
"Our results show the pain of paying can affect behavioral intentions to make medical appointments," wrote lead study author Helen Colby, of the Kelley School of Business at Indiana University, and colleagues.
The study authors declared no conflicts of interest.
Source: Psychology & Marketing