Out-of-pocket costs changed how adults judged recommended procedures
When patients were told they would owe money for a recommended procedure, their willingness to move forward dropped sharply. The effect was not limited to simple sticker shock. Out-of-pocket costs also changed how people anticipated the procedure itself, with financial anxiety feeding into higher expected pain even when the procedure, the billing amount, and the insurance coverage stayed the same.
Adults who imagined a physician-recommended endoscopy and were told they would owe $787 out of pocket rated their likelihood of scheduling it at 2.87 on a 7-point scale. Adults who saw the same scenario with a $0 out-of-pocket bill rated scheduling likelihood at 4.26. In another experiment, adults considering a nerve conduction test were also less willing to book when the full charge landed on them directly, with scheduling ratings of 4.19 versus 5.66. The message from the data is blunt: when the patient is asked to absorb the cost, follow-through weakens.
Financial anxiety became part of the pain pathway
Three online experiments, conducted with U.S. adults recruited through Prolific, tested whether price changes alone could alter both expected pain and the intention to schedule care. The procedures varied — a blood draw, an endoscopy, and a nerve conduction test — but the design stayed constant. Participants saw the same procedure, the same billed price, and the same insurance coverage. The only variable was the out-of-pocket burden, which was either the full billed amount or nothing.
That controlled setup allowed the investigators to separate a direct emotional reaction to paying from the physical expectation tied to the procedure. As the cost rose, participants reported greater discomfort about paying and more financial anxiety. That anxiety then predicted how much pain they expected the procedure to cause. In other words, the mind did not keep payment and bodily pain in separate compartments; financial stress appeared to bleed into the anticipated sensory experience.
For the blood draw experiment, 293 participants saw a billed price of $53. Those facing the charge rated expected pain at 2.03 on a 7-point scale, compared with 1.84 among those told the procedure would cost nothing. The difference did not reach conventional statistical significance. Even so, the pattern fit the broader mechanism observed across the studies: cost first increased the “pain of paying,” then raised financial anxiety, then nudged expected physical pain upward.
The strongest signal appeared when patients had to decide whether to book
The endoscopy experiment sharpened the practical consequence. Unlike the blood draw and nerve conduction test experiments, this one measured whether participants said they were likely to call and schedule the procedure within three days. No pain prediction scale was used here. The endpoint was behavioral intent, and the gap was wide.
A $787 out-of-pocket obligation pulled willingness to schedule down to 2.87. With no out-of-pocket cost, the figure rose to 4.26. For clinicians, that kind of drop matters because recommended procedures often depend on a patient taking one final administrative step after the visit ends. A recommendation is not the same thing as completion. The financial burden sits between those two moments and can break the chain.
The nerve conduction test experiment, involving 391 participants and a billed price of $1,120, showed the same direction of effect. Scheduling likelihood was 4.19 with the out-of-pocket cost and 5.66 without it. Expected pain was 2.51 with the cost and 2.26 without it, although that direct pain comparison also fell short of significance. Once the researchers accounted for the emotional chain linking payment discomfort and financial anxiety to pain expectations, the out-of-pocket effect itself no longer remained independently associated with pain estimates in the blood draw and nerve conduction experiments.
Money stress amplified the hesitation
The third experiment went one step deeper by asking participants how often they felt stressed about money, including whether money worries kept them up at night. That detail turned out to matter. Cost-driven anxiety reduced willingness to schedule across every level of financial stress, but the effect was about twice as large among the most financially stressed participants as among the least stressed.
That finding fits common clinical experience. Patients living with constant financial pressure do not evaluate a procedure in isolation; they evaluate it against rent, groceries, transportation, missed work, and the fear of another bill arriving before the last one is paid. A procedure that is medically sensible on paper can feel more threatening when the bill seems to threaten the rest of a household budget. The emotional burden of payment becomes part of the treatment decision itself.
Cost conversations may change decisions before they harden into refusal
The study’s implications point toward bedside communication, not just pricing policy. Physicians rarely discuss costs with patients, yet the investigators argue that cost conversations could reduce the emotional strain that comes with a high bill. A lower-cost generic drug, a cheaper site for testing, or a payment plan can change how a patient interprets the recommendation before anxiety turns into avoidance.
A concrete example is simple. Prescribing a generic instead of a brand-name drug and explaining the savings may lower the perceived burden enough to keep the patient engaged. The same logic applies to directing patients toward lower-cost testing sites with similar quality or linking them to price comparison tools when blood work can be done at several clinics. These are not abstract communication strategies. They are practical ways to keep a patient from mentally converting a bill into a forecast of physical suffering.
The study also raises questions for hospital price transparency rules. Making prices easier to see could increase financial discomfort and expected pain in settings where there is no cheaper alternative. In more competitive markets, visible price differences could work differently and help patients choose lower-cost options. The effect depends on whether the patient sees a path to savings or only a larger number attached to the same recommendation.
Hypothetical decisions leave important gaps
The experiments were built around imagined procedures, not real ones. Participants had no actual appointment on the calendar, no real bill in hand, and no physical procedure to undergo. The outcomes measured expected pain and stated intent, not completed appointments or pain experienced in a clinical setting. Real-world behavior could diverge from these hypothetical judgments in either direction.
Prior experience with a physician or clinic could blunt the effect of cost on anxiety, while genuine financial pressure could intensify it. The U.S. setting also limits how far the findings can travel across different payment systems. A field study with patients deciding on procedures recommended by their own physicians would provide a stronger test of how much the financial burden changes care-seeking in practice. For now, the evidence shows a clear behavioral pattern: when patients are asked to pay more out of pocket, they become less likely to schedule care and more likely to expect pain from the procedure itself.