Money conversations are some of the most difficult. They require an openness and vulnerability that many people struggle to show with their family and friends, let alone their physician. 

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Higher deductibles and premiums, coinsurance and frequent copayments — Americans are paying more for their health coverage now than in the past decade, according to the Commonwealth Fund. And these costs are leading Americans to make dangerous sacrifices. The number of people putting off medical treatments due to cost has been climbing since Gallup began asking about it in 2001. In fact, in 2014, 34 percent of insured and 57 percent of uninsured adults said they had delayed or skipped medical care because of cost concerns.

Patients and doctors want to talk about money

“I think clinicians are aware that many of their patients are burdened but have a hard time identifying which patients are burdened,” says Caleb Alexander, co-director at the Johns Hopkins Center for Drug Safety and Effectiveness.

In 2003, Alexander led a study published in the Journal of the American Medical Association that found 63 percent of patients wanted to discuss costs with their doctors, and 79 percent of doctors believed their patients wanted to have these conversations. Despite this, the conversations were rare, something Alexander says hasn’t likely changed.

“Most (physician) trainees do not leave medical school or residencies well equipped to talk with patients about the cost of care,” Alexander says. There are several reasons these conversations are difficult, he says: “Patients may be concerned the quality of their care will be compromised, both patients and physicians may be embarrassed talking about costs, and all too often, clinicians are unaware of the cost of treatments they prescribe or recommend.”

‘Financial toxicity’ a dangerous side effect

A physician-directed 2013 paper in the New England Journal of Medicine strongly recommended that doctors treat costs as a potentially dangerous side effect of some treatments. This “financial toxicity” could, after all, lead to skipped medications and disastrous health outcomes.

“Because treatments can be ‘financially toxic,’” the paper reads, “imposing out-of-pocket costs that may impair patients' well-being, we contend that physicians need to disclose the financial consequences of treatment alternatives just as they inform patients about treatments' side effects.”

Having the conversation

Until doctors routinely ask patients about their ability to pay, the responsibility to bring up the subject rests with patients. No matter how uncomfortable money conversations might seem, you are the one who stands to struggle with high medical bills, potentially forced to make dangerous sacrifices.

READ MORE: Have a High Medical Bill? Here’s How to Negotiate It Down

Your doctor is used to difficult, personal conversations. People go to their physicians with some of the most embarrassing symptoms and disclosures. Keeping this in mind when you need to talk money can put things in perspective.

Here are 4 tips for talking to your doctor about money:

1. Be frank.

There is no need to sugar-coat your concerns. If you can’t afford an additional $50 in monthly prescription costs, say so. Beating around the bush or making your situation seem less serious in an effort to save face only stands to hurt you in the long-run.

READ MORE: How an FSA Could Help You Save On Medical Costs

2. Discuss alternatives, and don’t be afraid to ask about potential outcome differences.

Whether it’s prescription drugs or an operation, there are often more affordable treatment alternatives available. One obvious concern here is any potential differences in health outcomes. Ask your doctor if there is any downside to opting for a less expensive alternative, and discuss how the two of you can work to mitigate those drawbacks.

3. Ask for samples or information on drug assistance programs.

If you are concerned about drug costs, ask whether your doctor has samples, whether there is a cheaper therapeutic alternative or generic version of the drug available, or whether your doctor can put you in contact with a drug assistance program that could reduce or eliminate your monthly prescription costs.

READ MORE: This Guide Can Help You Save on Prescription Drug Costs

4. If your doctor doesn’t have the answers, work together to get them.

Doctors often simply don’t know the costs associated with medical treatments and drugs, particularly when nuanced insurance plans come into play. Working together with the doctor, the billing office and possibly your insurance company will help you get the most accurate information and estimates on your out-of-pocket responsibilities.

Talking about money doesn’t come easy, but these conversations are increasingly necessary, Alexander says. “The more that patients can identify concerns when they’re present and bring them to the attention of clinicians, the better-functioning the health care team will be.”