The findings of this study demonstrate that less than one in four over-indebted individuals ever discussed financial problems in general practice. Even among those who reported high subjective financial distress or cost-related medication nonadherence, less than one in three talked with their GP about financial issues.
In line with previous research on patient-physician communication about financial problems [27, 31, 33–35, 40, 42, 55], these results reflect a considerable communication gap among over-indebted individuals. Opportunities to discuss financial problems in general practice might have been missed by both patients and general practitioners. Previous studies suggested that reasons why patients do not talk about financial problems in general practice may relate to individuals’ preferences and abilities to communicate as well as their expectations of the patient-physician relationship and prior experiences [38, 42, 43, 56, 57]. Some patients may not disclose financial problems to their GP if they seek advice from other medical or social services such as debt advice agencies instead. General practitioners may also fail to initiate such conversations due to time constraints and competing demands, discomfort or perceived lack of knowledge about solutions to patients’ financial problems [56, 58, 59].
Although all participants in the present study were considered over-indebted, there were significant variations in patient-physician communication about financial problems by specific patient characteristics.
Over-indebtedness may affect any individual across the socioeconomic spectrum . However, experiences of loss of status, stigmatization and feelings of shame that can arise from ongoing over-indebtedness  possibly hamper patient-physician communication. Such experiences might be particularly distressing for individuals with a high educational level, and in turn reflect a barrier to communication about financial problems with their general practitioner. Likewise, cultural variations in the perception of debt-related worries, shame as well as expectations of the patient-physician relationship might contribute to the significant differences in patient-physician communication about financial problems by ethnic origin [48, 53].
Moreover, this study found an association between chronic disease as well as subjective financial distress and cutting on necessities to pay for medications in the last 12 months, and patient-physician communication about financial problems after adjustment. Patients who are chronically ill may be more likely to discuss their financial problems linked to continuity of care as well as co-payments for necessary medical services. In Germany, about 90 percent of the population is enrolled in statutory health insurance which enables adults to apply for reimbursement or waiver of co-payments that exceed two percent of the annual household income. When a physician attests a chronic condition, this ceiling can be reduced to one percent (§ 62 German Social Code Book V). High self-reported subjective financial stress and cutting on necessities to pay for medications might reflect the severity of financial problems on the one hand, and individuals’ willingness to disclose and proactively deal with their financial problems on the other hand.
An encouraging finding is that some over-indebted patient groups that possibly bear a particularly heavy burden regarding their health status and financial distress are more likely to communicate about their financial problems with their general practitioner. The predictors of patient-physician communication in general practice identified in the present study were in line with several prior patient surveys [35, 40, 41]. However, most previous research has examined patient-physician communication about financial problems in diverse US patient groups whereas this is the first explorative study to provide insights into such communication in a population of over-indebted individuals in Germany. Thus, the findings warrant further research to draw conclusions about underlying reasons for differences in communication about financial problems within the over-indebted population.
This study has several limitations. First, data on patient-physician communication about financial problems was self-reported. Thus, data might be subject to recall or social desirability bias and differ from actual behaviour. Second, those who visit a debt advice agency to seek help might be less likely to seek additional advice from their GP. Therefore, the prevalence of patient-physician communication in the over-indebted population could be underestimated. Likewise, individuals who disclosed communicating about their financial situation with their general practitioner might have been more likely to participate in the study to communicate about their debt-related health problems. Moreover, only patients who had reported having a regular general practitioner were subsequently asked about their communication with their GP. Due to the latter aspects, the prevalence of conversations about financial distress by the over-indebted in the primary care setting might be overestimated. However, this selection bias can be assumed to have a minor effect on results of multiple regression analysis.
Third, on the basis of the available data, it is not possible to identify reasons why patients or general practitioners chose (not) to discuss financial problems but previous studies have addressed this issue [35, 38, 58]. Prior studies identified various strategies used during consultation to deal with health-related expenses in general practice [29, 62]. It remains to be established to what extent the conversations examined in the present study reflect an effective pathway for over-indebted patients and their general practitioners to enhance health outcomes and course of treatment, or to address the overall causes and consequences of financial problems.
Several methodological limitations and country-specific legal consequences of over-indebtedness limit the generalizability of our findings. Nevertheless, the present study reveals a need to raise awareness of patients’ financial problems among relevant stakeholders throughout Germany. These findings may also apply to similar health and legal systems because any over-indebted individual can be considered at increased risk of illness and may experience limited access to health care.