Patients May Face Sticker Shock on New Prescriptions

LOS ANGELES, Nov. 10 -- Physicians need to be more sensitive to whether patients can afford to pay for new prescriptions or, indeed, whether patients even know how to go about filling or refilling them.

So found a UCLA team that studied 185 recorded doctor-patient encounters at two health care systems during which there were 243 first-time prescriptions written.

Physicians discussed out-of-pocket costs for the drugs and insurance coverage with only12% of patients, the logistics of filling the prescriptions with only 18%, and how to refill the prescriptions with only 9%, reported Derjung M. Tarn, M.D., and colleagues, in the Nov. 8 issue of the American Journal of Managed Care.

"Because physicians may not recognize patients' financial impediments to acquiring medications, this issue should be raised when prescribing new medications," they wrote.

They also pointed out that patients fail to refill about 33% of antihypertensive medications, and patients lacking knowledge about refills or pharmacy contacts were twice as likely to seek refills from emergency departments.

The researchers found that physicians discussed drug cost and acquisition less often with older patients (odds ratio 0.57, 95% confidence interval 0.35 to 0.93) but significantly more frequently with low-income patients (OR 8.27 for ,000 versus ,000 per year, 95% CI 1.29 to 52.80).

Although cost discussions are not always necessary, especially if physicians know a patient's financial situation and are familiar with the insurance formulary, Dr. Tarn and colleagues said, these issues can impact patient health through lack of adherence to treatment.

They cited previous studies that have found high medication costs strongly associated with medication underuse, particularly in the elderly, and that patients may not fill a new prescription based on cost.

"It is concerning that older patients received less counseling about cost, because these patients are most likely to be taking multiple medications and to have the most difficulty with financial strain," the authors wrote.

The investigators analyzed data from a larger study of patient-physician communication in which office visits were audiotaped and both patients and physicians completed surveys. The analysis included only the 185 encounters in which prescriptions were written for drugs the patient had never before taken or medications like antibiotics for acute conditions or symptoms.

Participants had a mean age of 55, were primarily white (83%), were nearly all insured (94.1%), and typically paid less than half of their prescription drug costs (77.5%). Thirty-one percent of the patients were seen by 15 family physicians, 47% by 18 internists, and 23% by 11 cardiologists.

The recorded office visits were transcribed and searched for discussion of financial and drug acquisition issues. The researchers reported:

• Twenty-eight total encounters in which physicians discussed cost and insurance issues involving newly prescribed medications,
• Twelve visits that included mention of medication price, half of which referred to dollar amounts and the other half of which referred to medication being expensive,
• Five office visits in which patients were asked about out-of-pocket costs,
• Ten discussions that centered on insurance formulary restrictions,
• Seven encounters during which physicians asked patients what insurance plan they belonged to, and
• Seven discussions that included tips for cost savings, such as "You know, you probably could find it at [pharmacy name] or somewhere cheaper. Shop around."

Patients initiated less than 2% of these conversations (four office visits).

In a multivariate analysis, the investigators found that discussions varied significantly by type of practice. The findings were:

• Cost was significantly less likely to be discussed by family physicians (OR 0.003, 95% CI 0.000 to 0.150) or internists (OR 0.02, 95% CI 0.00 to 0.49) compared with cardiologists.
• Cardiologists had significantly more acquisition communication than family physicians or internists (47% versus 37% and 26%, P<0.05).

The researchers said these differences may be explained by cardiologists' potentially prescribing fewer generic medications. Controlling for length of visit or physician ethnicity did not substantially change the associations.

The study was limited in that it examined single encounters whereas physicians may address these issues in more detail during subsequent visits. Also, it did not examine whether physicians had prior knowledge of a patient's financial situation or knowledge of the patient's drug formulary when prescribing the new medication or whether these discussions were left to office staff.

Furthermore, the findings may not be generalizable to populations with more uninsured patients, those without prescription drug coverage, or those with more racial or ethnic diversity, the researchers noted.

However, they said the findings were similar to those of a Canadian study, suggesting that these issues are not limited to U.S. physicians.

"Discussions about cost and medication acquisition are particularly important because they form the context in which patients obtain their medications," the authors concluded. "Data for this study were collected before the advent of three-tier formulary systems and the Medicare Part D insurance plan, both of which have increased the complexity of medication decision making related to coverage and cost.

"Physician and patient discomfort, along with physician lack of knowledge about how to help patients with medication unaffordability, may be barriers to cost discussions. Interventions should target improving physician knowledge about helping patients achieve affordable medication regimens, as well as stressing the importance of recognizing and addressing cost and acquisition issues with patients."

The study was funded by the Robert Wood Johnson Foundation, the Health Resources Services Administration, and the National Institutes of Health.