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Research Letters | Health Care Reform

Patients' Willingness to Discuss Trade-offs to Lower Their Out-of-Pocket Drug Costs FREE

Chien-Wen Tseng, MD, MPH; Beth E. Waitzfelder, PhD; Edward F. Tierney, MPH; Robert B. Gerzoff, MS; David G. Marrero, PhD; John D. Piette, PhD; Andrew J. Karter, PhD; J. David Curb, MD, MPH; Richard Chung, MD; Carol M. Mangione, MD, MSPH; Jesse C. Crosson, PhD; R. Adams Dudley, MD, MBA
[+] Author Affiliations

Author Affiliations: Pacific Health Research Institute, Honolulu, Hawaii (Drs Tseng, Waitzfelder, and Curb); Departments of Family Medicine and Community Health (Dr Tseng) and Geriatric Medicine (Dr Curb), John A. Burns School of Medicine, University of Hawaii, Honolulu; Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Tierney and Mr Gerzoff); Department of Medicine, Indiana University School of Medicine, Indianapolis (Dr Marrero); Department of Veterans Affairs Center for Practice Management and Outcomes Research and Department of Internal Medicine, University of Michigan, Ann Arbor (Dr Piette); Division of Research, Kaiser Permanente Medical Care Program, Northern California, Oakland (Dr Karter); Hawaii Medical Services Association, Honolulu (Dr Chung); David Geffen School of Medicine and School of Public Health, University of California, Los Angeles (Dr Mangione); Research Division, Department of Family Medicine and Community Health, University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, Somerset, New Jersey (Dr Crosson); and Department of Medicine and Institute for Health Policy Studies, University of California, San Francisco (Dr Dudley).


Arch Intern Med. 2010;170(16):1502-1504. doi:10.1001/archinternmed.2010.287.
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Efforts to reform the US health care system have placed considerable attention on patients' financial burden from out-of-pocket drug costs. Patients frequently have difficulty paying for medications, and although they are encouraged to discuss ways to lower drug costs with physicians, such communication frequently fails to occur.14 Physicians may be reluctant to initiate these cost discussions because some cost-cutting strategies involve potential trade-offs such as increased dosing frequency, risk of adverse effects, or lower treatment effectiveness.1 Knowing patients' willingness to consider such less than optimal cost-lowering strategies could encourage physicians to discuss drug costs with their patients.

We conducted a 2004 patient survey as part of the longitudinal Translating Research Into Action for Diabetes Study to examine diabetes quality of care in 10 health plans and 6 states.5 Participants reported whether they wanted physicians to talk about medications that cost less but (1) had to be taken more often, (2) may have a slightly higher chance effects, or (3) may not work as well.

Of the 5085 patients (CASRO response rate, 75%), two-thirds were willing to discuss at least 1 of the 3 trade-off strategies. Patients said they wanted to be told about lower-cost drugs with a higher chance of adverse effects (38%), lower effectiveness (32%), or higher dosing frequency (59%). Among the 712 participants (14%) who said they had reduced medication use because of cost, rates were 47%, 42%, and 82%, respectively. Even among the 4373 participants who had not reduced medication use because of cost, rates were 37%, 30%, and 56%, respectively. Among those open to discussing trade-offs, only 19% said their physician usually or always discussed drug costs when prescribing. In multivariate analyses, participants with lower income, higher out-of-pocket drug costs, and poorer health were significantly more willing to discuss trade-offs (Table).

Table Graphic Jump LocationTable. Patients' Willingness to Discuss Trade-offs to Lower Out-of-Pocket Drug Costs

To our knowledge, this is the first large-scale study to examine the willingness of patients with diabetes to discuss specific types of trade-offs to lower drug costs with their physicians. The majority wanted physicians to discuss ways to lower drug costs even if it required higher dosing frequency, and 1 in 3 wanted to know about lower-cost drugs with potentially greater adverse effects or lower effectiveness. Importantly, even among participants who did not decrease medication use because of cost, 1 in 4 wanted to know about cost-lowering strategies that could negatively affect health. Our findings are novel in that prior studies have only documented patients' willingness to discuss out-of-pocket drug costs in general and not specific strategies that would require trade-offs.3,4 Physicians may be appropriately reluctant to discuss drug costs when they perceive cost-lowering strategies to be less optimal than patients' current medications.1 However, physicians then risk that patients will reduce medication use to lower costs without telling them or getting their advice.2 The fact that participants with poor (vs good) health were significantly more willing to consider such trade-offs highlights further that physicians need to be actively involved in advising patients on the appropriateness of such trade-offs.

A limitation of our study is that we did not present specific prescribing scenarios or measure patients' actual treatment choice. When faced with real rather than theoretical choices, patients may opt to pay more rather than making any trade-offs. Patients' willingness to make trade-offs may also vary substantially across disease targets.6 However, our results support that patients are at least open to such discussions with physicians.

In conclusion, given patients' financial burden from drug costs and willingness to discuss drug costs, physicians should not avoid initiating such cost discussions, even if the available strategies to lower drug costs could require patients to accept potential trade-offs.

Correspondence: Dr Tseng, Pacific Health Research Institute, c/o Department of Family Medicine and Community Health, University of Hawaii, 677 Ala Moana Blvd, Ste 815, Honolulu, HI 96813 (cwtseng@hawaii.edu).

Author Contributions: Dr Tseng had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Tseng, Marrero, Piette, Curb, Crosson, and Dudley. Acquisition of data: Tseng, Waitzfelder, Gerzoff, Marrero, Piette, Karter, Curb, Chung, and Dudley. Analysis and interpretation of data: Tseng, Tierney, Gerzoff, Marrero, Piette, Curb, Mangione, and Dudley. Drafting of the manuscript: Tseng, Marrero, and Dudley. Critical revision of the manuscript for important intellectual content: Tseng, Waitzfelder, Tierney, Gerzoff, Marrero, Piette, Karter, Curb, Chung, Mangione, Crosson, and Dudley. Statistical analysis: Tseng, Tierney, Gerzoff, and Piette. Obtained funding: Waitzfelder, Karter, and Curb. Administrative, technical, and material support: Waitzfelder, Karter, Curb, Chung, and Crosson. Study supervision: Tseng, Curb, Mangione, and Dudley.

Financial Disclosure: None reported.

Funding/Support: This study was jointly funded by Program Announcement No. 04005 from the Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases.

Additional Contributions: We acknowledge the participation of our health plan partners. Significant contributions to this study were made by members of the Translating Research into Action for Diabetes (TRIAD) Study Group.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the opinions of the funding organizations.

Alexander  GCCasalino  LPTseng  CW McFadden  DMeltzer  DO Barriers to patient-physician communication about out-of-pocket costs. J Gen Intern Med 2004;19 (8) 856- 860
PubMed Link to Article
Piette  JDHeisler  MWagner  TH Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Arch Intern Med 2004;164 (16) 1749- 1755
PubMed Link to Article
Alexander  GCCasalino  LPMeltzer  DO Patient-physician communication about out-of-pocket costs. JAMA 2003;290 (7) 953- 958
PubMed Link to Article
Tseng  CWDudley  RABrook  RH  et al.  Elderly patients' preferences and experiences with providers in managing their drug costs. J Am Geriatr Soc 2007;55 (12) 1974- 1980
PubMed Link to Article
Tseng  CWTierney  EFGerzoff  RB  et al.  Race/ethnicity and economic differences in cost-related medication underuse among insured adults with diabetes: the Translating Research Into Action for Diabetes Study. Diabetes Care 2008;31 (2) 261- 266
PubMed Link to Article
Goldman  DPJoyce  GFEscarce  JJ  et al.  Pharmacy benefits and the use of drugs by the chronically ill. JAMA 2004;291 (19) 2344- 2350
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable. Patients' Willingness to Discuss Trade-offs to Lower Out-of-Pocket Drug Costs

References

Alexander  GCCasalino  LPTseng  CW McFadden  DMeltzer  DO Barriers to patient-physician communication about out-of-pocket costs. J Gen Intern Med 2004;19 (8) 856- 860
PubMed Link to Article
Piette  JDHeisler  MWagner  TH Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Arch Intern Med 2004;164 (16) 1749- 1755
PubMed Link to Article
Alexander  GCCasalino  LPMeltzer  DO Patient-physician communication about out-of-pocket costs. JAMA 2003;290 (7) 953- 958
PubMed Link to Article
Tseng  CWDudley  RABrook  RH  et al.  Elderly patients' preferences and experiences with providers in managing their drug costs. J Am Geriatr Soc 2007;55 (12) 1974- 1980
PubMed Link to Article
Tseng  CWTierney  EFGerzoff  RB  et al.  Race/ethnicity and economic differences in cost-related medication underuse among insured adults with diabetes: the Translating Research Into Action for Diabetes Study. Diabetes Care 2008;31 (2) 261- 266
PubMed Link to Article
Goldman  DPJoyce  GFEscarce  JJ  et al.  Pharmacy benefits and the use of drugs by the chronically ill. JAMA 2004;291 (19) 2344- 2350
PubMed Link to Article

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