Physician Communication About the Cost and Acquisition of Newly Prescribed Medications

Published Online: November 01, 2006
Derjung M. Tarn, MD, PhD; Debora A. Paterniti, PhD; John Heritage, PhD; Ron D. Hays, PhD; Richard L. Kravitz, MD, MSPH; and Neil S. Wenger, MD, MPH

Objective: To describe the frequency and content of physician discussions about the cost and acquisition of new medications.

Study Design: Qualitative and quantitative study combining patient and physician surveys with transcribed audiotaped office visits from 185 outpatient encounters with 15 family physicians, 18 internists, and 11 cardiologists in 2 Sacramento healthcare systems between January and November 1999, in which 243 new medications were prescribed.

Methods: Transcripts were qualitatively analyzed to describe conversations concerning the cost and acquisition of new medication prescriptions, frequencies of discussions were described, and multivariate logistic regression was used to examine the predictors of cost discussions.

Results: For one third of newly prescribed medications, physicians discussed an aspect of acquisition, including cost and insurance coverage for 12%, logistics of obtaining medications for 18%, and medication supply for 9%. Patients initiated cost or insurance concerns for fewer than 2% of the new medications prescribed. There were 5 discussions about patient out-of-pocket costs and 7 discussions offering tips for cost savings. In multivariate analysis, cost discussions were more likely to occur with patients earning less than $20 000 per year compared with those earning more than $60 000 per year, were less likely to occur with medications prescribed by family physicians or internists compared with cardiologists, and were less likely with medications prescribed to older patients.

Conclusions: Physician-patient discussions about new medication cost and other acquisition issues, especially medication affordability, occur infrequently. Because physicians may not recognize patients' financial impediments to acquiring medications, this issue should be raised when prescribing new medications.

(Am J Manag Care. 2006;12:657-664)


The enormous potential of medicine to cure and treat medical conditions is often unrealized when medications are not obtained or are not taken as directed because of cost or acquisition problems. High medication costs are strongly associated with medication underuse.1-7 One quarter of older patients cite cost as a factor for not taking their medications as prescribed.2 Patients also cite cost as a reason for not filling a new prescription.8 Patients exceeding drug benefit caps often underuse medications for chronic health problems such as hypertension, hyperlipidemia, emphysema, and asthma.6 Inconsistent use of essential medications, often related to increased prescription drug cost-sharing, has been shown to increase drug-related serious adverse events and emergency department visits.9

By physician and patient report, physicians infrequently discuss out-of-pocket costs with patients, despite reported patient desire to converse about the topic.10,11 Clinicians and patients cite discomfort and insufficient time as barriers to discussions.11,12 More discussions about cost are reported by patients who have no insurance,13 who are burdened by out-of-pocket costs,10 or who are seen in a community practice.10 Investigations have examined cost as a barrier to medication use, but only a couple of studies2,8 have examined the actual conversations occurring during physician-patient encounters. Most observational studies14-18 do not comment on discussions of cost or insurance, although some have shown infrequent communication about the cost of new medication prescriptions (in 11% of their sample)19 and antibiotics (in 0.5% of their sample).20

Other organizational factors may affect whether a patient is able to access medications.21,22 For example, patients fail to refill about 33% of antihypertensive medications,23 and patients lacking knowledge about refills or pharmacy contacts were twice as likely to seek refills from emergency departments.24 Although 72% of patients in a subsidized prescription program appropriately obtained medication refills, only 73% of those requesting refills obtained them on time.25 Therefore, conversations about refills may be important when prescribing chronic medications. Physicians in one study15 were observed asking patients about medication supply or quantity for 51% of current, past, or new medications, and physicians in another study17 made a mean of 2.6 statements per visit about supply and uttered a mean of 0.21 statements per encounter about refilling medications. These studies were not specific to new medications, for which patients may need the most instruction.

The actual content and predictors of observed discussions about cost and insurance have not been well explored, and studies of physician-patient encounters have not documented the frequency at which refills or other medication acquisition issues are discussed for new medication prescriptions, to our knowledge. This article examines whether and how physicians conduct discussions about cost when a new medication is prescribed. It also examines the frequency of discussion about medication acquisition. We expected low frequencies of counseling about cost and other acquisition issues but anticipated that discussion contents would cover several cost and insurance issues. We also hypothesized that more cost discussions would occur among patients with lower income levels and with less prescription drug coverage.

METHODS

We analyzed data from the Physician Patient Communication Project, a study of outpatient visits to family physicians, internists, and cardiologists in 2 healthcare systems in Sacramento. The study was originally designed to investigate the relationship between request fulfillment and patient outcomes and was not specific to medications. In this study, 44 physicians were recruited, 21 from Kaiser Permanente (a group-model health maintenance organization with salaried physicians) and 23 from the University of California, Davis Medical Group (a multispecialty group practice with discounted fee-for-service compensation for physicians and salaried specialists). Study participants consisted of 15 family physicians, 18 internists, and 11 cardiologists. One family physician who prescribed no new medications was excluded. The study design was previously described.26 The University of California, Davis Institutional Review Board approved the overall study (protocol 992212), and the University of California, Los Angeles, Institutional Review Board approved this analysis (exemption 04-193).

Patients were recruited between January and November 1999. A research assistant reviewed appointment books 1 to 2 days before patient appointments and randomly sampled and telephoned patients to screen for study eligibility. Patients had to be 18 years or older, speak English, and have a new or worsening problem or be somewhat concerned about their health or about having a potentially serious undiagnosed condition. Of 4560 patients selected for telephone contact, the response rate was 32%; 68% (909 of 1332 eligible patients) of eligible patients were enrolled. Study participants provided informed consent and were compensated $10.

Among 860 of 909 patients enrolled in the study who had their visits successfully audiotaped and transcribed, physicians identified 270 patients as receiving new prescriptions via a postvisit survey. A review of 90 randomly selected transcripts indicated that physicians correctly identified 24 of 25 encounters in which new medications were prescribed. A new medication was defined as one that a patient had never before taken or one that was given for an acute condition or symptom (such as an antibiotic or analgesic). Therefore, medications taken in the past and new prescriptions belonging to the same class as a previously used medication were not included. We identified 185 encounters in which 243 new medications were prescribed.

Patient and Physician Characteristics

Patients provided information about their demographic characteristics, whether they had a prior visit with the physician, and about their out-of-pocket prescription drug costs. Physicians provided demographic information and characteristics of their practice and reported on the number of "old drugs" continued.

Qualitative Analysis

We used 185 transcripts in which new medications were prescribed to develop a coding framework to describe the content of conversations about new medications. Transcripts were reviewed to identify every piece of conversation relating to any newly prescribed medication. Each identified conversational element was assigned a code. The initial coding categories were based on existing literature16,17,20 and on clinical experience, and we used analytic induction to expand the categories in an iterative process until no further codes could be developed. We split, merged, and adjusted the coding categories27,28 until they were mutually exclusive and represented all communication about new prescriptions. Conversation corresponding to themes concerning medication cost and insurance, whether a medication was a generic or brand name drug, logistics of obtaining medication, medication supply (quantity of medication to be dispensed), and medication refills were assigned to relevant codes. Two coders worked together to develop the codes and to ensure reliable implementation. A third coder independently coded 29 (16%) of the transcripts. The overall mean κ was 0.90 (range, 0.79-0.98). A detailed description of the coding framework and its development is given elsewhere.29 ATLAS/ti 4.2 (Thomas Muhr Scientific Software Development, Berlin, Germany) was used to code the transcripts.

Statistical Analysis

Each code developed inductively through qualitative analysis was assigned a variable corresponding to the conversational content. Using new medication prescriptions as the unit of analysis, we constructed a data set of communication behaviors about each new prescription, which allowed us to determine the occurrence of conversations about different themes. STATA 8.0 (StataCorp LP, College Station, Tex) was used to calculate descriptive frequencies of the communication topics by site, physician specialty, general medication class, over-the-counter (OTC) medications, and "as needed" (pro re nata [PRN]) medication status. A summary of any of the 5 acquisition topics was captured as "any acquisition communication." Whether the patient or physician initiated the conversation was also noted.

Medications were classified into general medication classes according to their purpose. Over-the-counter medications are those that a patient can buy without a prescription. However, OTC medications recommended at prescription strength were classified as non-OTC medications because they required more extensive counseling. A PRN medication was one that a physician recommended be taken on an as-needed basis.30 If no verbal recommendation was made during the office visit, a medication was classified as PRN if it was not prescribed for a chronic condition and if it was presumed acceptable for the patient to stop taking it on his or her own without further physician instructions based on the content of the conversation.

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