Doctors mindful of patients' out-of-pocket drug costs

Although a recent study found more than one-third of physicians did not discuss out-of-pocket costs of prescription drugs with patients, the report's lead author agrees with others who say there is a growing awareness and that change already is taking place among doctors.

According to the study, published in the March 28 Archives of Internal Medicine, nearly 93% of the 519 internists and cardiologists who responded to a survey said that they know prescription costs can be a financial hardship for some patients.

Only slightly more than a third were aware of the extent of the hardship. But the report indicated there was potential that more doctors will become cognizant of their patients' economic challenges, with 75.2% of the responding physicians saying they believed they had an obligation to initiate conversations on drug costs.

"The most important finding is that a considerable proportion of physicians are entirely engaged in this issue," said the study's lead author G. Caleb Alexander, MD, an instructor in medicine and affiliate faculty member of the MacLean Center for Medical Ethics at the University of Chicago.

"I believe increasing awareness of the burden that many patients face will create a 'tension for change' that will, ultimately, facilitate doctors and patients working together to address these issues," he said.

American Medical Association Trustee Edward L. Langston, MD, said that prescription drug costs get addressed every day at his practice in Lafayette, Ind.

Dr. Langston, a family physician, keeps a list on his handheld computer of which health plans cover which drugs. After writing a prescription, he doesn't hesitate to ask the patient "Are you going to be able to get this?"

Bruce Bagley, MD, medical director for quality improvement at the American Academy of Family Physicians, said doctors are recognizing that prescription drug costs have become a "side effect" of the medications they prescribe. "Cost is just as powerful as any other side effect, maybe more so in some cases," he said. "If you can't afford it, you aren't going to take it."

Once costs are addressed, Dr. Bagley said patients become relieved and are better able to focus on what he's telling them about their health and treatment options.

"Sometimes the cost of the medicine is so much on their minds that they don't hear the message about how important it is to take it," Dr. Bagley said.

If physicians are too uncomfortable in bringing up the subject, Dr. Bagley suggested hanging a sign that reads: "I'm open to discussing the cost of your medication" and that helps empower patients to start the conversation themselves.

"Usually, they are thankful to have the discussion because they're embarrassed," he said.

"Who wants to bring it up that they don't have $10 to pay the co-pay?"

Doctors who took part in the Archives of Internal Medicine study cited a lack of time, patient discomfort, a lack of being able to offer a solution, and their own discomfort as barriers to discussing the issue.

But once physicians broach the sensitive issue, the study found that several strategies are used in attempts to lower a patient's out-of-pocket costs. Cost-cutting strategies included using generic drugs, offering free samples, splitting high-dose tablets and evaluating whether some prescriptions can be discontinued.

"I was somewhat surprised that the second-most common strategy physicians reported using was giving office samples," Dr. Alexander said. "There is considerable debate about the practice. It's a complicated issue, and people will argue about it until the cows come home

Drs. Bagley and Langston are split on the issue.

"Samples, in the big picture, make things worse," Dr. Bagley said. But Dr. Langston said that if he has samples of a drug that a patient needs but can't afford, he doesn't hesitate to offer them.

"The criticism for sampling is that, if you only use samples, are you overlooking other alternatives?" Dr. Langston said. "I use a lot of samples and I use a lot of generic medicines. You just try to get what your patients need in any way feasible."

Jettison the unnecessary

All three doctors agreed that doing away with what patients don't need may be the best strategy for addressing physical and financial health.

"There are few better ways [to reduce out-of-pocket expenses] than to stop a medication that is not needed," Dr. Alexander said.

Dr. Bagley said patients also are more open to discussing changes in diet and lifestyle if it may make some of their prescriptions unnecessary.

"That's when you can tell them 'If you stop drinking coffee, smoking cigarettes and eating buffalo wings, you'll probably be OK,' " he said. "But we should be doing that with everybody -- not just people who can't afford prescriptions, and not just for cost, but for side effects and interactions, too."

The three also agreed that most drug company assistance programs are not that useful because there are too many "hurdles and hassles" for their patients to navigate.

"They can be very cumbersome, but if I can plug someone into one, I certainly will," said Dr. Langston, who added that drugmakers will sometimes listen to constructive criticism. "I told one company 'You've created a barrier to access. These people have enough problems, and I'm just telling you your program is not that helpful,' " he said. "And they changed their program."