Cost vs. compliance: Physicians encouraged to discuss prescriptions

A 45-year-old woman with type 2 diabetes was showing some control of her hemoglobin A1c under the supervision of Virag Y. Shah, MD, but not as much as the Whittier, Calif., family physician would have liked. He decided to add pioglitazone, a thiazolidinedione marketed as Actos, to the patient's armamentarium. The woman's blood sugar levels did not drop after three months, so he upped the dosage. Another three months passed, and still nothing. To the contrary, the woman's glucose levels rose slightly.

"Are you taking the medication?" Dr. Shah remembers asking his patient.

"Not all the time," the woman sheepishly answered.

"How often are you taking it?" he asked. "Once a week? Every other day?"

"Well, less than that," she said.

"You're not really taking it at all," Dr. Shah said.

"Well, that's right," the woman answered.

"Did you fill the prescription?"

"No," she said. "It was going to be $180 a month because it wasn't covered. And I can't afford that."

With this new information, Dr. Shah could act. While there is no generic equivalent for Actos, he was able to start her on an insulin regime.

Unfortunately, the right treatment for Dr. Shah's patient was delayed because he did not initially discuss costs with his patient, and she was reluctant to bring up the matter.

The lesson Dr. Shah took away from this experience -- one borne out by the evidence -- is that patients' out-of-pocket prescription drug costs can play a big role in how well they follow doctors' orders.

Physicians have an obligation to consider costs when prescribing and should save their patients any potential awkwardness by initiating the conversation, Dr. Shah and others say. But while doctors' awareness of the crucial relationship between costs and compliance is widespread, recent studies show that, more often than not, physicians fail to talk with their patients about a major side effect of many of the prescriptions they write -- a dwindling bank account.

A November 2006 American Journal of Managed Care study of 185 Sacramento, Calif.-area audiotaped patient encounters with 44 family physicians, internists and cardiologists found that when writing a new prescription, physicians brought up cost and insurance coverage only 12% of the time. And while doctors would like to believe they can tell who might be having trouble with out-of-pocket drug costs, that is often not the case.

An Aug. 20, 2003, Journal of the American Medical Association study found that for 45 patients with whom doctors had not discussed out-of-pocket costs, physicians were right only half the time in guessing whether the patients had trouble paying for their drugs.

"It's the physician's job to proactively ask questions and probe this issue, just like any sensitive family issue, abuse or depression or anything else," said Dr. Shah, director of the Presbyterian Intercommunity Hospital Family Practice Residency Program. "Patients don't come in with a sign on their foreheads saying, 'I'm financially struggling.' "

Noncompliance adds up

With 16% of patients reporting that they have skipped their meds to save cash during the previous year, studies estimate that medication nonadherence for financial or other reasons costs the health care system $100 billion a year and leads to thousands of serious adverse events or deaths each month.

Out-of-pocket spending now accounts for half the country's prescription drug costs, as insurers have shifted costs onto patients to reduce utilization, and is part of the movement toward consumer-driven health care. Patients often act without their physicians' advice when it comes to cutting back.

And while doctors know the facts, they are reluctant to talk money.

A March 28, 2005, Archives of Internal Medicine survey of 510 primary care physicians and cardiologists found that 92% said doctors should consider patients' out-of-pocket costs when writing prescriptions, and three-quarters agreed they are obligated to initiate the money talk. But only a third of these doctors talked the talk, saying conversation gets cut off due to lack of time, worries about insulting the patient, and ignorance on both sides about what a given drug will wind up costing at the pharmacy.

Richard Kravitz, MD, MSPH, director of the Center for Health Services Research in Primary Care at the University of California, Davis, said concern about offending patients can be mitigated. "Start with a broad question when meeting a new patient, like 'Have you ever had trouble getting medications, or trouble getting reimbursed for medications?' " Dr. Kravitz said. "You need to let the patient take the lead on that."

G. Caleb Alexander, MD, lead author of the 2005 Archives physician/patient survey, said he attempts to make a general statement such as, "Many patients are burdened by out-of-pocket costs and may not take all of their prescribed medications because of this. Is this a problem for you?"

Time in the exam room is short, Dr. Alexander added, so raising the cost issue during every patient visit or before writing any new prescription is "both unrealistic and not the best use of patients' and physicians' valuable time."

The best physicians, he said, "create a climate with patients where they feel more comfortable directly asking about costs." Then, doctors can explore other alternatives such as generic medications, splitting higher-dose pills, reviewing med lists to cut out nonessential or less important drugs, drugmakers' patient assistance programs, referrals to welfare agencies, or doling out samples in a pinch.

AMA ethical opinion says physicians should base their prescribing solely on medical criteria and do their best to secure formulary exceptions for "significantly advantageous drugs" while advocating for adequate health care coverage for all. Failing that, the AMA Code of Medical Ethics says, doctors should offer patients the chance to opt for a more beneficial, albeit more expensive, drug. Doctors also should be aware of drugmakers' marketing efforts in deciding if, when and how to use sample medications, the AMA says.

A big problem is that cost-cutting strategies may be employed only after an unnecessary delay in care or a trip to the hospital because the health system leaves doctors largely in the dark about out-of-pocket charges. Just a third of the physicians in Dr. Alexander's Archives survey, for example, knew how much their patients were spending out of pocket for prescription drugs.

William H. Shrank, MD, of the Brigham and Women's Hospital and the Harvard Medical School in Boston, is a leading researcher on prescription drug formularies.

"We have a system that's incredibly complex, especially when you think about Medicare Part D, where doctors are prescribing from dozens of formularies just for their seniors," Dr. Shrank said. "It is hard to be aware of formulary placement, pharmacy benefit designs, and understand what patients' costs are going to be."

Electronic prescribing systems can reduce the uncertainty and will help doctors as they grow more widespread, Dr. Shrank added. Still, e-prescribing systems can tell a physician whether a drug is on the plan formulary and how it is tiered, but none can yet pinpoint patients' out-of-pocket costs, said Anthony J. Schueth, managing partner of the Florida-based health information technology firm Point-of-Care Partners LLC.

Cost-conscious ethics

Every day, physicians get about five calls from pharmacists about nonformulary prescriptions and 18 a day about "nonpreferred" drugs, according to Dr. Shrank's research. Half the time doctors wind up changing the prescription because of the cost.

Dealing with prescription drug costs, then, is a daily reality for physicians, said UC Davis's Dr. Kravitz. Yet "some doctors still wonder whether understanding and communicating about the economics of medications is part of their job description."

Bringing dollars into the drug-prescribing discussion is still a touchy subject, but Dr. Alexander said it is imperative.

"There's a clinical mandate to discuss costs, and there's an ethical mandate to discuss costs," he said. "Clinical decisions increasingly have implications not only for patients' medical well-being but for their economic well-being.

"I want to work with my patients to help them get the best health care they can get within the constraints of the current system," Dr. Alexander said.