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

Efforts to reform the U.S. 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.^1-4 Physicians may be reluctant to initiate these cost discussions because some cost-cutting strategies involve potential trade-offs such as increased dosing frequency, or risk of side 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.

Methods

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 six states.⁵ Participants reported whether they wanted physicians to talk about medications that cost less but a) had to be taken more often, b) may have a slightly higher chance of side effects, or c) may not work as well.

Results

Of the 5,085 patients (CASRO response rate 75%), two-thirds were willing to discuss at least one of the three trade-off strategies. Patients said they wanted to be told about lower cost drugs with higher chance of side-effects (38%), or 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 4,373 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 1).

Table 1.

Patients’ willingness to discuss trade-offs to lower out-of-pocket drug costs (Adjusted Predicted Percents)^* 1 of 2

	Higher dosing frequency		Higher risk of side effects		Lower effectiveness
Age
18-44 (reference)	63%	0.73	39%	0.99	31%	0.83
45-64	61%		39%		31%
65+	62%		39%		33%
Gender
Female (reference)	63%	0.06	36%	<.01	30%	0.02
Male	60%		42%		34%
Ethnicity
White (reference)	62%	0.33	38%	0.02	27%	<.01
African American	60%		38%		38%
Latino	58%		34%		30%
Asian/Pacific Islander	64%		44%		38%
Other	63%		46%		37%
Education
< High school	60%	0.19	40%	0.82	33%	0.49
High school graduate	60%		38%		38%
Some college or higher (reference)	63%		39%		31%
Annual household income
< $25,000	64%	<.01	41%	<.01	34%	0.02
$25,000 to $50,000	63%		42%		35%
>$50,000 (reference)	57%		34%		28%
Health status
Excellent/very good (reference)	55%	<.01	35%	0.04	29%	0.049
Good	63%		39%		32%
Fair/poor	63%		41%		34%
Number of prescription medications
1-5 medications (reference)	61%	0.42	40%	0.31	32%	0.63
6 or more medications	63%		38%		32%
Has prescription drug insurance
Yes	61%	0.18	38%	0.23	31%	<.01
No (reference)	63%		41%		36%
Out-of-pocket drug costs (per month)
$50 (reference)	55%	<.01	38%	<.01	32%	0.08
$51 to $100	61%		36%		29%
$101 to $150	68%		42%		33%
> $150	77%		46%		37%

^*Adjusted for age, gender, race/ethnicity, education, income, health status, number of medications, have drug insurance, and monthly out-of-pocket drug costs

Discussion

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 side-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 patients reducing medication use to lower costs without telling their physicians’ 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 tradeoffs may also vary substantially across disease targets.⁶ However, our results support that patients are at least open to such discussions with physicians.

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.