Priceless Knowledge: Attitudes and Awareness Around Drug Pricing Among US Medical Students

Abstract

High US drug costs have garnered increasing attention, with multiple proposed reforms. While physicians are key stakeholders, medical education about drug pricing is not described, and medical students’ understanding and attitudes are poorly understood. To assess students’ awareness of drug pricing and its determinants, the authors conducted a cross-sectional, web-based survey of US medical students. Survey items included attitudes and knowledge around drug pricing and relevant education received (e.g., importance, quantity/quality of instruction). A composite knowledge score summed correct responses to 10 knowledge items. Descriptive statistics and t tests were used to evaluate associations. Among 815 viewers of the survey invitation, 361 visited the survey and 240 completed it (view rate 44%; participation rate 77%; completion rate 87%). Most participants were white (62%), in MD programs (82%), and female (53%). Nearly all (> 99%) said it was somewhat or very important to understand factors influencing drug pricing; over 90% were interested in learning more. Among year 3–4 students (n = 108), 59% reported receiving medical school instruction on pricing; few rated the quantity as adequate (7%) or the quality as excellent (3%) or good (8%). Among 10 knowledge questions, the median correct score was 6. Fewer than half (44%) knew that prices are uncorrelated with research/development costs. Knowledge was associated with year in school (p = 0.011) but not reported instructional quality or quantity. In sum, medical students report interest in drug pricing but inadequate instruction, and their knowledge is incomplete. Enhanced education is needed to equip future doctors to advocate effectively for patients around drug prices.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-020-01190-x.

Introduction

In recent years, increasing attention has focused on high and rising drug prices in the USA, with broad concern for the impact on patients. Nearly 30% of American adults have skipped medication because of cost, and one-quarter of those taking prescription drugs report difficulty affording medication [17]. Numerous policy solutions from across the political spectrum have been proposed [16], but little progress is apparent.

Physicians are key players in the drug ecosystem, both as prescribers and as advocates for patients. Professional societies, including the American Medical Association (AMA) [2], the American College of Physicians (ACP) [6], and others, have highlighted the problem of high drug prices and advocated for policy reforms, and the issue has spurred some practicing physicians toward activism [5]. However, most attention to the problem by the medical profession aims to foster cost-conscious prescribing by raising physician awareness of individual product prices [1]. To effectively advocate for patients and contribute to policy solutions, physicians must also understand the complex drivers of high prices.

Educating medical students about the determinants of drug prices is particularly crucial to ensuring robust physician advocacy in the future. Yet little is known about students’ understanding of or interest in this topic, or the extent to which medical schools are preparing the next generation of physicians to meaningfully address this critical problem. We thus sought to assess student attitudes toward and knowledge of drug pricing, as well as their exposure to relevant instruction in medical school. We hypothesized that student interest in drug pricing would be high but that knowledge would be lacking.

Methods

Survey Administration

We conducted a cross-sectional, web-based survey of US medical students. Participants were recruited from Student Doctor Network (SDN), a non-profit, online forum for current and future healthcare students and professionals. The survey link was posted on a blog post on the SDN website. SDN distributed the post to self-identified medical students who had previously opted to receive SDN emails. SDN also featured it on the SDN homepage, forums for allopathic and osteopathic medical students, and SDN’s Facebook and Twitter pages. The survey was anonymous, but responders could opt to provide their email address to enter a lottery for 1 of 20 $100 gift cards.

The survey launched on August 13, 2019, and closed on October 15, 2019. Responses were collected and managed using Research Electronic Data Capture (REDCap), a secure, web-based software platform hosted at Memorial Sloan Kettering (MSK) [12, 13]. Our findings are reported according to the Checklist for Reporting Results of Internet E-Surveys [9] (Supplemental Digital Appendix 1).

Survey Instrument

We adapted some survey items from prior studies and developed additional, novel questions focusing on study objectives [3, 11]. A response to each question was required in order to proceed to the next. The survey included demographic items and several measures addressing attitudes toward and understanding of drug pricing, including importance, self-assessed knowledge, and quantity and quality of related instruction in medical school (Supplemental Digital Appendix 2). Response options included Likert scales for agreement (strongly agree, agree, disagree, strongly disagree) and importance (very important, somewhat important, not important). Ten additional questions tested knowledge of drug pricing facts; 8 were true/false, and 2 were multiple choice (Supplemental Digital Appendix 2). Two other items prompted participants to characterize the influence of various groups and issues on the prices of new drugs. For these, participants were asked to identify up to 5 “most influential” groups/issues and to indicate whether the remaining groups/issues were somewhat or not influential (Supplemental Digital Appendix 2). All knowledge measures were developed in consultation with drug pricing experts (AK and Peter Bach). We piloted a preliminary version of the survey with 15 medical students and internal medicine residents at Weill Cornell Medical Center and made minor changes to the survey based on their feedback and responses.

Analysis

We used descriptive statistics to summarize participant demographics, attitudes, and knowledge. We used census zones to determine geographic region of participants’ schools (Midwest Region, Northeast Region, South Region, and West Region). We created a composite knowledge score for each participant by summing the number of correct responses to the 10 true/false and multiple-choice questions. We dichotimized knowledge scores by their relationship to the mean and median (greater than vs. equal to or less than) and used t tests to evaluate associations with self-reported quality and quantity of relevant instruction. The study was reviewed by the Memorial Sloan Kettering Cancer Center Institutional Review Board and deemed exempt.

Results

There were 815 visitors to the SDN blog linked to the survey. Three hundred sixty-one unique individuals accessed the survey link, and 356 completed the first page to determine eligibility (based on attendance at an accredited US medical school). Of 277 eligible participants, 240 completed the survey (view rate 44%; participation rate 77%; completion rate 87%) [9] (Supplemental Digital Appendix 1).

Participant characteristics are shown in Table 1 and Supplemental Digital Appendix 2. Eighty-three percent of participants were enrolled in MD programs. The majority were 25–34 years old (63%), about half were women (53%), and most (62%) were white. Participant gender and race were similar to characteristics of US medical students overall [10]. All years of medical school were represented, with slight overrepresentation of first-year students. All geographic regions were represented.

Table 1.

Characteristics of study participants (N = 240)

		N (%)
Year in medical school	1	80 (33)
	2	52 (22)
	3	57 (24)
	4+	51 (21)
Age (years)	18–24	82 (34)
	25–34	150 (62.5)
	35–44	7 (2.9)
	45+	1 (0.4)
Gender	Male	112 (47)
	Female	127 (53)
	Non-binary	1 (0.4)
Racea	American Indian or Alaska Native	3 (1.3)
	Asian	68 (28.3)
	Black or African American	17 (7.1)
	Native Hawaiian or other Pacific Islander	1 (0.4)
	White	149 (62.1)
	Other	16 (6.7)
Hispanic, Latino, or Spanish	Yes	22 (9)
	No	218 (91)
Degree program	MD	197 (82)
	DO	31 (13)
	MD/PhD	3 (1.2)
	MD/MPH	4 (1.6)
	MD/MS	5 (2.1)
Geographic region of participant school	Midwest Region	28 (12)
	Northeast Region	127 (53)
	South Region	29 (12)
	West Region	54 (23)
	Puerto Rico and Caribbean	3 (0.8)
Anticipated future field	Primary care	48 (20)
	Non-primary care clinical	147 (61)
	Non-clinical	4 (1.6)
	Undecided	41 (17)

^aParticipants were asked to check all that apply; do not sum to 100%

Nearly all participants (> 99%) believed that it is very or somewhat important to understand factors influencing drug pricing; 57.5% indicated that it is very important, with no differences by gender or anticipated future field. Nearly half (46%) rated their current understanding of these factors as fair; 24% rated it as poor, 28% as good, and 3% as excellent. Most indicated interest in learning more about how drug prices are determined (87%) and potential solutions to high prices (87%). Among third- and fourth-year students (n = 108), 44 (41%) reported receiving no medical school instruction related to drug pricing, most reported an inadequate quantity of instruction (52%), and many characterized the quality of instruction as fair (21%) or poor (23%).

Knowledge of drug pricing was inconsistent. Among 8 true/false questions (Supplemental Digital Appendix 2), only 5 were answered correctly by a majority of participants (Table 2). Nearly all participants (95%) knew that drug prices in the USA are NOT the same as those in other developed countries. Most also understood that US prices are rising faster than inflation (85%) and are uncorrelated with effectiveness (83%). However, fewer than one-third knew that physicians administering intravenous drugs in clinics do not receive higher payments for using lower-priced, more cost-effective drugs, and fewer than half (44%) understood that prices are uncorrelated with research and development (R&D) costs. Very few (15–16%) participants correctly identified the proportions of brand-name prescriptions and spending in the USA. Notably, the majority (54% and 56%) responded “don’t know” to these 2 questions.

Table 2.

Responses to true/false knowledge items

	True N (%)	False N (%)	Don’t know N (%)
Drug prices in the USA are about the same as prices in other developed countries.	2 (1.0)	228 (94.7)	10 (4.2)
Drug PRICES in the USA are rising faster than inflation.	204 (84.8)	5 (2.1)	31 (12.9)
US drug SPENDING is rising less than other health care spending.	28 (11.9)	137 (56.8)	75 (31.3)
Drug prices are NOT correlated with effectiveness.	199 (82.7)	10 (4.1)	31 (12.9)
Drug prices are correlated with research and development costs.	92 (38.3)	106 (44.0)	42 (17.5)
The rise in US drug SPENDING is driven more by increased utilization than by higher prices.	24 (9.9)	146 (60.5)	70 (29.2)
Drugs with higher retail prices always cost health plans more than drugs with lower retail prices.	30 (12.8)	114 (46.9)	96 (40.0)
When administering intravenous drugs to patients in clinics, physicians receive higher payments from insurers if they use lower-priced, more cost-effective drugs.	39 (16.1)	79 (32.5)	122 (50.1)

Italic emphasis indicates correct responses, as determined by content experts

Summing participants’ correct responses to the 10 knowledge questions (including the items in Table 2), composite knowledge scores ranged from 0 to 9, with a median of 6.0 and mean of 5.7. Median, but not mean, scores correlated to year in medical school (p = 0.011), with 43% of fourth-year and 53% of third-year students scoring above the median, compared to 26% of first-year and 33% of second-year students. Composite knowledge scores were uncorrelated with self-assessed quality or quantity of drug pricing instruction in medical school.

Participants’ knowledge of groups and issues influencing the prices of new drugs was mixed. In rating the influence of different groups, most participants correctly identified pharmaceutical (94%) and insurance (85%) companies as among the most influential, but only 36% so identified pharmacy benefit managers. Many participants inaccurately identified the Food and Drug Administration and fictitious “international pricing committees” as most or somewhat influential. In rating the influence of various issues, 58% of participants correctly identified insurance companies’ policies as among the most influential; fewer participants rightly identified rarity of disease/condition and government regulations as most influential (41% and 28%, respectively) (Table 3). Two-thirds (67%) incorrectly selected R&D costs as most influential, and 42% erroneously believed that the cost of marketing to consumers was most influential. Only one-third (32%) knew that drug safety and effectiveness were not influential (Table 4).

Table 3.

Assessments of the influence of different groups on the price of a new drug (italic emphasis indicates correct responses, as determined by content experts)

	Most influential N (%)	Somewhat influential N (%)	Not influential N (%)	Don’t know N (%)
Drug companies	226 (94.17)	5 (2.08)	0	9 (3.75)
Insurance companies	205 (85.42)	20 (8.33)	5 (2.08)	10 (4.17)
Pharmacy benefit managers	85 (35.42)	87 (36.25)	29 (12.08)	39 (16.25)
Medicare/Medicaid	111 (46.25)	86 (35.83)	22 (9.17)	21 (8.75)
Pharmacies	69 (28.75)	100 (41.67)	50 (20.83)	21 (8.75)
Congress	62 (25.83)	116 (48.33)	38 (15.83)	24 (10.00)
Wholesalers	60 (25.00)	116 (48.33)	24 (10.00)	40 (16.67)
Hospitals/clinics	44 (18.33)	108 (45.00)	68 (28.33)	20 (8.33)
Patient advocacy groups	6 (2.50)	99 (41.25)	104 (43.33)	31 (12.92)
International pricing committees	56 (23.33)	112 (46.67)	36 (15.00)	36 (15.00)
Food and Drug Administration	50 (20.83)	85 (35.42)	81 (33.75)	24 (10.00)
National Institutes of Health	13 (5.42)	84 (35.00)	112 (46.67)	31 (12.92)
Professional medical societies	10 (4.17)	108 (45.00)	91 (37.92)	31 (12.92)
Private practices	6 (2.50)	72 (30.00)	133 (55.42)	29 (12.08)

Table 4.

Assessments of the influence of different issues on the price of a new drug (italic emphasis indicates correct responses, as determined by content experts)

Issue	Most influential N (%)	Somewhat influential N (%)	Not influential N (%)	Don’t know N (%)
Insurance company policies	139 (57.92)	86 (35.83)	5 (2.08)	10 (4.17)
Rarity of the disease/condition	100 (41.67)	107 (44.58)	13 (5.42)	20 (8.33)
Government regulations	67 (27.92)	131 (54.58)	22 (9.17)	20 (8.33)
Number of other drugs for the disease/condition	101 (42.08)	108 (45.00)	16 (6.67)	15 (6.25)
Middlemen in the drug distribution system	98 (40.83)	107 (44.58)	10 (4.17)	25 (10.42)
Novelty of the drug’s mechanism	72 (30.00)	104 (43.33)	42 (17.50)	22 (9.17)
Financial incentives of healthcare providers	43 (17.92)	120 (50.00)	48 (20.00)	29 (12.08)
Cost of the drug’s development	162 (67.50)	65 (27.08)	5 (2.08)	8 (3.33)
Cost of marketing to consumers	102 (42.50)	111 (46.25)	13 (5.42)	14 (5.83)
Consumer demand	87 (36.25)	108 (45.00)	31 (12.92)	14 (5.83)
Cost of marketing to doctors	65 (27.08)	131 (54.58)	29 (12.08)	15 (6.25)
Population burden of the disease/condition	46 (19.17)	141 (58.75)	31 (12.92)	22 (9.17)
Safety and effectiveness of the drug	22 (9.17)	118 (49.17)	76 (31.67)	24 (10.00)
Safety and effectiveness of other drugs for the disease/condition	15 (6.25)	135 (56.25)	66 (27.50)	24 (10.00)

Discussion

Our survey suggests that US medical students are keenly interested in understanding drug pricing, with most participants reporting a need for more instruction around this issue. Few rated their knowledge as good or excellent, and high rates of incorrect and “don’t know” responses to many knowledge questions suggest ample room for improvement. For instance, while 60% of participants knew that rising drug spending in the USA is driven not by high utilization but by high prices, the remainder provided incorrect or “don’t know” responses to this question. Similarly, more than half answered incorrectly or “don’t know” to the question about the relationship between retail prices and costs to health plans, and two-thirds provided incorrect or “don’t know” answers to the question concerning physician reimbursement for high- versus low-cost intravenous drugs. While median composite knowledge scores correlated with year in school, mean scores did not, suggesting a weak correlation at best; there may be some formal or informal education in medical school around these issues, but it appears to be inadequate.

Our findings also suggest that, while medical students understand the broad strokes of the problem of high drug prices, their understanding of more nuanced issues is often lacking. Participants’ knowledge of the determinants of new drugs’ prices is particularly noteworthy in this regard. For example, the large majority of medical students in our study knew that drug companies and insurers strongly influence pricing. However, responses related to wholesalers, pharmacy benefit managers, hospitals/clinics, and pharmacies suggest confusion about the importance of other major players in the drug ecosystem [18, 19]. Further, the estimated influence of these groups was similar to that of “international pricing committees,” a fictional entity. Similarly, only one-third of participants were aware that drug safety and effectiveness are not influential on price. And many mistakenly believed that consumer demand and the costs of marketing to physicians are influential, revealing additional, widespread knowledge gaps.

Misconceptions about the influence of R&D costs on prices merit specific discussion. Industry representatives often claim that R&D investments drive and justify high prices, suggesting lower prices would impede innovation [7, 16]. Illustrating the pervasive influence of this notion, nearly all participants in our study believed that R&D costs are at least somewhat influential on price, with over two-thirds selecting it as among the 5 most influential issues. Indeed, participants rated the influence of R&D costs highest among all issues (Table 4). Yet, in fact, R&D costs correlate poorly with prices, and the claim that such costs justify exorbitant prices has been broadly questioned and is at best overstated [15, 20, 21]. Nonetheless, our findings indicate that many medical students believe this dubious claim, suggesting the need for focused education. It may be beneficial to introduce students to drug pricing issues during their undergraduate medical education, followed by more intensive instruction in graduate medical education.

This study has some limitations. First, data on the quality and quantity of instruction were self-reported; participants may not have accurately characterized their schools’ efforts to educate them about drug pricing and its determinants. More, participants represented a convenience sample of US medical students responding to a web-based survey invitation. Thus, they may not be representative of the overall population of medical students. Nonetheless, the study captured attitudes and experiences from medical students with diverse demographic characteristics and geographical locations.

Conclusions

High drug prices are a critical problem for a growing number of US patients, garnering attention from health policy experts and legislators alike [4, 18]. Physicians, too, should have a voice in this important debate [8]. US medical students report keen interest in this issue, but knowledge gaps and misconceptions are pervasive. The current system is arcane and proposals for reform are complex [14], so medical schools must do more to educate the next generation of physicians about drug prices and prepare them to advocate for the change that is needed.

Funding

This work was made possible by a grant from the Laura and John Arnold Foundation. This work was also supported in part from a grant to Memorial Sloan Kettering Cancer Center from the National Cancer Institute (P30 CA008748).

Compliance with Ethical Standards

Conflict of Interest

Dr. Korenstein’s spouse serves on the Scientific Advisory Board of Vedanta Biosciences and provides consulting for Takeda. No other authors have conflicts of interest to report.

Ethical Approval

The study was deemed exempt by the authors’ institutional IRB.

Disclaimers

None.