The effect of pharmacy benefit design on patient-physician communication about costs

AbstractBACKGROUND: Incentive-based formularies have been widely instituted to control the rising costs of prescription drugs. To work properly, such formularies depend on patients to be aware of financial incentives and communicate their cost preferences with prescribing physicians. The impact of financial incentives on patient awareness of and communication about those costs is unknown. OBJECTIVE: To evaluate the relationship between enrollment in incentive-based pharmacy benefit plans and awareness of out-of-pocket costs and rates of communication about out-of-pocket costs. DESIGN: A matched telephone survey of patients and their primary care physicians. SETTING: Los Angeles County. PARTICIPANTS: One thousand nine hundred and seventeen patients aged 53 to 82 (73% response rate). MEASUREMENTS: Patient-reported pharmacy benefit design, knowledge of out-of-pocket costs, and discussion of out-of-pocket costs with physicians. RESULTS: Sixty-two percent of patients who had prescription drug coverage and were aware of their pharmacy benefit design reported being enrolled in incentive-based plans. The majority of these (54%) were “never” or only “sometimes” aware of their out-of-pocket cost requirements at the time of the physician visit. After controlling for numerous physician and patient level variables, we found that patients enrolled in pharmacy benefit designs requiring no copayments were more likely to report they “never” discuss out-of-pocket costs with physicians compared with patients enrolled in incentive-based pharmacy benefit designs (81% vs 67%, P=.001) and patients with no prescription drug insurance (57%, P<.001). CONCLUSIONS: Incentive-based pharmacy benefit plans and lack of insurance are associated with increased rates of discussions about out-of-pocket costs. Nonetheless, most incentive-based enrollees are unaware of out-of-pocket costs when prescriptions are written and never discuss out-of-pocket costs with their physicians, likely mitigating the effectiveness of financial incentives to guide decision making. Considering that out-of-pocket costs are associated with adherence to medical therapy, interventions to improve patient access to out-of-pocket cost information and the frequency of patient-physician discussions about costs are needed.

[1]  E. Ziegel,et al.  Bootstrapping: A Nonparametric Approach to Statistical Inference , 1993 .

[2]  J. Newhouse,et al.  Cost-Sharing: Patient Knowledge and Effects on Seeking Emergency Department Care , 2004, Medical care.

[3]  M. Solomon,et al.  Benefits and the Use of Drugs by the Chronically Ill , 2004 .

[4]  Susan L Ettner,et al.  The implications of choice: prescribing generic or preferred pharmaceuticals improves medication adherence for chronic conditions. , 2006, Archives of internal medicine.

[5]  Thomas Pasko,et al.  Physician Characteristics and Distribution in the Us: 1999 , 1998 .

[6]  Melissa Bradley,et al.  Provider Perceptions of Pharmacy Management: Lessons From the Military Health System , 2004, Medical care.

[7]  B. Stuart,et al.  Who bears the burden of Medicaid drug copayment policies? , 1999, Health affairs.

[8]  L. Ried,et al.  The Effect of Drug Co-Payments on Utilization and Cost of Pharmaceuticals in a Health Maintenance Organization , 1990, Medical care.

[9]  Robert B. Doherty.  Assessing the New Medicare Prescription Drug Law , 2004, Annals of Internal Medicine.

[10]  R. Kravitz,et al.  Do the incentives in 3-tier pharmaceutical benefit plans operate as intended? Results from a physician leadership survey. , 2005, The American journal of managed care.

[11]  David O Meltzer,et al.  Physician strategies to reduce patients' out-of-pocket prescription costs. , 2005, Archives of internal medicine.

[12]  R. Epstein,et al.  The effect of incentive-based formularies on prescription-drug utilization and spending. , 2003, The New England journal of medicine.

[13]  D. Smith,et al.  The effects of copayments and generic substitution on the use and costs of prescription drugs. , 1993, Inquiry : a journal of medical care organization, provision and financing.

[14]  K. Langa,et al.  The Health Effects of Restricting Prescription Medication Use Because of Cost , 2004, Medical care.

[15]  Joy M Grossman,et al.  Patient cost-sharing innovations: promises and pitfalls. , 2004, Issue brief.

[16]  L. Casalino,et al.  Patient-physician communication about out-of-pocket costs. , 2003, JAMA.

[17]  Reed Ce,et al.  The differential impact of copayment on drug use in a Medicaid population. , 1985 .

[18]  J A Hanley,et al.  Adverse events associated with prescription drug cost-sharing among poor and elderly persons. , 2001, JAMA.

[19]  Malone Bl.  Health care in the 21st century. , 1996 .

[20]  A. Hillman,et al.  Financial incentives and drug spending in managed care. , 1999, Health affairs.