Talk Dollars and Cents With Patients


TUCSON, ARIZ. — Physicians and patients seldom discuss new medication costs and other acquisition issues, Dr. Derjung Mimi Tarn and associates reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

The investigators audiotaped the clinic visits of 185 patients who were receiving 243 new medication prescriptions and found that discussions about cost occurred in only 28 of the encounters. Patients rarely initiated conversations about cost, doing so for only four new prescriptions.

Physicians talked about cost or insurance for 12% of the 243 prescriptions, mentioned whether the medication was generic or brand name for only 2% of the prescriptions, talked about how to obtain the medication for 19%, about how long the supply would last for 9%, and about refills for 5%.

The analysis was based on the taped clinic visits that were conducted in 1999 at the University of California's Davis Medical Group and Kaiser Permanente, both in Sacramento, Calif., as part of the Physician Patient Communication Project. The project included 15 family physicians, 18 internists, and 11 cardiologists. The patients' mean age was 55 years, 83% were Caucasian, and more than 75% paid less than half of prescription drug costs. Overall, 31% were seen by family physicians, 47% by internists, and 23% by cardiologists (percentages do not total 100 because of rounding).

As patient age increased, the chances of physicians discussing cost decreased, according to a multivariate analysis that adjusted for medication class, over-the-counter and as-needed medication status, patient gender and race, prescription drug coverage, number of continued medications, and number of new medications prescribed. One possible explanation for that finding may be that time constraints and multiple health concerns were a factor, Dr. Tarn said in an interview.

Patients with a yearly income of less than $20,000 had significantly more conversations about medication costs than did those with an annual income of $40,000–$60,000 (odds ratio 8.27 vs. 0.29, respectively).

Family physicians (OR 0.003) and internal medicine physicians (OR 0.02) were less likely to discuss cost than were cardiologists. The investigators suggested that cardiologists may encounter more patients with chronic conditions and thus are more aware of cost issues, or perhaps that in this setting, they were prescribing more brand name or expensive medications and have had more problems with insurers not covering these drugs, said Dr. Tarn, department of family medicine, David Geffen School of Medicine, University of California, Los Angeles.

The results don't necessarily mean that primary care physicians are really doing that much worse, as the study did not evaluate previous interactions. It may be that primary care physicians have been seeing these patients for years, have a much closer relationship, and have had these types of discussions with their patients in previous visits, she said.

Other study results have also shown that physicians and patients seldom discuss cost because they are uncomfortable about raising the subject. However, both parties need to be more aware of the issue, because high medication costs are strongly associated with medication underutilization and noncompliance, she said.

“Patients really shouldn't be scared to ask if there are cost issues” or to ask if it's the cheapest medication available, Dr. Tarn said. “On the flip side, previous studies have shown that doctors aren't very good at recognizing whether patients are having trouble with costs. A simple exchange can bring out a lot of concerns with patients.”

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