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

Efforts to reform the US 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, risk of adverse 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.

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 6 states.⁵ Participants reported whether they wanted physicians to talk about medications that cost less but (1) had to be taken more often, (2) may have a slightly higher chance effects, or (3) may not work as well.

Of the 5085 patients (CASRO response rate, 75%), two-thirds were willing to discuss at least 1 of the 3 trade-off strategies. Patients said they wanted to be told about lower-cost drugs with a higher chance of adverse effects (38%), 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 4373 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).

To our knowledge, 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 adverse 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 that patients will reduce medication use to lower costs without telling them 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 trade-offs may also vary substantially across disease targets.⁶ However, our results support that patients are at least open to such discussions with physicians.

In 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.

Correspondence: Dr Tseng, Pacific Health Research Institute, c/o Department of Family Medicine and Community Health, University of Hawaii, 677 Ala Moana Blvd, Ste 815, Honolulu, HI 96813 (cwtseng@hawaii.edu).

Author Contributions: Dr Tseng had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Tseng, Marrero, Piette, Curb, Crosson, and Dudley. Acquisition of data: Tseng, Waitzfelder, Gerzoff, Marrero, Piette, Karter, Curb, Chung, and Dudley. Analysis and interpretation of data: Tseng, Tierney, Gerzoff, Marrero, Piette, Curb, Mangione, and Dudley. Drafting of the manuscript: Tseng, Marrero, and Dudley. Critical revision of the manuscript for important intellectual content: Tseng, Waitzfelder, Tierney, Gerzoff, Marrero, Piette, Karter, Curb, Chung, Mangione, Crosson, and Dudley. Statistical analysis: Tseng, Tierney, Gerzoff, and Piette. Obtained funding: Waitzfelder, Karter, and Curb. Administrative, technical, and material support: Waitzfelder, Karter, Curb, Chung, and Crosson. Study supervision: Tseng, Curb, Mangione, and Dudley.

Financial Disclosure: None reported.

Funding/Support: This study was jointly funded by Program Announcement No. 04005 from the Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases.

Additional Contributions: We acknowledge the participation of our health plan partners. Significant contributions to this study were made by members of the Translating Research into Action for Diabetes (TRIAD) Study Group.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the opinions of the funding organizations.