With increasing out-of-pocket drug costs in the US, medication affordability remains critical to adherence—nearly one-third of adults report not taking their medicines as prescribed because of the cost—and, in turn, health outcomes.1 Affordability plays a central role, for example, when deciding on stroke prevention in patients with atrial fibrillation: although the newer direct oral anticoagulants are safer and easier to use than warfarin, they are also much more expensive. In such situations, cost conversations can help patients make more informed medical decisions that are aligned with their preferences and circumstances.2 However, despite the importance of these conversations and patients’ desire to have them with their doctors,3 they are uncommon, occurring in the minority of clinical encounters for which they might be most beneficial because of time and other constraints.4
To understand the factors associated with and consequences of such conversations in atrial fibrillation care, Kamath et al5 performed a secondary analysis of data from a randomized clinical trial of a shared decision-making tool that included estimated out-of-pocket costs for warfarin and direct oral anticoagulants. The study spanned 5 US medical centers for 2.5 years and included patients with nonvalvular atrial fibrillation at high risk of thromboembolic event who were taking or considering anticoagulation therapy. By examining 830 audiovisual encounter recordings and participant surveys, the authors found that cost conversations occurred in a remarkably high 77% of all encounters and were more likely to occur when shared decision-making tools were used (90% vs 64% of encounters).5
When examining physician factors associated with having cost conversations, the authors found that clinical load or years in practice did not matter but gender did.5 Women doctors were more likely to have cost conversations, building on substantial evidence that, on average, they conduct longer visits with patients, engage in more shared decision-making, and have more patient-centered communication styles.6 These differences are likely attributable to a mix of differing patient expectations, sociocultural norms, and personal characteristics. Staff physicians were also more likely to have cost conversations than clinicians in training, perhaps because of their experience with managing atrial fibrillation and using language to discuss associated costs.5 Finally, Kamath et al5 found that cost conversations were more common with primary care doctors than cardiologists, which may reflect the primary care specialty’s focus on whole-person care and yet is remarkable given the number of competing priorities in a typical primary care visit.
Turning to patient factors, in their multivariable analysis, Kamath et al5 found no differences in likelihood of cost conversations by age, sex, race/ethnicity, education, stroke risk, or whether patients were already taking an anticoagulant. However, cost conversations were more common among patients with middle incomes compared with patients with low and high incomes, similar to prior work examining rheumatoid arthritis care.7 This may reflect that patients with lower incomes tend to have more generous drug coverage (eg, via Medicaid), whereas those with higher incomes can afford the medications directly. This finding hints at the nonlinear relationship between traditional socioeconomic indicators and medication affordability and highlights the need to offer cost conversations broadly.
Although patients who participated in cost conversations were more likely to report that cost was one factor or even the sole factor in their anticoagulant decision, they were not more likely to select one medication over the other.5 This might reflect unproductive conversations or competing factors in the decision. We also note that because most (79%) patients in the study were already taking an anticoagulant, clinical inertia may have proven more powerful than any conversation.5
Even if medication choices were unaffected, there is still enormous value in normalizing cost conversations. These conversations continue to carry stigma, especially for historically marginalized populations.8 Developing more shared decision-making tools with cost information and offering them at the point of care may lower the activation energy to have these conversations, especially for clinicians who cite lack of knowledge about costs as a barrier or are otherwise less likely to offer them organically. This is not a trivial undertaking given the heterogeneity of cost inputs and the limited time in visits to use the tools. Yet there are clear benefits to folding such tools into standard practice, especially for the many patients who want these conversations but are understandably afraid to ask. Our patients’ health may depend on it.
Published: July 13, 2021. doi:10.1001/jamanetworkopen.2021.16670
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Ganguli I et al. JAMA Network Open.
Corresponding Author: Ishani Ganguli, MD, MPH, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont St, 3rd Fl, Boston, MA 02120 (email@example.com).
Conflict of Interest Disclosures: Dr Ganguli and Ms Thakore reported receiving grants from the Robert Wood Johnson Foundation outside the submitted work. No other disclosures were reported.
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Ganguli I, Thakore N. Cost Conversations About Atrial Fibrillation Care—Who Is Talking the Talk? JAMA Netw Open. 2021;4(7):e2116670. doi:10.1001/jamanetworkopen.2021.16670
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