June 05, 2019, 11:43 am Sheri Porter – Despite evidence that increasing out-of-pocket expenses may keep patients from buying the prescriptions they need, most physicians don't routinely screen their patients for cost-of-medication concerns.
Researchers set out to tackle the issue by implementing a single 60-minute interactive training session for clinicians and staff at seven primary care practices spread over three states -- New York, Georgia and California -- and then evaluating the impact of the intervention.
Results showed that after the training, the frequency of cost-of-medication conversations improved in six of the seven practices and stayed the same in one.
Furthermore, 86% of participating practices said it was likely or very likely they would continue to screen patients after the pilot.
The research article, titled "Addressing Medication Costs During Primary Care Visits: A Before-After Study of Team-based Training," was included in the May 7 issue of Annals of Internal Medicine as part of a special supplement on cost-of-care conversations.
The Robert Wood Johnson Foundation provided funding to publish the supplement, and the AAFP's National Research Network served as a research partner on the project.
Corresponding author and family physician Kevin Fiscella, M.D., M.P.H., told AAFP News he's been taking care of patients for 30-plus years and has seen firsthand how medication costs have evolved.
"We know from national studies that about 25% of people cannot afford their medications," said Fiscella, a professor in the departments of Family Medicine and Public Health Sciences and the Center for Community Health & Prevention at the University of Rochester Medical Center in Rochester, N.Y.
"About 30% of prescriptions go unfilled, and among those that are filled, about 30% are not taken as prescribed. And cost is one of the leading reasons for both of these drop-offs," he added.
Too often, said Fiscella, patients arrive at the pharmacy to pick up a prescription, but then decline to purchase when they discover the out-of-pocket cost. Or sometimes patients buy a costly drug then cut pills in half or take them intermittently.
"In some cases, if they're committed to taking a medication, patients will even put off other necessities like rent, food and utility payments. It's a huge health problem and a major concern of patients nationally," said Fiscella.
Experience has proven that the only way to know how much a patient is paying out of pocket is to ask. "And from an adherence perspective, if I don't know if a patient can afford the medication I'm prescribing, then I'm doing my patient a disservice," he said.
Researchers surveyed 700 patients before and after the intervention and also interviewed clinicians and nursing and reception staff members to assess the implementation process.
Family medicine, internal medicine and medicine-pediatrics specialties participated in the pilot, and each practice agreed to complete a training session that addressed the importance and impact of patient medication costs, as well as baseline survey findings for each clinic.
Trainers suggested that practices use a team-based approach to screening and management of patient medication costs and encouraged all team members to attend the training.
Authors reported that overall, 17% of patients reported having cost-of-medication discussions at baseline; that number improved to 32% after the intervention. Additionally, more patients reported receiving cost-reduction suggestions (15.5% before versus 25.1% after).
Researchers noted that across the seven practice sites, the percentage of visits that included cost-of-medication discussions ranged from 8% to 45% before the intervention and from 18% to 82% after.
"Practices adopted systematic screening during the medication reconciliation process through written questions posed during reception or as part of the nursing assessment in the exam room," said the authors.
Most practices simply asked patients whether any medication posed a financial burden. "Others phrased the question more broadly -- for example, whether patients had any barriers to obtaining their medication," wrote the authors.
When patients indicated they faced obstacles, practices offered various cost-reduction strategies, including use of discount coupons and $4-per-month prescription programs. "A few clinicians mentioned using a formulary app to determine medication copayment, as well as deprescribing," the researchers noted.
Practices also reported obstacles to implementing cost-of-medication conversations that included
According to Fiscella, family physicians are particularly adept at figuring out alternative strategies to help patients who struggle with prescription costs.
"The most obvious tactic is prescribing something different that may accomplish the same purpose. It could be a different medication or a medication in a different class that results in a lower copay," he said.
Fiscella noted the challenges of polypharmacy -- particularly in older patients with multiple chronic conditions. "So, when a patient asks if a medicine is really necessary, it's sometimes useful to step back and say, 'Let's talk about that -- maybe we could try a deprescribing trial and see how you feel when you're off the medication completely.'"
He's also a strong proponent of requesting outside assistance from social workers, care coordinators and others who are trained to help people enroll in Medicare Part D or switch to a different plan that would cover additional medications and services.
Fiscella also stressed the need to ask the all-important "cost" question in a nonjudgmental way so people feel comfortable answering. "I've found that most patients are really excited and quite anxious to talk about potential alternatives, and then they can make an informed decision about whether they want to try that out," he said.
As for key takeaways, Fiscella emphasized the benefits of implementing a team-based approach to cost-of-medication conversations. "If you can build it right into the workflow where you have other team members helping out, you're going to be able to reach most patients with minimal extra work," he said.
"And at the end of the day, family physicians should know that patients are going to be really grateful," he added.