The promise and peril of sharing costs with patients

It wasn’t so much the side effects — nausea and belly pain that had once kept me from enjoying my aunt’s home cooking. I didn’t fill my prescription for the malaria prophylactic Malarone before a family trip to India because the $50 co-pay seemed outlandishly expensive to a medical-student-in-debt. Years later, I find that my patients skip crucial medications to treat diabetes and depression because of the reality or even just the fear of insurmountable co-pays.

2012 survey of more than 1200 American adults by the Kaiser Family Foundation suggests that my patients and I aren’t alone. Twenty four percent of respondents reported that they or their family members had neglected to fill a prescription because of cost in the previous twelve months. Sixteen percent admitted to cutting pills in half or skipping doses to extend a medication.

Save for the opulent few, we all factor cost into our daily decisions and health care is no exception. This principle is the basis for not-so-new efforts by policymakers to give patients a larger stake in rising health care costs. If patients share a larger portion of their costs through mechanisms like coverage limits and higher deductibles, they might make more responsible use of these resources, the thinking goes.

And we have growing evidence that we respond to these pressures: There’s the classic 1970′s-80′s RAND health insurance experiment showing that when subjects paid a greater share of their health care costs, they reduced how much health care they used. A study published in the journal Health Affairs corroborated these results. Researchers compared a large company that had adopted consumer-directed health plans (or CDHPs, in which employees use savings accounts to pay for much of their health needs) with another that hadn’t. After four years, the employees who had switched to CDHPs had, on average, made 0.26 fewer doctor’s office visits and filled 0.85 fewer prescriptions each year than their counterparts.

So we self-ration, but that doesn’t mean we make the right decisions. Some discretionary non-use may be appropriate — say, saving Viagra for special occasions. But just as often, we don’t choose wisely. The RAND study linked increased cost-sharing to decreased use of both necessary and unnecessary health care, particularly among low income populations. Medical complications from patients not taking prescribed medications leads to $105 billion in avoidable costs each year, according to recent estimates from the IMS Institute for Healthcare Informatics (If I had come down with malaria on that trip to India, I’d be part of the statistic).

Cost-sharing isn’t an inherently bad idea, but it requires some work to be effective. Patients need to price-shop and to be honest with their doctors about what they are and aren’t taking, and why. Doctors need to be creative about prescribing medications that both patients and their pocketbooks can stomach (generic rather than name-brand statins, for example), to not make perfect the enemy of good enough.

Technology can facilitate these efforts: When I prescribe medications electronically, each option is coded with dollar signs and coded symbols — preferred, not covered, low or high cost — to guide me. Though cost is only a small part of the decision to take a medication, it’s one that both patients and doctors must acknowledge and address openly.

Ishani Ganguli is a journalist and an internal medicine-primary care resident who blogs at The Boston Globe’s Short White Coat, where this article originally appeared. 

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  • Mengles

    Yes, bc I’m sure doctors enjoy being bean counters for their patients, rather than concentrating on being good clinicians.

  • Ron Smith

    Hmmmm… why didn’t these patients call their physician’s office for possible alternatives?

    ‘A 2012 survey of more than 1200 American adults by the Kaiser Family Foundation suggests that my patients and I aren’t alone. Twenty four percent of respondents reported that they or their family members had neglected to fill a prescription because of cost in the previous twelve months. Sixteen percent admitted to cutting pills in half or skipping doses to extend a medication.’

    My patient’s parents always call my office when they can’t afford the meds? Especially they call when ADD meds which are outrageously expensive. Yes it would be great if they could ‘just get it’ and not have to cal the office, but these are generally young families like my daughter, son-in-law, and the three grands and they watch all their pennies and legal tenders.

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • guest

      Well you sound like a diligent doc but I imagine pts feel their doctor might be unsympathetic or not have satisfying alternatives for them.

      • Ron Smith

        It is far more complicated. Because each policy holder can have different formularies that can change each time I write the prescription, I don’t know that the medication that I refill today will be allowed or even available next month. And then the pharmacy will often glibly tell the patient that all they have to do is get the doctor to do a PA (prior authorization), as though I am the gatekeeper. And then my office staff will spend sometimes hours trying to contact the insurance company only to find out that its all a game of ‘wear the doctor down so he’ll just go away’ or ‘no matter what you say, you’re not getting a PA.’

        Patients and physicians are pawns alike in the game of insurer-provided pharmacotherapeutics. The fault of this problem lies squarely at the foot of the insurers (Medicaid CMOs are the worst offenders). Whoever pays the insurance policy is ultimately the one saying what meds that policy will or will not cover.

        Ron Smith, MD
        www (adot) ronsmithmd (adot) com

        • guest

          thank you so much for the detailed response. But it sounds like the obstacles encountered support the above study. I am guessing from the pt’s point of view they feel they can’t win.

    • SarahJ89

      I don’t call my doctor’s office because it’s a total pita to deal with them. I avoid having anything to do with them whenever possible. I suppose that’s one solution to over utilization.

  • Suzi Q 38

    I can afford the meds, but my insurance changed and my bill for 30 Diovan was about $198.00. I paid it, but was a bit annoyed.
    Yes, it would clear out a bit of my $3K deductible for the year, BUT STILL.

    I called my pharm D back. I mentioned my concerns. She got a bit defensive. I told her that my insurance change was not her fault, but I was incredulous that my insurance had been paying so much for Diovan.
    I asked her for a name of a generic alternative.

    The name that she gave was Cozar. I called my doctors office and he prescribed the Cozar without a discussion. I have been on the Cozar (my co pay was $10.00) for two weeks, and it too is holding down my BP.
    I do not notice any side effects at this time, but I will look them up, just in case.

    WalMart charges $4.00 for prescriptions.

    Thank you for caring enough about your patients to consider alternative generic drugs for them.

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