Heart Failure and Shared Decision-Making: Patients Open to Medication-Related Cost Discussions

Rao, Birju; Dickert, Neal W.; Morris, Alanna A.; Speight, Candace; Smith, Graham; Shore, Supriya; Moore, Miranda

doi:10.1161/circheartfailure.120.007094

Cited by 22 publications

(21 citation statements)

References 20 publications

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“…Prior research has shown that patients may not disclose barriers due to embarrassment or doubt that providers can help. 80 , 81 Patients may not discuss cost unless asked, 82 such as when providers note adherence problems. 23 , 60 Similarly, we found that information about challenges might be elicited only after prescriptions went unfilled.…”

Section: Discussionmentioning

confidence: 99%

Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want

et al. 2022

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Objective To explore diverse provider perspectives on: strategies for addressing patient medication cost barriers; patient medication cost information gaps; current medication cost-related informatics tools; and design features for future tool development. Materials and Methods We conducted 38 semistructured interviews with providers (physicians, nurses, pharmacists, social workers, and administrators) in a Midwestern health system in the United States. We used 3 rounds of qualitative coding to identify themes. Results Providers lacked access to information about: patients’ ability to pay for medications; true costs of full medication regimens; and cost impacts of patient insurance changes. Some providers said that while existing cost-related tools were helpful, they contained unclear insurance information and several questioned the information’s quality. Cost-related information was not available to everyone who needed it and was not always available when needed. Fragmentation of information across sources made cost-alleviation information difficult to access. Providers desired future tools to compare medication costs more directly; provide quick references on costs to facilitate clinical conversations; streamline medication resource referrals; and provide centrally accessible visual summaries of patient affordability challenges. Discussion These findings can inform the next generation of informatics tools for minimizing patients’ out-of-pocket costs. Future tools should support the work of a wider range of providers and situations and use cases than current tools do. Such tools would have the potential to improve prescribing decisions and better link patients to resources. Conclusion Results identified opportunities to fill multidisciplinary providers’ information gaps and ways in which new tools could better support medication affordability for patients.

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Section: Discussionmentioning

confidence: 99%

Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want

et al. 2022

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“…Although integrating price into clinical decisions rarely occurs today, price is an important consideration for initiating medication discussions that should be on the table during clinical encounters, and available evidence suggests that patients agree. 8 , 26 …”

Section: Discussionmentioning

confidence: 99%

“… 34 Integrating medication cost discussions into shared decision‐making may present an opportunity to mitigate financial toxicity and help patients make decisions that cohere with their preferences and personal financial constraints and goals. 26 …”

Section: Discussionmentioning

confidence: 99%

Impact of Financial Considerations on Willingness to Take Sacubitril/Valsartan for Heart Failure

Rao

Speight

Allen

et al. 2022

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Background Sacubitril/valsartan improves health outcomes for heart failure with reduced ejection fraction relative to angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, but it carries higher out‐of‐pocket costs. Neither the impact of cost nor how to integrate cost into medical decisions is well studied. Methods and Results To evaluate the impact of out‐of‐pocket costs and a novel cost‐priming intervention on willingness to take sacubitril/valsartan for heart failure with reduced ejection fraction, participants with self‐reported heart disease were surveyed using the online Ipsos Knowledge Panel. Participants were presented with a modified decision aid for sacubitril/valsartan and then, in a 3×2 factorial design, randomly assigned to 1 of 3 cost conditions ($10, $50, or $100/month) and to a control group or cost‐priming intervention, defined by being asked questions about their financial situation before learning about the benefits of sacubitril/valsartan. Of the 1013 participants included in the analysis, 85% of respondents were willing to take sacubitril/valsartan at $10, 62% at $50, and 33% at $100 ( P <0.0001). In a multivariable logistic regression model, participants were more likely to take sacubitril/valsartan at $10 versus $100 (odds ratio [OR], 14.3 [95% CI, 9.4–21.8]) and $50 compared with $100 (OR, 3.6 [95% CI, 2.5–5.1]). Overall, participants in the cost‐primed group were more willing to take sacubitril/valsartan than those not primed to consider their financial situation (63% versus 56%, P =0.04). There was no statistically significant interaction between cost conditions and cost priming. Perceived benefit of sacubitril/valsartan over angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers decreased as cost increased but did not vary by cost priming. Conclusions Commonly encountered out‐of‐pocket costs of sacubitril/valsartan may impact individuals’ willingness to take the medication even when recommended by their physicians. Priming individuals to consider personal finances before learning about the drug increased willingness to take sacubitril/valsartan.

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“…Such costsharing mechanisms exist to address moral hazard and prevent overconsumption of medical resources, but their complexity often confuses patients, 13 who turn to their clinicians for assistance. [14][15][16][17][18][19][20] Although patients may not expect clinicians to have all the answers, they do report hoping for changes in prescription patterns or referrals to pharmaceutical assistance programs when out-of-pocket costs are projected to be high. 21,22 Physician experts and patient advocacy groups have recommended that communication about the financial trade-offs of potential treatment options become part of routine clinical practice.…”

Section: Introductionmentioning

confidence: 99%

“…Such cost-sharing mechanisms exist to address moral hazard and prevent overconsumption of medical resources, but their complexity often confuses patients, 13 who turn to their clinicians for assistance. 14 , 15 , 16 , 17 , 18 , 19 , 20 Although patients may not expect clinicians to have all the answers, they do report hoping for changes in prescription patterns or referrals to pharmaceutical assistance programs when out-of-pocket costs are projected to be high. 21 , 22 …”

Section: Introductionmentioning

confidence: 99%

Accuracy of Physician Estimates of Out-of-Pocket Costs for Medication Filling

et al. 2021

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IMPORTANCE One-third of US residents have trouble paying their medical bills. They often turn to their physicians for help navigating health costs and insurance coverage.OBJECTIVE To determine whether physicians can accurately estimate out-of-pocket expenses when they are given all of the necessary information about a drug's price and a patient's insurance plan. DESIGN, SETTING, AND PARTICIPANTSThis national mail-in survey used a random sample of US physicians. The survey was sent to 900 outpatient physicians (300 each of primary care, gastroenterology, and rheumatology). Physicians were excluded if they were in training, worked primarily for the Veterans Administration or Indian Health Service, were retired, or reported 0% outpatient clinical effort. Analyses were performed from July to December 2020. MAIN OUTCOMES AND MEASURESIn a hypothetical vignette, a patient was prescribed a new drug costing $1000/month without insurance. A summary of her private insurance information was provided, including the plan's deductible, coinsurance rates, copays, and out-of-pocket maximum.Physicians were asked to estimate the drug's out-of-pocket cost at 4 time points between January and December, using the plan's 4 types of cost-sharing: (1) deductibles, (2) coinsurance, (3) copays, and (4) out-of-pocket maximums. Multivariate linear regression was used to assess differences in performance by specialty, adjusting for attitudes toward cost conversations, demographics, and clinical characteristics. RESULTSThe response rate was 45% (405 of 900) and 371 respondents met inclusion criteria.Among the respondents included in this study, 59% (n = 220) identified as male, 23% (n = 84) as Asian, 3% (n = 12) as Black, 6% (n = 24) as Hispanic, and 58% (n = 216) as White; 30% (n = 112) were primary care physicians, 35% (n = 128) were gastroenterologists, and 35% (n = 131) were rheumatologists; and the mean (SD) age was 49 (10) years. Overall, 52% of physicians (n = 192) accurately estimated costs before the deductible was met, 62% (n = 228) accurately used coinsurance information, 61% (n = 224) accurately used copay information, and 57% (n = 210) accurately estimated costs once the out-of-pocket maximum was met. Only 21% (n = 78) of physicians answered all 4 questions correctly. Ability to estimate out-of-pocket costs was not associated with specialty, attitudes toward cost conversations, or clinic characteristics. CONCLUSIONS AND RELEVANCEThis survey study found that many US physicians have difficulty estimating out-of-pocket costs, even when they have access to their patients' insurance plans. The mechanics involved in calculating real-time out-of-pocket costs are complex. These findings suggest that increased price transparency and simpler insurance cost-sharing mechanisms are needed to enable informed cost conversations at the point of prescribing.

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Heart Failure and Shared Decision-Making: Patients Open to Medication-Related Cost Discussions

Cited by 22 publications

References 20 publications

Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want

Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want

Impact of Financial Considerations on Willingness to Take Sacubitril/Valsartan for Heart Failure

Accuracy of Physician Estimates of Out-of-Pocket Costs for Medication Filling

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