One in eight primary care clinicians revised prescriptions after receiving electronic alerts that estimated how much patients would pay out of pocket and that offered cheaper alternatives if available, according to findings from a new study published September 5 in JAMA Internal Medicine.
The findings suggest that incorporating the alerts into electronic health record (EHR) software could be useful for reducing patient expenses, said lead author Anna D. Sinaiko, PhD, assistant professor of health economics and policy at Harvard T. H. Chan School of Public Health. Showing clinicians the actual prices of medications their patient would pay led to changes in 1 in 6 orders when the potential cost savings to the patient was $20 or more, she said.
“This suggests that clinicians are taking medication out-of-pocket prices into account when they are most meaningful for patients.”
Such “real-time benefit tools” provide more meaningful information about patient drug prices in clinical settings than has previously been available, Sinaiko said. They provide out-of-pocket price estimates specific to individual patients and account for their health plans as opposed to symbols or colors indicating drugs that are more or less expensive, which has been the status quo.
Also, she said, Medicare has promoted the use of these tools by health systems and health plans.
Sinaiko and colleagues examined EHR data for 103,953 primary care clinic encounters with 72,420 patients in the University of Colorado Health system (81.5% White; 59.5% female; 51.4% aged 65 years or older; 51.9% on Medicare). The patients were treated from July 2019 to July 2022 by 889 clinicians (physicians, nurse practitioners, and physician assistants), who wrote nearly 1.9 million medication orders. Of those orders, 181,887 (9.7%) included a price estimate.
For each prescription, the EHR displayed out-of-pocket costs for patients and offered alternative drugs if those drugs were at least 15 cents cheaper or if they were available at an on-site pharmacy.
Clinicians changed prescriptions 12.3% of the time after they saw price information. The percentage went up to 14% when possible cost savings were $5 or more.
Researchers also found that while there was the option for clinicians to click a button in the EHR and learn a patient’s specific medication price prior to ordering a drug, very few clinicians requested price estimates directly, Sinaiko said. Fewer than 1% (0.9%) did so. The other 99.1% did not, meaning they only received information about prices via alerts after ordering prescriptions.
Researchers also found that clinicians weren’t more likely to change psychiatric medications when the cost savings for the patient was higher. The demographics of patients ― such as whether they were poorer or richer ― didn’t affect the willingness of clinicians to change prescriptions after receiving price information.
In the big picture, Sinaiko said, “The fact that medication orders were changed more often when the potential cost savings for patients were larger suggests to me that clinicians were taking out-of-pocket cost into account when it was most salient for the patient.”
It’s not clear, however, why clinicians did not revise more prescriptions to help patients save money.
One theory is that they may ignore the alerts because of “alert fatigue,” she said. “I’d like to know if clinicians discount or ignore the price estimate because they don’t know where it comes from or whether it is accurate. It’s also possible that clinicians discuss the option to change a medication order with their patient, and for reasons other than cost, they decide to keep the original selection. This suggests that clinicians might be using price information to guide ― not dictate ― their clinical decisions.”
The study had limitations. The researchers did not assess whether the cheaper alternative medications were appropriate in individual cases. Also, they did not take into account other factors, such as patient preferences, that affect how clinicians make prescription decisions.
Clinicians may also not know whether their patients worry about drug costs.
“There isn’t really good data on who wants to talk to their physician about costs, but it is definitely nowhere near 100%,” said health services researcher Alyna Chien, MD, a pediatrician at Boston Children’s Hospital. “For physicians, there is also good reason to keep cost out of the picture until asked so that patients don’t feel like they’re getting suboptimal choices.”
University of Washington graduate student Shiven Bhardwaj, PharmD, who studies health policy, told Medscape that the new study “suggests that physicians are not frequently selecting less costly agents suggested by the real-time benefit tool, and they may not even be considering these alternatives.”
According to Bhardwaj, previous research has found that physicians “are unable to estimate what their patients’ out-of-pocket costs may be, which is not surprising, given wide variation in health insurance benefit designs.”
Why aren’t more clinicians choosing cheaper alternatives, even when they’re directly told about them? Bhardwaj suggests that many health systems may be implementing electronic drug cost alerts in the absence of official notification or training.
“Health systems should be making providers aware of the system and its potential to reduce patients’ out-of-pocket costs.”
What’s next for research in this area?
Lead author Sinaiko said she and her team will interview clinicians and patients in practices at University of Colorado Health to understand how these price estimates are used in clinical encounters and how they affect clinician practice and patient experiences
“We are interested in learning about the cost-savings thresholds that are important to patients,” she said.
The researchers will also examine whether cost information helps to boost access to medications for chronic conditions among Black and Hispanic patients and patients who live in rural areas, she said.
The study was funded by the Harvard T. H. Chan School of Public Health Dean’s Fund and the National Institute on Minority Health and Health Disparities. Sinaiko, Bhardwaj, and Chien have no relevant disclosures. Two study authors report having received a grant from the National Institute on Aging and consulting fees from Dispatch Health and Credo Health.
JAMA Intern Med. Published online September 5, 2023. Full text
Randy Dotinga is a freelance medical journalist and board member of the Association of Health Care Journalists.
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