Mr. Jones enters the pharmacy expecting to pick up his prescription. But when he gets to the window, he gets a rude awakening. His acne cream is $200, much too expensive for him to afford. Mr. Jones (not his real name) was told that his doctor needed to fill out paperwork for the insurance to pay for his medication. He leaves the pharmacy upset, and without the prescription.
A study my colleagues and I recently published in JAMA Dermatology found that when patients like Mr. Jones do not pick up their prescriptions, out-of-pocket costs are the primary reason why.
These costs may be from copays or prior authorizations needed through a patient’s insurance. Even as the Affordable Care Act has made great strides in improving the insurance coverage gap in the U.S., more and more patients are now covered by high-deductible plans, leading to higher out-of-pocket costs.
As doctors, we are taught to think about safety and effectiveness when choosing treatments. But the reality is that these standards do not exist in a vacuum. In fact, they exist within fixed monetary constraints on an individual level and for the health system. The question is not simply: Should I prescribe drug A, which sometimes works, or drug B, which always works? Doctors must consider that drug A is 100 times cheaper, so we should probably try that first, unless there is sufficient injury or urgency to justify drug B. There is not necessarily a direct relationship between the cost of a medication and its effectiveness.
Patients are loath to bring up issues of cost, our study found. Certainly, it can be embarrassing to admit when cost is a restriction, and, surprisingly, patients do not expect doctors to be knowledgeable in this area. We conducted in-depth interviews with patients seen by dermatologists in Philadelphia who had not picked up their acne prescriptions.
A few patients in our study noted potential side effects or a feeling that their acne was not serious enough as reasons they didn’t pick up the prescription. But the majority of patients were stopped by cost.
For a wealthy patient, paying $20 for an acne cream might not seem a big deal. But for a family that struggles to put food on the table, can a patient justify spending the money on his acne? And what if it’s $200, which did happen to some patients, like Mr. Jones, in our study? How supposedly “serious” must a condition be to make it worth it?
Our interviews suggested that patients appreciate it when doctors have a well-thought-out backup plan (for example, an over-the-counter or other prescription alternative) and bring up costs during an office visit. Patients do not like being told reflexively to call if there’s an issue filling the medication at the pharmacy — that puts the responsibility on them to figure out a complicated system.
I know as well as any doctor how incredibly frustrating it is not knowing at times what to tell patients. Insurance coverage changes constantly, different pharmacies may have different costs for the same medications, and pricing of even generic medications has proven unpredictable in recent years. With all this, we have no way of knowing ahead of time what the out-of-pocket cost for a medication will be for an individual patient.
Despite being in this age of crowdsourcing and big data, an individual doctor still can only draw upon his or her own anecdotal experience of how much something usually costs, or if it is usually covered. I envision a future where my sophisticated and efficient electronic medical record can process it all for me. With a patient’s clinical data and insurance information, as the patient sits in front of me, the system instantaneously generates a list of real-time verified options with confirmed costs, both overall and out-of-pocket. Then, the patient and I can review these together to make an informed decision regarding treatment options.
Doctors must not assume that cost of care is out of our purview. On the contrary, doctors must remember our responsibility to consider the whole patient, including his or her financial livelihood, and make a point of bringing up cost of care with each of our patients. If patients with limited means spend more money on medications, that expense means less money for the rest of their budget, with real consequences. With better transparency and advocacy on behalf of our patients, we as physicians must strive for the most cost-effective care.
Jules Lipoff, M.D., is assistant professor of clinical dermatology at the University of Pennsylvania.