In past entries, we have described different issues that hinder the compliance of patients to taking prescribed medications. A common barrier centers on the costs of drugs. There is no doubt that this can be a problem, particularly if a patient lacks health insurance or has a plan that fails to cover the costs of medications. Increasing, patients face greater cost sharing through higher deductibles and other out of pocket expenses. Under this situation, the costs have uncertain effects on decision making by patients and health care professionals alike.

In a recent study, Hoangmai and colleagues looked at data on 6,628 patients who responded to a survey to see how often physicians considered their patients out of pocket expenses when prescribing drugs, ordering diagnostic tests, and choosing inpatient vs outpatient care settings. Responses were divided into two categories: always/usually vs sometimes/rarely/never. The results of the survey found that 78% of physicians reported they considered out of pocket expenses when prescribing drugs, while 51.2% reported doing so when selecting care settings, and 40.2% when selecting diagnostic tests. Primary care physicians were more likely than medical specialists to consider patients' costs in choosing prescription drugs, care settings, and diagnostic tests. Physicians working in large groups or health maintenance organizations were more likely to consider out of pocket costs in prescribing generic drugs, but those in solo or 2-person practices were more likely to do so in choosing tests and care settings. Physicians providing at least 10 hours of charity care a month were more likely than those not providing any to consider out of pocket costs in both diagnostic testing and care setting decisions.

Comments: Despite the practices of some health care providers, the authors of the study concluded that cost-sharing arrangements are likely to have limited effects in reducing health care spending because physicians do not routinely consider their patients’ out of pocket costs when deciding upon more expensive medical services. These are the major conclusions that emerged from the study. However, as we all know, the practices of individual physicians vary widely. Some do consider their patients’ costs, often giving out samples of drugs to reduce patients’ costs. The majority, however, are like those in this survey and do not consider these costs. It would be impractical for all physicians to give free drugs all the time with all of their patients; this would be impossible both for them and for pharmaceutical companies. Maybe what we need as patients is some sort of guide as to the amount of charity work physicians performs before when selecting a health care provider! We have no idea, however, how we could find out this information.

Do you have any comments or suggestions on this growing problem and barrier to medication adherence? As out of pocket expenses are increasing, it would be great to hear some useful suggestions.

H. Hoangmai et al. Physician Consideration of Patients' Out-of-Pocket Costs in Making Common Clinical Decisions. Archives of Internal Medicine, 2007;167:663-668.