Intervention boosts discussion of out-of-pocket HF drug costs between patients, doctors
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Key takeaways:
- An intervention increased discussion of medication cost between patients with HFrEF and their clinicians.
- The intervention provided information about out-of-pocket costs and copay assistance programs.
PHILADELPHIA — Patients with HF with reduced ejection fraction who were provided information about out-of-pocket costs for medications were more likely to discuss costs with their doctors than those who were not, researchers reported.
Results of the POCKET-COST-HF stepped-wedge, cluster-randomized trial were presented at the American Heart Association Scientific Sessions.
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“Medical treatment for heart failure with reduced ejection fraction has become both more effective and more expensive in recent years, with annual out-of-pocket costs for patients with Medicare Part D coverage exceeding $2,600 for four-drug guideline-directed medical therapy,” Neal W. Dickert, MD, PhD, associate professor of medicine in the division of cardiology and the Thomas R. Williams Professor of Medicine at Emory University, said during a presentation. “We know that drug costs matter for patients, but we also know that there are barriers to integrating cost into decision-making. There may be discomfort on the part of patients and clinicians to talk about money, time constraints for clinical encounters and difficulty framing value propositions for various components of guideline-directed medical therapy. We also know that in most cases, neither the patient nor the clinician knows that patient’s out-of-pocket costs at the time of the encounter. Tools are emerging within electronic medical records, but we don’t know the impact of providing this kind of information.”
The researchers hypothesized that providing patients and clinicians with their out-of-pocket costs for multiple medication options at the time of their encounter would increase patient-clinician discussion of out-of-pocket costs.
Intervention to prompt cost discussion
The study intervention was built on the platform of the EPIC-HF checklist. The platform was updated with costs of currently approved medications for HFrEF and information about copay assistance programs, Dickert said during the presentation. The patients and clinicians in the control group received the checklist only. The patients and clinicians in the intervention group received the checklist plus a list of out-of-pocket costs for the more expensive medications at the time of their encounter. The cost estimates were obtained by TailorMed, a financial navigation company, he said.
The trial included six clinic sites from two health systems, and cluster size was limited to 40 patients each.
After the encounter, patients took a survey, and an EHR chart review was performed, Dickert said.
The primary outcome was cost-informed decision-making, defined as clinicians or patients mentioning medication cost during the encounter. Encounters were recorded and transcripts were reviewed.
The cohort consisted of 247 patients who had an encounter, of whom 126 were assigned to the control group (118 of whom took the follow-up survey; mean age, 64 years; 71% men) and 121 were assigned to the intervention group (113 of whom took the follow-up survey; mean age, 62 years; 69% men). There were 25 clinicians in both the control and intervention groups.
After adjustment for age, sex, payor status, quarter and financial well-being, cost-informed decision-making was higher in the intervention group (68% vs. 49%; P = .021), Dickert said during the presentation, noting there was no statistically significant difference between the groups in the unadjusted analysis.
“Importantly, we did observe a positive impact in five out of the six sites,” he said.
Conversations about specific dollar amounts occurred in 48.1% of the intervention group and 39.1% of the control group (P = .2726), he said.
He added that the intervention group was less likely to discuss contingency plans — defined as when a patient and clinician make a tentative decision about a prescription, but the final decision whether to take the drug is made at the pharmacy by the patient — than the control group (16.5% vs. 31.9%; P = .0276).
On the survey, the intervention group was numerically more likely than the control group to report they were taking the medicines decided on at the encounter (92.4% vs. 77.9%; P = .0697), Dickert said.
“Tailored, comprehensive cost disclosure had a modest but significant impact on the proportion of encounters in which cost was discussed for patients with HFrEF,” Dickert said during the presentation. “We have important hypothesis-generating findings that I think suggest cost disclosure may reduce things like contingency planning and may increase the extent to which patients are actually taking the medications they decided upon with their clinicians.”
What is the optimal outcome?
In a discussion after the presentation, Dhruv S. Kazi, MD, MSc, MS, associate director of the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, director of the cardiac critical care unit at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School, said it may be difficult to determine what is the optimal outcome of a study such as this.
“It is possible that if we talk to people about costs, people choose to receive fewer medications,” Kazi said. “We have got to figure out how to test this in other settings, going beyond academic sites, including rural and primary care settings. [There is a] need to study non-English-speaking patients. If a patient truly cannot afford the medication, if they forgo the medication, is that a quality penalty for the physician or is that a quality bonus for the health system for doing what patients actually want?”
Perspective
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This is a really important study because cost is so important. One limitation that wasn’t brought up is that these are centers that all use EPIC, which is the biggest EHR vendor but not the only EHR vendor. It is not possible for all EHR vendors to provide costs like they did. But the study shows the importance of talking about cost and about the fact that we as clinicians don’t always know what the cost is. In our EHR system, oftentimes we can prescribe to the patient’s pharmacy and tell what the cost is, if we do a 30- or 90-day prescription, and can actually bring that into the discussion. What we don’t know is what kind of insurance coverage the patient has. That is why this study was important, because it was able to bring that kind of information into the conversation.
This is so important for people with no insurance coverage and also those with Medicare Part D because their cost is variable throughout the year; they may have coverage up to a certain point and then they are in the “donut hole.”
This was also important because it addressed something completely different, how people view cost.
We would like patients’ insurance companies to cover the drugs that have shown benefit. We also need to know more about how to communicate cost data to patients. We talk a lot about shared decision-making around elective surgical procedures and other things, but this is another area for shared decision-making. Often this is a values-and-preferences choice for the patients.
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Dickert NW, et al. LBS.03. Heart failure - VADS, kids, and money. Presented at: American Heart Association Scientific Sessions; Nov. 11-13, 2023; Philadelphia.
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