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Rao BR, Akrobetu DJ, Dickert NW, Nguyen T, Davis JK, Campagna A, Mitchell AR, Sharma A, Speight CD, Barks MC, Farley S, Gutterman S, Santanam T, Ubel PA. Deciding Whether to Take Sacubitril/Valsartan: How Cardiologists and Patients Discuss Out-of-Pocket Costs. J Am Heart Assoc 2023; 12:e028278. [PMID: 36974764 PMCID: PMC10122884 DOI: 10.1161/jaha.122.028278] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/23/2023] [Indexed: 03/29/2023]
Abstract
Background Out-of-pocket costs have significant implications for patients with heart failure and should ideally be incorporated into shared decision-making for clinical care. High out-of-pocket cost is one potential reason for the slow uptake of newer guideline-directed medical therapies for heart failure with reduced ejection fraction. This study aims to characterize patient-cardiologist discussions involving out-of-pocket costs associated with sacubitril/valsartan during the early postapproval period. Methods and Results We conducted content analysis on 222 deidentified transcripts of audio-recorded outpatient encounters taking place between 2015 and 2018 in which cardiologists (n=16) and their patients discussed whether to initiate, continue, or discontinue sacubitril/valsartan. In the 222 included encounters, 100 (45%) contained discussions about cost. Cost was discussed in a variety of contexts: when sacubitril/valsartan was initiated, not initiated, continued, and discontinued. Of the 97 cost conversations analyzed, the majority involved isolated discussions about insurance coverage (64/97 encounters; 66%) and few addressed specific out-of-pocket costs or affordability (28/97 encounters; 29%). Discussion of free samples of sacubitril/valsartan was common (52/97 encounters; 54%), often with no discussion of a longer-term plan for addressing cost. Conclusions Although cost conversations were somewhat common in patient-cardiologist encounters in which sacubitril/valsartan was discussed, these conversations were generally superficial, rarely addressing affordability or cost-value judgments. Cardiologists frequently provided patients with a course of free sacubitril/valsartan samples without a plan to address the cost after the samples ran out.
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Affiliation(s)
- Birju R. Rao
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | | | - Neal W. Dickert
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
- Department of EpidemiologyEmory University Rollins School of Public HealthAtlantaGAUSA
| | | | | | - Ada Campagna
- Duke‐Margolis Center for Health PolicyDurhamNCUSA
| | - Andrea R. Mitchell
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | - Anu Sharma
- Duke‐Margolis Center for Health PolicyDurhamNCUSA
| | - Candace D. Speight
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | | | | | | | | | - Peter A. Ubel
- Duke University School of MedicineDurhamNCUSA
- Duke‐Margolis Center for Health PolicyDurhamNCUSA
- Duke University’s Fuqua School of BusinessDurhamNCUSA
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Sloan CE, Gutterman S, Davis JK, Campagna A, Pollak KI, Barks MC, Santanam T, Sharma M, Grande DT, Zafar SY, Ubel PA. How can healthcare organizations improve cost-of-care conversations? A qualitative exploration of clinicians' perspectives. Patient Educ Couns 2022; 105:2708-2714. [PMID: 35440376 DOI: 10.1016/j.pec.2022.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Clinicians increasingly believe they should discuss costs with their patients. We aimed to learn what strategies clinicians, clinic leaders, and health systems can use to facilitate vital cost-of-care conversations. METHODS We conducted focus groups and semi-structured interviews with outpatient clinicians at two US academic medical centers. Clinicians recalled previous cost conversations and described strategies that they, their clinic, or their health system could use to facilitate cost conversations. Independent coders recorded, transcribed, and coded focus groups and interviews. RESULTS Twenty-six clinicians participated between December 2019 and July 2020: general internists (23%), neurologists (27%), oncologists (15%), and rheumatologists (35%). Clinicians proposed the following strategies: teach clinicians to initiate cost conversations; systematically collect financial distress information; partner with patients to identify costs; provide accurate insurance coverage and/or out-of-pocket cost information via the electronic health record; develop local lists of lowest-cost pharmacies, laboratories, and subspecialists; hire financial counselors; and reduce indirect costs (e.g., parking). CONCLUSIONS Despite considerable barriers to discussing, identifying, and reducing patient costs, clinicians described a variety of strategies for improving cost communication in the clinic. PRACTICE IMPLICATIONS Health systems and clinic leadership can and should implement these strategies to improve the financial health of the patients they serve.
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Affiliation(s)
- Caroline E Sloan
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Sophia Gutterman
- University of Michigan School of Medicine, Ann Arbor, MI, USA; Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - J Kelly Davis
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA
| | - Ada Campagna
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University, Durham, NC, USA; Duke Cancer Institute, Duke University Health System, Durham, NC, USA
| | - Mary Carol Barks
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA
| | - Taruni Santanam
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Meghana Sharma
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David T Grande
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - S Yousuf Zafar
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Durham, NC, USA; Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Peter A Ubel
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Fuqua School of Business, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Durham, NC, USA; Sanford School of Public Policy, Duke University, Durham, NC, USA
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Abstract
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 PARTICIPANTS This 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 MEASURES In 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. RESULTS The 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 RELEVANCE This 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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Affiliation(s)
- Caroline E. Sloan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Lorena Millo
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Peter A. Ubel
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Fuqua School of Business, Duke University, Durham, North Carolina
- Sanford School of Public Policy, Duke University, Durham, North Carolina
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