1
|
Montembeau SC, Rao BR, Mitchell AR, Speight CD, Allen LA, Halpern SD, Ko YA, Matlock DD, Moore MA, Morris AA, Scherer LD, Ubel P, Dickert NW. Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF): A Trial Providing Out-of-Pocket Costs for Heart Failure Medications during Clinical Encounters. Am Heart J 2024; 269:84-93. [PMID: 38096946 PMCID: PMC11002964 DOI: 10.1016/j.ahj.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/05/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Evidence-based medical therapy for heart failure with reduced ejection fraction (HFrEF) often entails substantial out-of-pocket costs that can vary appreciably between patients. This has raised concerns regarding financial toxicity, equity, and adherence to medical therapy. In spite of these concerns, cost discussions in the HFrEF population appear to be rare, partly because out-of-pocket costs are generally unavailable during clinical encounters. In this trial, out-of-pocket cost information is given to patients and clinicians during outpatient encounters with the aim to assess the impact of providing this information on medication discussions and decisions. HYPOTHESIS Cost-informed decision-making will be facilitated by providing access to patient-specific out-of-pocket cost estimates at the time of clinical encounter. DESIGN Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF) is a multicenter trial based at Emory Healthcare and University of Colorado Health. Adapting an existing patient activation tool from the EPIC-HF trial, patients and clinicians are presented a checklist with medications approved for treatment of HFrEF with or without patient-specific out-of-pocket costs (obtained from a financial navigation firm). Clinical encounters are audio-recorded, and patients are surveyed about their experience. The trial utilizes a stepped-wedge cluster randomized design, allowing for each site to enroll control and intervention group patients while minimizing contamination of the control arm. DISCUSSION This trial will elucidate the potential impact of robust cost disclosure efforts and key information regarding patient and clinician perspectives related to cost and cost communication. It also will reveal important challenges associated with providing out-of-pocket costs for medications during clinical encounters. Acquiring medication costs for this trial requires an involved process and outsourcing of work. In addition, costs may change throughout the year, raising questions regarding what specific information is most valuable. These data will represent an important step towards understanding the role of integrating cost discussions into heart failure care. CLINICALTRIALS GOV IDENTIFIER NCT04793880.
Collapse
Affiliation(s)
- Sarah C Montembeau
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Birju R Rao
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Andrea R Mitchell
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Candace D Speight
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Larry A Allen
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center and Department of Medicine, Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yi-An Ko
- Department of Biostatistics, Emory University Rollins School of Public Health, Atlanta, GA
| | - Daniel D Matlock
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Miranda A Moore
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
| | - Alanna A Morris
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Laura D Scherer
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Peter Ubel
- Duke University Fuqua School of Business, Durham, NC
| | - Neal W Dickert
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA; Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| |
Collapse
|
2
|
Dusetzina SB, Sarpatwari A, Carrier MA, Hansen RA, Keating NL, Huskamp HA. Patient and Payer Incentives to Use Patented Brand-Name Drugs vs Authorized Generic Drugs in Medicare Part D. JAMA Intern Med 2021; 181:1605-1611. [PMID: 34661600 PMCID: PMC8524353 DOI: 10.1001/jamainternmed.2021.5997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In response to scrutiny over high drug prices, manufacturers of insulin and direct-acting antiviral agents for treating hepatitis C have recently introduced authorized generic alternatives to their patented brand-name products. These authorized generic drugs have list prices at least 50% lower than the list price of the brand-name drugs, which should result in savings to patients. However, it is unclear whether these authorized generic drugs are offered on Medicare Part D formularies because they may not provide savings to plans or Medicare. OBJECTIVE To assess Medicare Part D formulary coverage for 4 brand-name formulations of insulin and direct-acting antiviral agents and their authorized generic formulations. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used Medicare Prescription Drug Plan Formulary and Pricing Information Files from quarter 3 of 2020 and Medicare Part D plan enrollment for September 2020. Four patented brand-name drugs (sofosbuvir and velpatasvir fixed-dose combination tablets [Epclusa], ledipasvir and sofosbuvir tablets [Harvoni], insulin lispro [Humalog], and insulin aspart [Novolog]) and their authorized generic formulations for all Part D stand-alone prescription drug plans (n = 959) and Medicare Advantage prescription drug plans (n = 3148) were studied. MAIN OUTCOMES AND MEASURES Beneficiary-weighted formulary coverage of brand-name and authorized generic products; beneficiary out-of-pocket costs; and prerebate plan, manufacturer, and Medicare spending on brand-name and authorized generic products. RESULTS In quarter 3 of 2020, 97% of beneficiaries were in plans that covered brand-name drugs only or both brand-name and authorized generic drugs; approximately 3% were in plans that covered authorized generic drugs only. Observed authorized generic drug list prices were 67%, 62%, and 50% lower than list prices for Epclusa, Harvoni, and each brand-name insulin product, respectively. Medicare beneficiaries using authorized generic drugs could save $270 per year for 12 vials of Humalog and $2974 for a full course of Harvoni. Plans, however, have limited incentives to encourage authorized generic drug use because rebates for brands likely exceed savings available with authorized generic drugs, particularly for beneficiaries with spending that reaches the Medicare Part D coverage gap. CONCLUSIONS AND RELEVANCE The results of this cross-sectional study suggest that authorized generic drugs for insulin and direct-acting antiviral agents may lower out-of-pocket spending for patients but are unlikely to provide savings for Part D plans or Medicare. Instead, these drugs allow manufacturers to offer products at a lower list price without materially lowering net prices or profits.
Collapse
Affiliation(s)
- Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee.,Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Ameet Sarpatwari
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
3
|
Ball JG, Hollin IL. Attention to price disclosures in direct-to-consumer prescription drug advertising and the impact on drug perceptions. Res Social Adm Pharm 2021; 18:3402-3413. [PMID: 34819265 DOI: 10.1016/j.sapharm.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/25/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Mandatory disclosure of the price of prescription drugs within direct-to-consumer pharmaceutical advertisements (DTCA) has been proposed as a potential means of curbing rising drug costs in the United States. While price transparency in DTCA has widespread public support, empirical evidence regarding the effects of such drug prices disclosures remains limited. OBJECTIVES This study assessed the degree to which a price disclosure was noticed, the individual characteristics associated with price disclosure recognition, and the impact on perceived drug affordability, effectiveness, and safety. METHODS A randomized experiment was conducted among 2,138 members of the Amerispeak online panel. Participants were shown a television commercial for a drug treating either type II diabetes, deep vein thrombosis/pulmonary embolism (DVT/PE), or rheumatoid arthritis (RA) that disclosed the list price, disclosed the list price plus the average out-of-pocket cost, or had no price disclosure. RESULTS Roughly forty percent of participants noticed when a price was disclosed while 20-24% noticed information about individual costs varying (the higher of these percentages occurred when the average out-of-pocket cost was provided). Attention did not vary systematically with the cost amount. Recognition of the different elements of the price disclosure were most predicted by sociodemographic variables such as race, education, and income as well as health characteristics. Price disclosure altered perceived affordability of the advertised medication in a manner consistent with the costs provided, but such consistent significant effects were not found for perceived drug effectiveness and safety. CONCLUSIONS Repeated exposure to price disclosure in television DTCA or supplementary sources of price information may be necessary to increase attention to drug price information, especially among those who are most vulnerable to the burden of drug costs. Price transparency appears useful for adjusting affordability perceptions, but additional research needs to examine how such perceptions factor into healthcare decision-making and drug pricing.
Collapse
Affiliation(s)
- Jennifer Gerard Ball
- Department of Advertising and Public Relations, Klein College of Communication, Temple University, 300 Annenberg Hall, Philadelphia, PA, 19122, United States.
| | - Ilene L Hollin
- Department of Health Services Administration and Policy, College of Public Health, Temple University, 1301 Cecil B. Moore Ave, Philadelphia, PA, 19122, United States.
| |
Collapse
|
4
|
Rao BR, Dickert NW, Morris AA, Speight CD, Smith GH, Shore S, Moore MA. Heart Failure and Shared Decision-Making: Patients Open to Medication-Related Cost Discussions. Circ Heart Fail 2020; 13:e007094. [PMID: 33176459 DOI: 10.1161/circheartfailure.120.007094] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Discussions of medication costs between patients and clinicians are infrequent and often suboptimal. In the context of recently introduced drugs that are effective but expensive, patients with heart failure with reduced ejection fraction provide an ideal population to understand the perspectives of patients with chronic illness on medication cost and cost discussions. METHODS To explore patients' perspectives on discussing out-of-pocket medication costs with clinicians, 49 adults, aged 44 to 70 years, with heart failure with reduced ejection fraction were recruited from outpatient heart failure clinics. Descriptive qualitative analysis was performed on open-ended text data. RESULTS Participants who had prior medication-related cost discussions described their experience as generally positive, but about half of the participants had never had a cost discussion with their clinician. Most participants were open to cost discussions with clinicians and preferred that the clinician initiate discussions regarding medication cost. Importantly, these preferences held constant across reported levels of financial burden. CONCLUSIONS These data suggest a substantial willingness on the part of patients with heart failure with reduced ejection fraction to incorporate cost discussions into their care and identify important aspects of these discussions for clinicians to consider when engaging in conversations where cost is relevant. Improving understanding about how to integrate patient preferences regarding cost discussions into clinical encounters is an important priority for advancing patient-centered care.
Collapse
Affiliation(s)
- Birju R Rao
- Division of Cardiology, Department of Medicine (B.R.R., N.W.D., A.A.M., C.D.S., G.H.S.), Emory University School of Medicine, Atlanta, GA
| | - Neal W Dickert
- Division of Cardiology, Department of Medicine (B.R.R., N.W.D., A.A.M., C.D.S., G.H.S.), Emory University School of Medicine, Atlanta, GA.,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (N.W.D.)
| | - Alanna A Morris
- Division of Cardiology, Department of Medicine (B.R.R., N.W.D., A.A.M., C.D.S., G.H.S.), Emory University School of Medicine, Atlanta, GA
| | - Candace D Speight
- Division of Cardiology, Department of Medicine (B.R.R., N.W.D., A.A.M., C.D.S., G.H.S.), Emory University School of Medicine, Atlanta, GA
| | - Graham H Smith
- Division of Cardiology, Department of Medicine (B.R.R., N.W.D., A.A.M., C.D.S., G.H.S.), Emory University School of Medicine, Atlanta, GA
| | - Supriya Shore
- Department of Medicine, Division of Cardiology, University of Michigan Medical School, Ann Arbor (S.S.)
| | - Miranda A Moore
- Department of Family and Preventive Medicine (M.A.M.), Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
5
|
Blumenthal-Barby J, Opel DJ, Dickert NW, Kramer DB, Tucker Edmonds B, Ladin K, Peek ME, Peppercorn J, Tilburt J. Potential Unintended Consequences Of Recent Shared Decision Making Policy Initiatives. Health Aff (Millwood) 2020; 38:1876-1881. [PMID: 31682503 DOI: 10.1377/hlthaff.2019.00243] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Shared decision making (SDM)-when clinicians and patients make medical decisions together-is moving swiftly from an ethical ideal toward widespread clinical implementation affecting millions of patients through recent policy initiatives. We argue that policy initiatives to promote SDM implementation in clinical practice carry the risk of several unintended negative consequences if limitations in defining and measuring SDM are not addressed. We urge policy makers to include prespecified definitions of desired outcomes, offer guidance on the tools used to measure SDM in the multitude of contexts in which it occurs, evaluate the impact of SDM policy initiatives over time, review that impact at regular intervals, and revise SDM measurement tools as needed.
Collapse
Affiliation(s)
- Jennifer Blumenthal-Barby
- Jennifer Blumenthal-Barby ( jsswinde@bcm. edu ) is the Cullen Associate Professor and associate director of the Center for Medical Ethics and Health Policy, Baylor College of Medicine, in Houston, Texas
| | - Douglas J Opel
- Douglas J. Opel is an associate professor of pediatrics at the University of Washington School of Medicine and director of clinical ethics at the Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, in Washington
| | - Neal W Dickert
- Neal W. Dickert is an associate professor of cardiology and epidemiology at Emory University, in Atlanta, Georgia
| | - Daniel B Kramer
- Daniel B. Kramer is an assistant professor at Harvard Medical School and faculty at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, both in Boston, Massachusetts
| | - Brownsyne Tucker Edmonds
- Brownsyne Tucker Edmonds is an associate professor of obstetrics and gynecology and assistant dean for diversity affairs at the Indiana University School of Medicine, in Indianapolis
| | - Keren Ladin
- Keren Ladin is an assistant professor of occupational therapy and community health at Tufts University, in Medford, Massachusetts
| | - Monica E Peek
- Monica E. Peek is an associate professor of medicine at the University of Chicago Medical Center, in Illinois
| | - Jeff Peppercorn
- Jeff Peppercorn is an associate professor in and director of the Cancer Survivorship Program, Cancer Center, Massachusetts General Hospital, in Boston
| | - Jon Tilburt
- Jon Tilburt is a professor of internal medicine and biomedical ethics at Mayo Clinic in Rochester, Minnesota
| |
Collapse
|