Discussing drug cost with patients may be awkward, but it’s vital

Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Payal Kohli, MD, an attending cardiologist for Kaiser Permanente in Denver, Colorado. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

Dr. PayalWith the ever-growing armamentarium of new therapies available today, a conversation about prescription drug costs with patients is rapidly becoming a reality for every physician.

I usually wait until the end of the office visit to bring up cost since patients tend to tune out everything else once they start thinking about money.  Then, I pull out the most benign analogy I can think of-cars-to break the ice in the most gentle fashion.

Further reading: There has to be better prescription drug price transparency

Let me illustrate.  A patient comes in with atrial fibrillation and has a high enough annual risk for stroke to warrant anticoagulation therapy based on his/her CHA2DS2-Vasc score. I start the conversation with the patient with a choice of rate vs. rhythm strategy.  Once he makes this decision, I turn to the decision of risks and benefits of anticoagulation for stroke prevention.

By now, the patient’s head is spinning with all these facts and decision fatigue has already permeated the visit.  Now, I am faced with offering the patient one of five choices for oral anticoagulation therapy: warfarin, pradaxa, xarelto, eliquis or savaysa.  To avoid information overload, I skip the discussion about each of the individual trials, their patient populations and their inclusion/exclusion criteria. 

More business news: What is the price of physician stress and burnout?

Instead, I start by asking the patient about cars. “If given a choice, would you rather choose a Toyota, a Tesla, a BMW or a Porsche?”  Immediately, their response provides me with great insight into their approach to cost vs. benefit ratio.  The Toyota driver may feel that a car’s purpose is to transport from one location to another in the most cost-efficient way and may be willing to tolerate a lower-cost vehicle that requires more frequent repairs (i.e. frequent INR checks with warfarin, a generic low cost drug).

The Tesla driver, on the other hand, favors luxury over cost and may be willing to pay the upfront cost of a more expensive vehicle in exchange for the convenience of fewer maintenance visits and better performance (i.e. eliquis, which is more expensive but does not require INR check and has a slightly better safety to efficacy profile). 

Next: The discussion can never be easy, but it's essential

A discussion about prescription drug costs can never be easy, but it is something we must all learn how to do with our patients because it is one of the biggest drivers of healthcare costs and dictates the degree to which patients are going to adhere to recommended therapies.

Further reading: It's time for fair pricing in medical transportation

In order to do this, however, we must all become aware of the costs of new drugs and incorporate that into our decisions of which drug to choose for which patient.

Even so, there remain drugs with prohibitively high costs, which may never be within the average patient’s reach.  For example, the wholesale cost of Repatha, the new injectable PCSK9 inhibitor, is a mere $14,100 for a year’s supply.  At that price, the drug becomes the equivalent of a Lamborghini, reserved only for an elite few. 

That’s where the physician’s knowledge of cost combined with the knowledge of the efficacy and safety of the drug from its clinical trials can allow for a truly informed discussion about drug selection, best tailored to each patient.

So I implore you to learn about costs for your most-frequently prescribed drugs, not just for the patient’s benefit and to maximize your patient outcomes, but because knowledge of a drug’s cost is quickly becoming just as important as the drug’s efficacy or safety. And since physicians’ own preferences can sometimes influence the recommendations we make, perhaps we should all also ask ourselves, ”What kind of car would I prefer to drive?”