Physicians' Attitudes About Prescribing and Knowledge of The

ORIGINAL INVESTIGATION Physicians’ Attitudes About Prescribing and Knowledge of the Costs of Common Medications

Steven Reichert, MD; Todd Simon, MD; Ethan A. Halm, MD, MPH

Background: Compliance with medical therapy is of- only 13% had been formally educated about drug costs. ten compromised because patients cannot afford to pay Regarding insurance coverage, 94% of physicians gave for medications. Inadequate physician knowledge of drug strong consideration to the cost of medications when pa- costs may unwittingly contribute to this problem. tients were self-paying, 68% when patients had Medi- care, and 30% when patients had Medicaid or were par- Objective: To measure attitudes about prescribing and ticipants in a health maintenance organization with a knowledge of medication costs and compare differences prescription plan. Physicians’ estimates of the cost of a among attending physicians and residents. month’s supply of 33 commonly used medications were accurate in 45% of cases, too low for 40%, and too high Design/Participants: Written survey of internal medi- for 15%. The costs of brand-name and expensive drugs cine house staff and general medicine attending physi- were most likely to be underestimated. House officers were cians in an urban hospital-based primary care center. less cost-conscious than attending physicians.

Results: One hundred thirty-four of 189 physicians re- Conclusions: Physicians were predisposed to being sponded (71% response rate). Seventy percent of respon- cost-conscious in their prescribing habits, but lacked dents were house officers and 30% were attending phy- accurate knowledge about actual costs and insurance sicians. Eighty-eight percent of physicians felt the cost coverage of drugs. Interventions are needed to educate of medicines was an important consideration in the pre- physicians about drug costs and provide them with reli- scribing decision, and 71% were willing to sacrifice some able, easily accessible cost information in real-world degree of efficacy to make drugs more affordable for their practice. patients. However, 80% often felt unaware of the actual costs. Only 33% had easy access to drug cost data, and Arch Intern Med. 2000;160:2799-2803

RESCRIPTION drugs ac- medication costs among family practition- counted for $93 billion in ers, neurologists, geriatricians, and pedia- health care costs in 1998 and tricians.4-13 Over the last decade, the rise are the fastest growing com- of managed care with its emphasis on con- ponent of health expendi- taining costs has had an enormous influ- Ptures.1,2 Total drug expenditures are esti- ence on the practice of medicine. Whether mated to have reached $120 billion in or not increasing cost-consciousness has 1999, making medication costs the sec- influenced physicians’ attitudes about pre- ond most expensive item in the national scribing and knowledge of medication health care budget, surpassing the cost of costs is unknown, and no studies have ex- hospital care.1-3 These dramatically rising amined attitudes and knowledge about From the Division of General pharmaceutical costs are due in part to the drug costs among general internists, who Internal Medicine, Department growth in number of drugs dispensed, the are the primary providers for a major pro- of Medicine, Englewood high price of new agents, and direct ad- portion of adults. Hospital and Medical Center, vertising to consumers. While physi- These knowledge deficits, if they still Englewood, NJ (Dr Reichert), cians are inundated with information about exist, are important for 2 reasons. First, and Division of General the availability and efficacy of drugs, they inattention to cost-effective prescribing Internal Medicine, Department of Medicine (Drs Simon and receive little information about actual drug contributes to the inefficient use of soci- Halm), and Department of costs in medical school, in residency train- etal resources and rising pharmaceutical Health Policy (Dr Halm), ing, or once in practice. spending. Second, because many pa- Mount Sinai School of Studies conducted in the 1980s and tients must pay for the full cost of their Medicine, New York, NY. early 1990s found poor knowledge of medications, expensive prescriptions may

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Downloaded From: https://jamanetwork.com/ on 09/30/2021 METHODS selected from longer lists of the 100 most frequently prescribed drugs in the United States, adapted to reflect pharmaceuticals commonly used in our local primary care prac- PHYSICIAN SURVEY DATA tices. The list represents a variety of brand-name and generic medications of varying costs across several therapeutic classes We surveyed internal medicine house staff (n=145) and including asthma and allergy, diabetes mellitus, analgesics, full-time and part-time attending physicians (n=44) in antihypertensives, antibiotics, and antisecretory agents, the Division of General Internal Medicine at the Mount among others. Sinai campus of the Mount Sinai–New York University Medical Center, New York, NY. These physicians staff STATISTICAL ANALYSES and write nearly all the prescriptions for the main hospital-based primary care clinic as well as several We report agreement with the drug attitude statements (4, small, private outpatient practices. The written survey somewhat agree, and 5, strongly agree). Physician cost es- was 3 pages, anonymous, and self-administered. It was timates were compared with the standard AWP listed in distributed in February 1998. We sent a reminder notice the 1998 Drug Topics Red Book.20 When the actual AWP fell and replacement questionnaires to all nonrespondents in into the same price category as the respondent estimate, March 1998. this was counted as an accurate answer. When the AWP Demographic variables were level of training, year of was greater than the physician estimate, this was an un- graduation from medical school, and sex. Physicians were derestimate, and vice versa for overestimates. Drug prices asked to agree or disagree with 8 medication attitude state- that were estimated correctly by half or more of respon- ments on a 5-point Likert scale (1, strongly disagree; 2, some- dents were considered to be correctly estimated. We used what disagree; 3, no opinion; 4, somewhat agree; and 5, ␹2, Fisher exact, and Wilcoxon tests to evaluate differ- strongly agree). We also asked them to agree or disagree that ences between responders and nonresponders and be- “The cost of medications is more of a concern to me when tween attending physicians and house officers. In order to my patient’s insurance status is: Medicare, Medicaid, self- compare the accuracy of cost estimates between attending pay, or HMO [health maintenance organization] with pre- physicians and house officers, we created a total cost score scription plan.” Another question asked about the sources in which price category estimates were converted into stan- respondents use to obtain information about drug costs. dardized z scores (ranging from+5 [overestimate by 5 cat- The second half of the survey had physicians estimate the egories], to –5 [underestimate by 5 categories], with 0 in- average wholesale price (AWP) of a 30-day supply of 33 com- dicating accurate). The total cost score was normally monly used outpatient medications (Table 1). Each medi- distributed. Negative total cost scores were interpreted as cation was listed by generic and brand name (if appropri- overall underestimation of drug costs. Two-sided values of ate), dose, and frequency. Respondents were given a choice PՅ.05 were considered statistically significant. All analy- of 5 different price categories: $1 to $10, $11 to $30, $31 to ses were performed with PC SAS 6.12 statistical software $50, $51 to $80, and Ͼ$80. These 33 medications were (Statistical Analysis Systems Inc, Cary, NC).

go unfilled or may be used less frequently than directed, RESULTS resulting in compromised patient health.14 This topic has risen to national prominence on the We received completed surveys from 134 of 189 physi- health policy agenda regarding the absence of prescrip- cians (71% response rate; 66% of house officers and 86% tion drug coverage by Medicare and its potential conse- of attending physicians). The characteristics of respon- quences.15-18 Eighty-five percent of Medicare beneficiaries dents are summarized in Table 2. Seventy percent of receive at least one prescription each year, though nearly those responding were house officers. The remaining 30% one third lack any supplemental insurance coverage of medi- were attending physicians, who had a median of 9 years cations.18,19 Medicare beneficiaries with incomes near the in clinical practice (range, 6-20 years). Response rates poverty line, but who are not poor enough to qualify for were similar across training levels. Medicaid assistance, spend as much as one third of their incomes on out-of-pocket drug expenses.18,19 To make mat- ATTITUDES ABOUT ters worse, patients in poor health have higher overall medi- MEDICATION COSTS AND cation costs, but tend to have lower incomes. PRESCRIBING PRACTICES The purpose of this survey was to measure attitudes about prescribing and knowledge of drug costs Overall, 88% of respondents felt that cost was an impor- among general medicine attending physicians and inter- tant consideration when making medication choices, and nal medicine residents. We were interested in assessing 71% were willing to sacrifice some degree of efficacy in or- the extent to which physicians are willing to consider the der to make drugs more affordable for their patients. How- cost of medications and a patient’s insurance coverage ever, 80% often felt unaware of the actual costs of medi- in the prescribing decision. We also sought to measure cations, and only 13% reported ever having any formal physicians’ knowledge of actual drug costs. We were ad- education about the cost of medications. Sixteen percent ditionally interested in assessing differences in knowl- of physicians reported asking patients about the costs of edge and attitudes between attending physicians and their medications. Only 8% of physicians preferred brand- house officers. name medications over generic drugs regardless of cost.

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Downloaded From: https://jamanetwork.com/ on 09/30/2021 Table 1. Medications Included in the Drug Cost Survey Table 2. Characteristics of Physician Respondents (n = 134)* Generic Name Brand Name Physician Characteristics No. (%) Albuterol sulfate Proventil (Schering Corp, Kenilworth, NJ) Sex Beclomethasone diproprionate Beclovent (Glaxo Wellcome Inc, Male 75 (56) Research Triangle Park, NC) Female 59 (44) Fluticasone propionate Flovent (Glaxo Wellcome Inc) House officers Zafirlukast Accolate (Zeneca Pharmaceuticals, PGY 1 30 (22) Wilmington, Del) PGY 2 28 (21) Loratadine Claritin (Schering Corp) PGY 3 35 (27) Diphenhydramine Attending physicians 41 (30) Glipizide Glucotrol XL (Pfizer Pharmaceuticals, Time in practice, median (IQR), y 9 (6-20) New York, NY) Metformin hydrochloride Glucophage (Bristol-Myers Squibb, *PGY indicates postgraduate year; IQR, interquartile range. Wallingford, Conn) Troglitazone Rezulin (SmithKline Beecham Pharmaceuticals, Philadelphia, Pa) that the cost of medicines was a strong concern. For a pa- 70% human insulin isophane Novolin 70/30 (Novo Nordisk suspension/ Pharmaceuticals Inc, Princeton, NJ) tient with Medicare coverage, two thirds of physicians 30% regular human insulin (68%) agreed that cost was a concern. Fewer than 1 in 3 injection physicians (30%) felt that cost was a concern for patients Fluoxetine hydrochloride Prozac (Eli Lilly & Co, Indianapolis, Ind) with Medicaid insurance or HMO prescription plans. Naproxen Acetaminophen Nabumetone Relafen (SmithKline Beecham KNOWLEDGE OF MEDICATION COSTS Pharmaceuticals) Ibuprofen In order to measure physicians’ knowledge of medication Acetaminophen with codeine Tylenol with Codeine No. 3 (McNeil costs, we asked them to estimate the AWP of a month’s sup- Pharmaceutical, Spring House, Pa) ply using 5 cost categories. Of the 33 commonly used drugs Itraconazole Sporanox (Janssen Pharmaceutica, that we asked about, the majority of physicians were ac- Titusville, NJ) Ranitidine Zantac hydrochloride (Glaxo Wellcome curate in their estimates for 45% of the drugs (n=15) and Inc) inaccurate in their cost estimates for 55% (n=18); 40% Cimetidine (n=13) were underestimated and 15% (n=5) were over- Omeprazole Prilosec (Merck & Co Inc, Whitehouse estimated. The mean±SD total cost accuracy score was Station, NJ) –0.74±8.09, indicating an overall tendency to underesti- Sustained-release verapamil mate costs (range, 19 to +24). The prices of 90% of the ge- Enalapril Vasotec (Merck & Co Inc) Amlodipine Norvasc (Pfizer Pharmaceuticals) neric drugs were correctly estimated, while the prices of Nifedipine XL Procardia (Pfizer Pharmaceuticals) 52% of brand-name drugs were underestimated (Figure). Propranolol The prices of 91% of the expensive drugs (cost Ͼ$80/ Atenolol month) and the prices of 86% of the high-priced drugs ($51- Hydrochlorothiazide $80/month) were underestimated, while the prices of 80% Lovastatin Mevacor (Merck & Co Inc) of the most inexpensive and moderately priced drugs Ciprofloxacin Cipro IV (Bayer Corp, West Haven, Conn) (Ͻ$30/month) were correctly estimated. Trimethoprim-sulfamethoxazole Clarithromycin Biaxin (Abbott Laboratories, COMPARISON OF ATTITUDES OF ATTENDING North Chicago, Ill) PHYSICIANS WITH HOUSE OFFICERS Erythromycin Cefpodoxime proxetil Vantin (Pharmacia & Upjohn Inc, Kalamazoo, Mich) Attending physicians were more cost-conscious than house officers (Table 3). Comparing the proportion of overall underestimation of drug costs using the total cost accu- SOURCES OF COST INFORMATION racy score, house officers were 50% more likely to underestimate drug costs than attending physicians (relative risk One third of respondents (33%) reported easy access to [RR], 1.5; 95% confidence interval [CI], 1.01-2.22). We drug cost information. The resources they reported found similar results when we compared the mean±SD using were The Medical Letter on Drugs and Therapeutics total cost scores for the 2 groups (house officers, –1.7±8.1; (65%), other physicians (52%), patients (45%), phar- attending physicians, 1.5±7.6; P=.04). In addition, house macists (41%), drug company representatives (25%), officers were more likely to report feeling unaware of medi- advertisements (17%), and journals (10%). cation costs (RR, 1.36; 95% CI, 1.10-1.68), but they were less likely to agree that cost was an important concern for INFLUENCE OF INSURANCE STATUS patients with Medicare insurance (RR, 0.74; 95% CI, 0.58-0.94). The sources of drug cost information also dif- Physicians’ concerns for costs of medications varied widely fered by training level. Residents were twice as likely to based upon their patients’ insurance status. When pa- ask other physicians for cost information and much less tients had no medical insurance, 94% of respondents agreed predisposed to query The Medical Letter on Drugs and Thera-

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Downloaded From: https://jamanetwork.com/ on 09/30/2021 peutics or pharmacists. Comparing responses among house viders we surveyed were not well equipped with the req- officers, there was a trend toward more senior residents uisite knowledge or cost information resources needed to having more knowledgeable and cost-conscious responses. facilitate cost-effective prescribing in everyday practice. There were no differences between the 2 groups in any of Four out of 5 physicians indicated that they were often the other attitudes or practices we examined, including unaware of actual drug costs, and most underestimated preference for brand-name drugs, willingness to sacrifice the cost of common brand-name medications we in- efficacy for affordability, or prescribing attitudes for self- quired about. Poor knowledge about medication costs was paying, Medicaid, or HMO patients. most acute among house staff, who were 50% more likely than attending physicians to underestimate prices. COMMENT We were also struck by the fact that nearly one third of physicians did not appear to understand that Medi- Too often, patients may fail to fill prescriptions or may care does not pay for medications. This misunderstand- ration their medications because they are too costly.14 The ing was much more common among house staff. The sub- ability to pay for expensive medications is most strained stantial economic burden borne by Medicare beneficiaries for those without a drug coverage benefit (no insurance without supplemental insurance to pay for their medi- or Medicare alone) and of limited financial means. For cations has recently emerged as a major national health physicians who care for the poor and elderly, such oc- policy issue.15-19 In our own practice, the high price of currences are all too common and contribute to subop- medications for Medicare patients of modest financial timal control of chronic diseases. Physicians may unwit- means is a frequent contributor to poor compliance and tingly exacerbate problems in many of these cases when suboptimal control of chronic medical problems such as they prescribe drugs without knowing the cost of medi- hypertension, diabetes, and asthma. From the perspec- cines for their patients. tive of an individual patient, it makes sense that physi- In our survey of general medicine attending physicians are much less concerned about the out-of-pocket cians and internal medicine residents, we found reasons cost of drugs for persons with Medicaid or HMO drug for optimism and concern. The good news was that, in gen- plan coverage. However, from a societal perspective, the eral, physicians appeared predisposed to practice cost- prospect of practicing cost-effectively for only a subset effective medicine. Nearly all respondents felt that the cost of patients may prove to be detrimental. of medications was important, and most were willing to Our results confirm the findings of studies in the sacrifice some degree of clinical efficacy to make therapy 1980s and early 1990s that physicians believe that the more affordable. However, the bad news was that the pro- costs of drugs are important,6,10,13 while their actual knowledge of costs was poor.4-7,9,11,12 Thus, primary care/ internal medicine physicians in 1998 appear to be no more Underestimation Correct Response Overestimation knowledgeable about costs than their family practice, ge- 100 riatrics, pediatrics, and neurology colleagues were a decade ago.4,6,7,12 While we confirmed previous reports that 80 physicians underestimate the cost of expensive medicines and overestimate the cost of inexpensive ones,4,6,8,12 60 we found that their accuracy was more closely related to whether a drug was a brand name or generic. In con- 40 trast to previous studies of pediatricians and family practitioners,6,7 we found differences in attitudes between at- 20 tending physicians and house officers. We suspect that variations in study design and statistical power may ex- Accuracy of Physicians’ Estimates, % 0 plain these discrepancies. Generic Brand Name 1-10 11-30 31-50 51-80 >80 Two factors likely contribute to continued inad- Drug Type Cost of 30-Day Supply, $ equate knowledge of medication costs. First, medical Accuracy of physicians’ estimates of monthly drug costs. schools and residency training programs provide little or

Table 3. Differences in Knowledge, Attitudes, and Practices Related to Medication Costs Between Attending Physicians and Residents (n = 134)*

Residents, % Attending Physicians, % (n = 93) (n = 41) RR (95% CI) P Underestimated drug costs 62 41 1.50 (1.01-2.22) .04 Feel unaware of costs of drugs 85 62 1.36 (1.10-1.68) .004 Consider cost for Medicare patients 61 82 0.74 (0.58-0.94) .01 Use The Medical Letter for cost data 60 77 0.77 (0.59-0.99) .05 Ask pharmacists for cost data 32 62 0.51 (0.34-0.76) .001 Ask other physicians about drug costs 62 30 2.06 (1.35-3.14) .001 Use drug representatives for cost data 20 35 0.58 (0.32-1.05) .07

*RR indicates risk ratio; CI, confidence interval.

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Downloaded From: https://jamanetwork.com/ on 09/30/2021 no formal education about medication costs and insur- time when needed. At our own institution, we have de- ance coverage of pharmaceuticals. Second, there are few veloped a drug cost guide for 100 commonly used outpa- ways to obtain reliable drug price information in a timely tient drugs that we have widely distributed as a pocket- fashion. Cost information is rarely if ever included in sized booklet. We have also made it available on the medical journals, textbooks, or drug-prescribing guides institution’s Intranet website, accessible from any physi- (including the Physicians’ Desk Reference). cian workstation. We hope interventions like these will While the most commonly cited cost reference was help empower physicians with the tools needed to prac- The Medical Letter on Drugs and Therapeutics, a peer- tice cost-effective prescribing, foster better medication com- reviewed publication, we were somewhat troubled by re- pliance, and ultimately improve health outcomes. ports of relying on drug company representatives and advertisements for price data. The accuracy of information Accepted for publication March 2, 2000. provided by pharmaceutical sales representatives has been 21,22 The authors thank all of the physicians who partici- questioned. In addition, greater exposure to drug rep- pated in this study. resentatives has been associated with higher prescrib- 23 Reprints: Ethan A. Halm, MD, MPH, Department of ing costs among primary care physicians. The greater Health Policy, Box 1077, Mount Sinai Medical Center, One use of pharmaceutical representatives by attending phy- Gustave L Levy Place, New York, NY 10029 (e-mail: sicians compared with house staff may reflect the fact that [email protected]). policies governing interactions between attending physicians and industry personnel at our institution are less restrictive than those for residents. However, since house REFERENCES staff were more likely to ask other physicians, presum- ably attending physicians, for drug cost information, we 1. Iglehart JK. The American health care system—expenditures. N Engl J Med. 1999; 340:70-76. are concerned about the propagation of biased or inac- 2. Kong D. US efforts urged to check high pharmaceutical costs. Boston Globe. July curate information. Few physicians have had sufficient 28, 1999:A8. training during medical school and residency regarding 3. Mehl B, Santell JP. Projecting future drug expenditures—1999. 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