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 (REPRINTED) ARCH INTERN MED/ VOL 160, OCT 9, 2000 WWW.ARCHINTERNMED.COM 2799 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 METHODS selected from longer lists of the 100 most frequently pre- scribed drugs in the United States, adapted to reflect phar- maceuticals 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, x2, 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 P#.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 .$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 atti- tudes 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.