Medication Costs Impact Patient Adherence Even in Oncology, Affecting Quality Care

Eileen Koutnik-Fotopoulos

August 2014, Vol 5, No 6 - Economics of Cancer Care

Nonadherence to medication has been associated with financial burden; however, little is known about the association between the discussion of cancer treatments between patients and oncologists regarding out-of-pocket cost and medication adherence. In a new study, researchers sought to explore the relationship between nonadherence, financial distress, and patient–physician discussions of costs related to the treatment of cancer. The findings of a cross-sectional survey show that many of today’s high-cost cancer drugs impose out-of-pocket costs on patients that affect their treatment decisions (Bestvina CM, et al. J Oncol Pract. 2014;10:162-167).

“A growing body of evidence suggests that insured cancer patients are suffering under mounting healthcare bills,” study coinvestigator S. Yousuf Zafar, MD, MHS, Associate Professor and Gastrointestinal Oncologist at Duke Cancer Institute, Durham, NC, told Value-Based Cancer Care. “Our findings suggest that patients might wait to talk about costs until they are already financially burdened. We need to work harder at identifying patients at risk for financial toxicity before they experience it.”

The survey included 300 insured respondents diagnosed with solid tumors who had received at least 1 month of anticancer therapy at the time of enrollment. The most common malignancy was colorectal (81%). The median income of the group was approximately $60,000 annually; 49 (16%) respondents reported a state of “high” or “overwhelming” financial distress. A total of 56 (19%) patients had talked with their oncologist about out-of-pocket costs, and 155 (52%) patients reported some desire to have cost discussions with their oncologist.

“Whether we are talking about cost, quality, or satisfaction, the patient–physician relationship is at the epicenter of how we define delivery of best possible care,” said Dr Zafar about why patient–physician communication is vital in preserving quality of care. “A great deal of work has been—and is being—done around how to optimize that relationship. We are learning more about how cost can harm the patient experience. Just like we have learned to communicate and teach patients about how to manage physical toxicity related to chemotherapy, we must foster patient–physician communication around financial toxicity. Importantly, not everyone wants to talk about costs. Part of the challenge is identifying those who might benefit most from such a discussion.”

Medication Cost and Nonadherence
Patient-reported nonadherence parameters in this study included:

  • Skipping doses
  • Taking less medication than prescribed to make it last longer
  • Or simply not filling a prescription because of cost.

Of the 300 patients in the study, 80 patients reported nonadherence to their medication. Of the nonadherent patients, 66 (22% of the total patients) did not fill a prescription because of cost, 42 (14%) skipped doses, and 33 (11%) took less medication.

When asked about adherence with chemotherapy drugs, 14 (approxi­mately 5%) patients reported nonadherence to their chemotherapy. To make a prescription last longer, 1% of the study patients skipped chemotherapy doses, approximately 2% took less chemotherapy drugs than prescribed, and 3% did not fill a prescription for a chemotherapy agent because of cost.

Discussing Costs with Your Patients
Dr Zafar said that there are strategies oncologists can use in their conversations with patients to help alleviate any financial concerns before they become a barrier to adherence.

“Keep it simple. We know that in the outpatient setting, prescription medications are the biggest culprit in terms of out-of-pocket costs. A simple question like, ‘Do you have prescription drug coverage?’ can save a patient thousands of dollars, especially as we prescribe more oral chemotherapy,” he said.

“Also, I engage the help of others. Our pharmacist in the clinic evaluates the insurance plans of my patients before they leave with their expensive prescription. This avoids problems down the road.”

The study findings raise important questions for oncologists regarding shared decision-making, said Dr Zafar. “First, we have to find ways to address the cost of care in decision-making without getting too bogged down in details of insurance plans and nontransparent pricing,” he advised.

“Most oncologists want to avoid adding to their patients’ financial burden, but we have little education as to how we can help. Second, we need more effective ways to educate patients about the risks and benefits of treatment. Only then can patients make informed decisions regarding the value of their cancer care.”

Dr Zafar emphasized, “We can no longer afford to ignore the impact of financial burden on the quality of care and patient well-being. We need to find ways to integrate value and costs to patients into decision-making. Again, not everyone wants or needs to discuss costs, but in the status quo, we are missing even the ones who do want to have that discussion.”

Dr Zafar acknowledged the study’s limitations. “These data suggest correlation but not evidence of direction. In other words, we could not tell specifically if nonadherence was a result of cost discussion or vice versa. Furthermore, details of the cost discussions between patients and physicians were not recorded. Specifically, it is unclear what event triggered the discussion or whether the patient or provider initiated the conversation. Future research should focus on whether promoting cost discussion can improve treatment adherence,” he suggested.