Seeing Sticker Price for HFrEF Meds Opens Door to Discussions
A column added to the EHR displaying out-of-pocket costs for various HFrEF meds inspired more-open conversations.
PHILADELPHIA, PA—For patients facing high prices for the drugs they need to manage their heart failure with reduced ejection fraction (HFrEF), easy access to information about their options for guideline-directed medical therapy (GDMT) can help spark conversations with clinicians about what’s often a taboo topic: money.
In the POCKET-COST-HF trial, presented this weekend at the American Heart Association (AHA) 2023 Scientific Sessions, researchers developed a way to provide patient-specific price details within the electronic health record (EHR), so that they could be seen during the clinical encounter.
While medical therapy for HFrEF has grown more effective in recent years, it’s also famously grown much more expensive, investigator Neal W. Dickert, MD, PhD (Emory University School of Medicine, Atlanta, GA), reminded the audience at AHA. For Medicare Part D patients, annual out-of-pocket costs for the “four pillars” of heart failure drugs exceed $2,600, a level that can be prohibitive.
“We know that costs matter to patients, but we also know there are barriers to integrating cost into decision-making,” said Dickert. “There may be discomfort on the part of clinicians and patients to talk about money, time constraints in clinical encounters, and difficulty framing the value propositions of the various components of GDMT. We also know that, in most cases, neither the patient nor the clinician knows that patient's out-of-pocket costs at the time of their encounter.”
Here's where the EHR-embedded tools might prove helpful, he said. While these options are emerging, “we don't know the impact of providing this kind of information.” POCKET-COST-HF researchers set out to find the answer.
Dhruv Kazi, MD (Beth Israel Deaconess Medical Center, Boston, MA), the study’s assigned discussant in the late-breaking session, praised the trialists for tackling this question. “In cardiology, we almost fetishize innovation in terms of technology. A new drug, a new device, a new wire even, gets more attention than the actual hard work of how do we get this information, this device, this technology to patients who are most likely to benefit from it,” he commented. POCKET-COST-HF is an example of “the hard work that it takes to understand how to disseminate new technology in an equitable manner.”
EPIC-HF Plus Cost
To start, Dickert and colleagues built their study intervention “on the platform of the EPIC-HF checklist, an evidence-based patient activation tool shown to increase uptake of GDMT,” he said.
At six clinic sites within two hospital systems, the researchers screened potential participants with HFrEF (LVEF ≤ 40%) a few weeks before their usual clinic visit and, for those who agreed to take part, the financial navigation company TailorMed estimated out-of-pocket costs. Non-English speakers were excluded from the study.
In cardiology, we almost fetishize innovation. Dhruv Kazi
For the control group, office visits were then conducted normally with the EPIC-HF checklist alone. Those in the intervention group, on top of that, were able to see a column in the checklist that included the out-of-pocket costs. Audio recordings were made during the clinical encounters, patients were surveyed by phone 2 to 3 weeks later, and an EHR chart review was conducted at 3 months.
A total of 247 clinical encounters were recorded (121 patients in the control group and 126 in the intervention group, with 25 clinicians in each). Mean age was just over 60, and around 70% were male. Two-thirds were white, a quarter Black/African American, and less than 5% Hispanic/LatinX.
Baseline GDMT rates were high across both groups, said Dickert, with over 90% on beta-blockers, over 80% on ACE inhibitors/ARBs, and over 60% on mineralocorticoid receptor antagonists. Rates of use of sacubitril/valsartan (Entresto; Novartis) were similar between groups, at roughly 45%, though sodium-glucose cotransporter 2 (SGLT2) inhibitors were more commonly used in the intervention arm than in the control arm.
The study’s primary outcome—cost-informed decision-making, defined as either the clinician or patient mentioning the costs of HFrEF drugs during the office visit—was less common in controls than with the intervention (49% vs 68%; P = 0.021). Success of the intervention varied, but results were positive across five of the six sites.
Once cost was brought up, the intervention group was more likely than the control group to discuss specific dollar amounts and less likely to talk more qualitatively about costs, though the differences weren’t significant. Yet those in the intervention group were significantly less likely to make a contingency plan based on cost (ie, have a backup in mind if the price was too high when filling the prescription) compared with controls (16.5% vs 31.9%; P = 0.0276).
When surveyed, patients who received the intervention were less likely than those given the ordinary checklist to say they had switched to a new medication (21.2% vs 36.4%; P = 0.0109). These patients also were more likely, though nonsignificantly so, to recall their physician discussing the medication costs (46.0% vs 36.4%) and how to reduce them (38.5% vs 28.8%). Among patients who had any change to their HF medication, those in the intervention group were more apt to say they were actually following that regimen.
“We have important hypothesis-generating findings that I think suggest that cost disclosure may reduce things like contingency planning and may increase the extent to which patients are actually taking the medications that are decided upon by their clinicians,” Dickert concluded. “Larger sample sizes and longer-term follow-up are needed to assess the impact of comprehensive out-of-pocket cost disclosure on medication choices, prescribing, and adherence, and further study is needed of implementation strategies and novel emerging tools that are embedded within EHR systems.”
In most cases, neither the patient nor the clinician knows that patient's out-of-pocket costs at the time of their encounter. Neal W. Dickert
Kazi, in his talk, said he sees two approaches to solving the problem of cost barriers for patients who need HFrEF meds.
On one hand, there’s the “individual solution,” which involves tailoring what therapies are chosen to whether the patient can afford them, Kazi explained. “The big-picture policy solution involves lowering drug prices and redesigning the benefit of insurance plans so that even if prices are high, patients are not responsible for them,” he noted, pointing out that some progress may come from the Inflation Reduction Act and Medicare price negotiations.
“But in the meantime, we've got to figure out how to talk about out-of-pocket costs, because patients want us to talk about them and clinicians either don't have the information they need [or] don't feel comfortable, and certainly don't have the time to do so,” said Kazi.
Following POCKET-COST-HF, it will be important to look at this intervention in patients who don’t speak English, who tend to be at higher risk; to better understand variations among the sites and how this applies in other settings; and to figure out what the optimal result of cost conversations should be, said Kazi. “It is possible that if we talk to people about costs, [then] people choose to receive fewer medications,” which could have ramifications down the line.
In fact, he added, “if a patient truly cannot afford the medication, and they forego the medication, is that a quality penalty for the physician? Or is that a quality bonus for the health system for doing what patients actually want? Plenty of food for thought here.”
Speaking with TCTMD, Dickert said that even clinicians who don’t have access to a custom-made column in the EHR system can try to incorporate costs into their discussions with patients.
“Every record system is a little different. There’s a number of tools coming out. I would say the biggest difference in what we did versus what’s available routinely, is [ours] had the costs displayed in a comparative way,” he said. In most EHR systems, clinicians must first enter in the prescription then follow through several additional steps before even being able to see costs, which are displayed individually rather than side by side.
The data are already there within existing EHRs, Dickert pointed out. What’s needed is an interface that makes this information more accessible and meaningful, as well as knowledge on how to apply the information. Exactly what form this will take isn’t yet certain, he noted, but “we’ve clearly learned that studying implementation strategies is important, and there are a lot of tools that are promising. I think this trial shows us [that work] is worth doing.”
Dickert NW. Integrating cost into shared decision-making for heart failure with reduced ejection fraction: a trial providing out-of-pocket costs for heart failure medications during clinical encounters. Presented at: AHA 2023. November 11, 2023. Philadelphia, PA.
- Dickert reports noncommercial research support from NCATS, AHRQ, PCORI, and the AHA; DSMB service with the NHLBI and PCORI; as well as research support from and consulting for Abiomed.
- Kazi reports no relevant conflicts of interest.