The Problem: In the past two decades, out-of-pocket medical costs have risen considerably, causing economic burdens for many patients and contributing to medication non-adherence in others. But to what extent, if any, do patients and their physicians discuss out-of-pocket medical expenses and their impact on health?
Grantee Background: Pittsburgh native G. Caleb Alexander, MD, MS, knew from boyhood that he wanted to be a psychiatrist like his father. In college, however, Alexander dropped pre-med to major in philosophy. “My interest in medicine had to do with interpersonal aspects of care and focusing on health and disease,” he says. “I saw little connection between first semester genetics and calculus and the field of medicine.” Questioning his future, Alexander left Oberlin College in Oberlin, Ohio, after his sophomore year, and worked for a year in an intensive care unit of a psychiatric hospital. When he resumed college, at the University of Pennsylvania, Alexander had no more questions about becoming a physician, though he still majored in philosophy. “I enjoyed the chance to develop the analytic skills that studying philosophy helped to cultivate,” he says. Alexander attended medical school at Case Western Reserve University in Cleveland from 1994 to 1998, and then returned to Penn to complete his internship and residency in internal medicine.
Grantee Perspective: At Case Western, Alexander developed an interest in the doctor-patient relationship, and in patients’ experience of the health care system. He sought out nephrologist Ashwini Sehgal, MD, a former Robert Wood Johnson Foundation Clinical Scholar (1989–1993), and worked with him examining quality of care for patients with end-stage renal disease. “He was a teacher, role model, adviser and friend,” says Alexander. “He introduced me to the principles and tools of health services research, and helped me realize the gratification I would find in trying to tackle important problems in health policy and clinical care. He also taught me lessons about mentoring that I continue to keep in mind.” A paper he and Sehgal wrote on barriers to renal transplantation in blacks, women and low-income people, was published in 1998 in the Journal of the American Medical Association (JAMA). When Alexander returned to Penn for his residency, his interest in health services research expanded to other populations and aspects of quality of care, especially regarding the role that medical expenses play during clinical decision-making.
“Penn was a busy, large, tertiary hospital. People would come in very sick, and we would order an incredible number of tests to try to help figure out what was going on. I noticed that nobody seemed to be considering costs in clinical decision-making for these hospitalized patients,” Alexander recalls. One explanation was that most of the care was non-discretionary, and another was that since insurance covers much of hospital-based care, patients’ expenses would be low. “This led me to wonder whether costs would be more frequently considered in the outpatient setting, where prescriptions and other treatments are so common, and often more discretionary as well.” Alexander conducted exploratory interviews with outpatient physicians about how they chose therapies and considered costs in medical decision-making. His experiences ultimately led to his Clinical Scholars project proposal to examine physician-patient communication about out-of-pocket costs.
Results: As a 2001–-2003 Clinical Scholar, Alexander pursued a master’s degree in science from the University of Chicago’s Department of Health Studies while doing research. He conducted a paired study of 133 area internists and 484 of their outpatients to compare views and practices about discussions of out-of-pocket health care and prescription costs. The results? Though most patients wanted to talk with their doctor about out-of-pocket expenses, only 35 percent of physicians and 15 percent of patients reported ever having discussed them. “Physician communication with patients about out-of-pocket costs may be an important yet neglected aspect of current clinical practice,” Alexander and his colleagues concluded.
At first, Alexander felt that the study’s results were somewhat obvious. “I questioned if it was a valuable use of my Clinical Scholars time,” he says. But his primary RWJF mentor, David Meltzer, MD, PhD, reassured him that sometimes the best projects prove the obvious. Indeed, Alexander’s findings were considered so significant to the field of clinical medicine that they were published in JAMA in August 2003. They also spawned other studies, illustrating another point made by an RWJF mentor—that research projects often raise as many questions as they answer. What, for instance, were the barriers to patient-doctor communication? How could physicians help patients burdened by prescription costs? And what are the cost implications—or clinical economics—of common decisions regarding prescriptions that doctors and patients must navigate, such as whether to prescribe generic vs. brand drugs, or a three- vs. one-month supply of medication? “There are many ways that doctors can help reduce prescription costs,” says Alexander.
Alexander is now an assistant professor of epidemiology at Johns Hopkins University. In 2003, RWJF granted him support for continued research, and in 2006, Alexander received a three-year Robert Wood Johnson Foundation Physician Faculty Scholars Award (grant ID# 057400) to build on his Clinical Scholars' project by developing and evaluating interventions to safely reduce patients’ out-of-pocket prescription costs. Under this program, Alexander recently conducted a study of the impact of free prescription drug samples on out-of-pocket prescription costs and spending for patients. The study, published in the March 24, 2008 issue of Medical Care, received wide press coverage, including reports in the New York Times and ScienceDaily.
Alexander sometimes refers to himself as an “amateur bioethicist” because of his continued interest in survey methods to examine important subjects in bioethics. “Clinical Scholars was an invaluable opportunity to get training in the non-biological science paths to health care delivery—biostatistics, epidemiology, health services research and health economics,” says Alexander. “One of the challenges of health services research is in designing and framing it to be of maximum interest to policy-makers and clinicians. And this is one of the many skills that the Clinical Scholars program provided some training in. I’m trying to reach the medical community and also the lay community. I’m trying to reach policy-makers and researchers, but also the general public. I think patient empowerment is often an effective way in shaping change in the clinical encounter. I view research studies as a really golden opportunity to work with stakeholders to leverage as much change as possible.”
RWJF Strategy: Originally authorized in 1972, the Robert Wood Johnson Foundation Clinical Scholars program is the oldest national program at RWJF. The program fosters the development of physicians who will lead the transformation of American health care. Former Clinical Scholars have become directors of federal, state and local health agencies and departments. Senior Program Officer J. A. Grisso, MD, MSc, who managed the program at RWJF, summed up the ideal Clinical Scholars candidate this way: “Someone with the passion to make a difference in health and health care, and the promise of being able to do it.”