Out-of-pocket costs comprise approximately one-sixth of health care expenditures and nearly one-half ofexpenditures on prescription medicines. These costs pose a burden on many patients and are associatedwith non-adherence and other barriers to quality care. Dr. Alexander's previous work suggests that patient-physician communication about out-of-pocket prescription costs is an important yet neglected aspect ofcurrent clinical practice. Such findings may be especially relevant to elderly patients who are more likely tobe on multiple medications and have fixed incomes. In this proposed randomized trial, Dr. Alexander willdevelop, implement, and evaluate the effectiveness of an intervention designed to assist patients andphysicians in safely reducing patients' out-of-pocket prescription costs. One hundred and eighty patientstreated by 45 general internists and geriatricians will be recruited for the study from 8 physician practices.The intervention includes both patient- and physician-targeted strategies designed to overcome previouslyidentified barriers to reducing patients' out-of-pocket costs. Primary outcomes of the study will be comparedbetween baseline and six to eight weeks following patients' index office visit and include the impact of theintervention on out-of-pocket costs, medication appropriateness, health status, and burden from out-of-pocket costs. Secondary outcomes will examine the effect of the interventions on rates of patient-physiciandiscussions about costs, how changes in out-of-pocket costs are achieved (e.g. switching from brand nameto generic equivalent), and barriers that may prevent enhanced intervention effectiveness (e.g. patientdiscomfort initiating discussions about prescription costs). The recently passed Medicare Modernization Actmakes this research especially relevant because it leaves substantial gaps in coverage for beneficiaries ofaverage means who incur high drug expenses. As a former Robert Wood Johnson Clinical Scholar with anestablished track record examining patient-physician communication about out-of-pocket costs, Dr.Alexander is in an ideal candidate to explore this important interface between bioethics, health policy, andclinical medicine.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Clinical Investigator Award (CIA) (K08)
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HSR Health Care Research Training SS (HCRT)
Program Officer
Anderson, Kay
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University of Chicago
Internal Medicine/Medicine
Schools of Medicine
United States
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Chien, Alyna T; Chin, Marshall H; Alexander, G Caleb et al. (2014) Physician financial incentives and care for the underserved in the United States. Am J Manag Care 20:121-9
Schwarze, Margaret L; Redmann, Andrew J; Alexander, G Caleb et al. (2013) Surgeons expect patients to buy-in to postoperative life support preoperatively: results of a national survey. Crit Care Med 41:1-8
Paul Olson, Terrah J; Brasel, Karen J; Redmann, Andrew J et al. (2013) Surgeon-reported conflict with intensivists about postoperative goals of care. JAMA Surg 148:29-35
Alexander, G C; Gallagher, S A; Mascola, A et al. (2011) Increasing off-label use of antipsychotic medications in the United States, 1995-2008. Pharmacoepidemiol Drug Saf 20:177-84
Alexander, G Caleb; O'Connor, Alec B; Stafford, Randall S (2011) Enhancing prescription drug innovation and adoption. Ann Intern Med 154:833-7, W-301
Higashi, Ashley; Zhu, Shu; Stafford, Randall S et al. (2011) National trends in ambulatory asthma treatment, 1997-2009. J Gen Intern Med 26:1465-70
Liu, Frank Xiaoqing; Alexander, G Caleb; Crawford, Stephanie Y et al. (2011) The impact of Medicare Part D on out-of-pocket costs for prescription drugs, medication utilization, health resource utilization, and preference-based health utility. Health Serv Res 46:1104-23
Qato, Dima M; Lindau, Stacy Tessler; Conti, Rena M et al. (2010) Racial and ethnic disparities in cardiovascular medication use among older adults in the United States. Pharmacoepidemiol Drug Saf 19:834-42
Lale, Allison; Moloney, Rachael; Alexander, G Caleb (2010) Academic medical centers and underserved communities: modern complexities of an enduring relationship. J Natl Med Assoc 102:605-13
Torke, Alexia M; Moloney, Rachael; Siegler, Mark et al. (2010) Physicians' views on the importance of patient preferences in surrogate decision-making. J Am Geriatr Soc 58:533-8

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