Physicians' Opinions About Responsibility for Patient Out-of-Pocket Costs and Formulary Prescribing in Two Midwestern States

BACKGROUND: Multi-tier copayment designs in pharmacy benefit plans are intended to steer patients and prescribers to preferred drug therapies that have lower out-of-pocket costs for patients. OBJECTIVES: To describe and assess physicians' prescribing experiences and opinions in a multi-tier, primarily 3-tier formulary environment in 2 Midwestern states. METHODS: This was a cross-sectional survey of physicians practicing in either Minnesota or North Dakota. A packet consisting of a survey instrument, a cover letter, and a postage-paid return envelope was mailed to a random sample of 690 physician members of the Minnesota Medical Association (n = 460, 5.1% of members) or the North Dakota Medical Association (n = 230, 25.6% of members). Surveys were mailed between March and May 2006. Nonresponders were mailed up to 2 additional surveys. Survey items included practice specialty, sources used to obtain drug information, perceived importance of cost containment actions (e.g., prescribing drug with lowest total cost, prescribing drug that minimizes patient out-of-pocket cost), and how often the physician was personally aware of the following when writing a prescription: identity of the patient's insurer, patient's pharmacy benefit structure, preferred medications on the insurer's formulary, patient's copayment (out-of-pocket cost) responsibility, and list price of the medication. RESULTS: The survey response rate was 49.8% (296 of 594). The results were as follows: 93.5% of respondents agreed that it was important to prescribe the drug that would minimize the patient's out-of-pocket costs, 73.2% agreed that it was important to discuss out-of-pocket medication costs with patients, 81.8% of respondents agreed that it was important to prescribe the drug with the lowest total costs, and 33.3% of respondents believed that it was their responsibility to prescribe a preferred (formulary) medication. According to the survey, 61.6% of respondents were rarely or never aware of their patient's copayment amounts, and 42.4% were rarely or never aware of the list price of the medication. Physician specialty was associated with the awareness of the identity of the patient's insurer (generalists, 41.1% vs. specialists, 19.2%; P = 0.001) and use of personal digital assistant (PDA) when prescribing (generalists, 38.9% vs. specialists, 21.1%; P = 0.005). CONCLUSIONS: Physicians who responded to this survey believed that it was important to prescribe drugs that would minimize patients' prescription copayments, but they were often unaware of the preferred medications on the formulary, the patients' copayment amounts, or the price of the drugs prescribed.