JAMA | Accuracy of Physician Estimates of Out-of-Pocket Costs for Medication Filling

November 5, 2021

Accuracy of Physician Estimates of Out-of-Pocket Costs for Medication Filling

JAMA Netw Open. 2021;4(11):e2133188. doi:10.1001/jamanetworkopen.2021.33188

Key Points

Question  Can physicians accurately estimate a patient’s out-of-pocket expenses if they are given all the necessary information about a drug’s price and the patient’s insurance plan?

Findings  In this survey study of 371 primary care physicians, gastroenterologists, and rheumatologists, only 21% could accurately estimate out-of-pocket drug costs using information about the drug’s price and an insurance plan’s cost-sharing mechanisms, including deductibles, copays, coinsurance, and out-of-pocket maximums.

Meaning  These findings suggest that few physicians are able to estimate out-of-pocket costs accurately enough to have informed conversations about financial trade-offs with their patients.


Importance  One-third of US residents have trouble paying their medical bills. They often turn to their physicians for help navigating health costs and insurance coverage.

Objective  To determine whether physicians can accurately estimate out-of-pocket expenses when they are given all of the necessary information about a drug’s price and a patient’s insurance plan.

Design, Setting, and Participants  This national mail-in survey used a random sample of US physicians. The survey was sent to 900 outpatient physicians (300 each of primary care, gastroenterology, and rheumatology). Physicians were excluded if they were in training, worked primarily for the Veterans Administration or Indian Health Service, were retired, or reported 0% outpatient clinical effort. Analyses were performed from July to December 2020.

Main Outcomes and Measures  In a hypothetical vignette, a patient was prescribed a new drug costing $1000/month without insurance. A summary of her private insurance information was provided, including the plan’s deductible, coinsurance rates, copays, and out-of-pocket maximum. Physicians were asked to estimate the drug’s out-of-pocket cost at 4 time points between January and December, using the plan’s 4 types of cost-sharing: (1) deductibles, (2) coinsurance, (3) copays, and (4) out-of-pocket maximums. Multivariate linear regression was used to assess differences in performance by specialty, adjusting for attitudes toward cost conversations, demographics, and clinical characteristics.

Results  The response rate was 45% (405 of 900) and 371 respondents met inclusion criteria. Among the respondents included in this study, 59% (n = 220) identified as male, 23% (n = 84) as Asian, 3% (n = 12) as Black, 6% (n = 24) as Hispanic, and 58% (n = 216) as White; 30% (n = 112) were primary care physicians, 35% (n = 128) were gastroenterologists, and 35% (n = 131) were rheumatologists; and the mean (SD) age was 49 (10) years. Overall, 52% of physicians (n = 192) accurately estimated costs before the deductible was met, 62% (n = 228) accurately used coinsurance information, 61% (n = 224) accurately used copay information, and 57% (n = 210) accurately estimated costs once the out-of-pocket maximum was met. Only 21% (n = 78) of physicians answered all 4 questions correctly. Ability to estimate out-of-pocket costs was not associated with specialty, attitudes toward cost conversations, or clinic characteristics.

Conclusions and Relevance  This survey study found that many US physicians have difficulty estimating out-of-pocket costs, even when they have access to their patients’ insurance plans. The mechanics involved in calculating real-time out-of-pocket costs are complex. These findings suggest that increased price transparency and simpler insurance cost-sharing mechanisms are needed to enable informed cost conversations at the point of prescribing.


Over the last 2 decades, out-of-pocket expenses have risen dramatically in the US due to a combination of increasing health care prices and increasing insurance cost-sharing requirements.1 As a result, one-third of US residents have trouble paying their medical bills, even when they have insurance.2 Patients who struggle to afford their medications may cut pills in half, take them every other day, or forego them altogether.35 Cost-related nonadherence is associated with a higher risk of financial instability, disease progression, hospitalization, and death.69

To make matters worse, out-of-pocket costs are often difficult to predict, leaving patients and clinicians unable to account for costs in their medical decisions.10,11 The out-of-pocket cost associated with a single medication might change multiple times between January and December in a given year, depending on the amount of care a patient’s insurance plan has already covered.12 For example, early in the year, a patient who has not yet met her prescription drug deductible might pay the full price for her prescription drugs. Later in the year, once she has met her deductible, she likely pays either a flat fee (copay) or a percentage of each drug’s cost (coinsurance). If she incurs enough medical expenses, she may reach her out-of-pocket maximum before the end of the year. Once she meets this limit, she pays nothing at all for prescription drugs for the rest of the year. Such cost-sharing mechanisms exist to address moral hazard and prevent overconsumption of medical resources, but their complexity often confuses patients,13 who turn to their clinicians for assistance.1420 Although patients may not expect clinicians to have all the answers, they do report hoping for changes in prescription patterns or referrals to pharmaceutical assistance programs when out-of-pocket costs are projected to be high.21,22


SOURCE: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2785905#zoi210940r40


Sloan CE, Millo L, Gutterman S, Ubel PA. Accuracy of Physician Estimates of Out-of-Pocket Costs for Medication Filling. JAMA Netw Open. 2021;4(11):e2133188. doi:10.1001/jamanetworkopen.2021.33188

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