Real-time benefit tools (RTBTs) are federally mandated clinician-facing applications embedded in the electronic health record (EHR) that display the out-of-pocket costs of prescribed medications and lower-cost alternatives, if available. RTBTs may be useful for primary care providers (PCPs), whose patients often take numerous medications; however, RTBTs may also add time to visits that are already complex and compressed. To explore PCP experiences with and attitudes toward RTBTs. We conducted a qualitative descriptive study of PCPs with access to an RTBT at primary care clinics affiliated with two large academic health systems. Semi-structured interviews elicited (1) attitudes toward medication cost transparency, (2) RTBT training, (3) experiences using RTBTs, and (4) perceived effects of RTBT use on decision-making and administrative burden. Primary care physicians and advance practice providers with ≥ 1 year of practice. Thematic analysis of interview transcripts. We interviewed 35 PCPs. Most were physicians (25/35) and female (23/35), and had ≥ 10 years’ experience (19/35). We identified three themes. First, PCPs received minimal education on RTBTs and were open to more training. Second, PCPs believe RTBTs have the potential to improve patient care by facilitating cost conversations and reducing administrative burden. Third, several pitfalls have hindered use, including incomplete information, inaccurate cost estimates, and clinically inappropriate lower-cost suggestions. Two study sites, both of which use the same EHR. While PCPs generally saw the RTBT as a promising tool that can facilitate compassionate, cost-conscious care, they identified problems that limited their desire to use it. For utilization to improve, EHR developers and insurers must ensure that RTBT information is actionable, clinically appropriate, and time saving.

Background Amyotrophic Lateral Sclerosis (ALS) is associated with substantial financial costs, both from lost income for patients (pALS) and caregivers (cALS) and medical expenses. There is no validated financial burden screening tool for ALS. We aim to define the main components of financial burden for pALS/cALS to develop an ALS-specific screening tool. Objective Analyze interviews with pALS/cALS to create a framework for financial burden in ALS that will inform the development of an ALS-specific financial burden screening tool. Methods Interview questions were developed using existing literature on financial burden, financial burden scales for other disease models, and input from ALS clinicians, pALS, cALS, and members of ALS advocacy organizations. pALS/cALS were recruited from an ALS clinic and ALS advocacy and research organizations. Video interviews were conducted, recorded, and transcribed. Those with barriers to verbal communication provided written responses. Two team members reviewed the transcriptions and written responses independently and identified codes, which were reconciled through discussion, then consolidated into themes. Results Eleven video and 2 written interviews were conducted with 12 pALS and 3 cALS. pALS’ average age was 61.5 years. All attend an ALS multidisciplinary clinic and identify their spouse as primary caregiver. Most participants reported equipment and hired caregivers as significant financial stressors. Participants also report employment and income disruption and barriers to insurance utilization and government and nonprofit resource engagement, leading to future-oriented financial anxiety. Participants balanced financial concerns with quality of life goals and discussed their financial concerns within the family unit, but rarely with their clinic team. Implications Equipment and caregiving costs, barriers to insurance and nonprofit utilization, and income changes contribute to financial burden among pALS/cALS. These findings will be confirmed during analysis of additional interviews and then used to develop an ALS-specific financial burden screening tool.

Cutaneous squamous cell carcinoma occurs with increasing incidence in the aging United States population and, depending on the tumor stage, can require multimodal treatment. Neoadjuvant cemiplimab has shown promise in improving pathological response and event-free survival, but its cost effectiveness compared with starting with upfront wide local excision has not been explored. This health economics evaluation aims to determine whether adding neoadjuvant cemiplimab may be a more economically valuable intervention in the management of head and neck locoregionally advanced cutaneous squamous cell carcinoma using a decision tree combined with a state-transition Markov model over a 10-year horizon. In the model's base-case analysis, the expected long-term cost per patient was $19,021 lower with the addition of neoadjuvant immunotherapy than with upfront wide local excision alone and yielded 0.11 more quality-adjusted life years, with adjusted time horizon and health utilities leading to the greatest differences in mean costs and quality-adjusted life years, respectively. In this model, neoadjuvant immunotherapy followed by wide local excision was associated with lower expected costs and modestly higher quality-adjusted life years over a 10-year horizon, although the results were sensitive to modeling parameters and assumptions. Future research is needed to clarify long-term costs, outcomes, and corresponding health state utilities.

From aggressive billing practices to neglectful or discriminatory care, news stories about the misconduct of healthcare organizations abound. Yet there has been limited ethical scrutiny of hospitals and other healthcare organizations in the bioethics literature. In this paper, we explore what philosophy and organizational theory can offer in terms of concepts for articulating the obligations of healthcare organizations, specifically hospitals. We highlight how the concepts of institutional agency and responsibility, administrative harms and burdens, and communicative blame provide theoretical resources that can help bioethics get closer to a more robust organizational ethics. We advance two claims: first, these concepts help us make sense of how hospitals or healthcare organizations-not just individuals and the broader systems they operate within-can be morally responsible or blameworthy. Second, critical reflection on these concepts as they apply to several historical examples suggest some prima facie obligations of organizations that provide patient care.

INTRODUCTION/AIMS:People living with amyotrophic lateral sclerosis (ALS; pALS) have extensive care needs, from wheelchairs to feeding tubes to caregiving support. The financial impact of these needs on pALS and their caregivers (cALS) has not been fully explored. We aimed to explore the types of expenses for which pALS and cALS crowdfund, and the financial circumstances that lead them to resort to crowdfunding. METHODS:We randomly selected 320 ALS-related crowdfunding campaigns posted on the GoFundMe platform from 2010-2020. We conducted a summative content analysis to categorize the expenses for which campaigns requested money and descriptions of financial burden. RESULTS:We included 266 campaigns. Most campaigns were written by people who were not the pALS or cALS, such as children or coworkers (85.3%). Most campaigns fundraised for medication and treatment costs (21.4%), equipment (25.2%), accessibility needs for home (24.0%), and transportation (19.5%), and in-home caregiving services (18%). Multiple campaigns (22.9%) requested assistance with nonmedical expenses ranging from rent and utilities to personal travel and hobby goals. Many campaign writers (47.7%) described financial burden related to the pALS' diagnosis, including medical debt (4.5%) and job loss of the pALS (30.5%) and/or cALS (6.8%). DISCUSSION:Our analysis of ALS-related crowdfunding campaigns highlights the breadth of medical and nonmedical care needs and quality of life goals for which people request additional financial support throughout the disease course. These findings provide important insights for ALS care teams into the expenses of pALS.

This Viewpoint describes the successes and areas for improvement of student-run clinics in the US.

Background: The underrepresentation of women in senior positions persists in academic medicine. Data-driven strategies are needed to catalyze advancement. Methods: We designed a novel, National Institutes of Health-funded intervention—Engaging Peer Mentors for Opportunity, Well-Being, and Equity Realization (EMPOWER) to be evaluated in a randomized study. This educational innovation was modeled on the Leadership Learning Model Framework developed for the Executive Leadership in Academic Medicine (ELAM)® program and integrated existing research and multidisciplinary content expertise. EMPOWER strives to support the career advancement of women faculty by cultivating fundamental leadership competencies implemented within a peer mentorship framework. Early outcomes surrounding perceptions, feasibility, as well as engagement are described. Results: We share the EMPOWER curriculum implemented among a national cohort of women clinician-scientists within a broader randomized trial design; 94 consenting participants were assigned to the intervention. Many participants (68%; n = 54) found EMPOWER valuable or very valuable for their personal or career development. It was easy or very easy for 79% ( n = 63) of participants to access the online educational materials, and 61% ( n = 49) attended all or almost all of the peer circle meetings. Conclusions: We describe EMPOWER, a novel, potentially scalable, virtual intervention, to address the unmet needs of women faculty in academic medicine at the pivotal transition to leadership. The EMPOWER intervention was feasible, and we report early lessons learned from its development. Future evaluation will include qualitative analyses and comparison of outcomes between program participants and control subjects.

BackgroundDespite rising rates of contralateral prophylactic mastectomy (CPM), little is known about how surgeons and patients communicate about the procedure. This study is among the first to use real-time audio recordings of CPM discussions, link conversations to treatment choice, and include multiple institutions. We assessed surgeon-patient discussions, focusing on how often CPM was addressed, who initiated it, and how decisions were made.MethodsWe recruited surgeons and patients from three academic centers and audio-recorded the first surgical consultation for patients with (1) early-stage unilateral breast cancer or ductal carcinoma in situ and (2) no strong family history or BRCA mutation. Transcripts were analyzed using an inductive, qualitative approach to generate themes and detect patterns.ResultsTwenty-seven patients and eight surgeons participated. In 14 cases, neither patient nor surgeon mentioned CPM. In the remaining 13, surgeons initiated the topic in 10, typically while introducing surgical options. Of the four patients who received CPM, each had a strong initial preference for CPM and was undeterred by the surgeon's cautionary statements against it. When patients lacked strong preferences for CPM, they generally followed surgeon recommendations to forego CPM or to delay the decision until tests (eg, genetics and MRI) were complete.DiscussionSurgeons, not patients, most commonly initiated CPM discussions. Initial patient preference strongly influenced surgical decisions. Surgeon recommendations to wait for additional information shaped decision making only when patients were initially undecided. Future research should explore how patients form preferences prior to consultation and how best to address them during clinical conversations.

This survey study examines attainment of professional and leadership milestones by middle to senior career women and men 12 to 15 years after receiving K awards.

RATIONALE: Raising money through online crowdfunding platforms is a popular way to pay for medical expenses. Analyzing medical crowdfunding campaigns can illuminate the financial struggles that patients and families face. Limited data exist on the financial impact of obstructive lung disease, which includes asthma, bronchiectasis, and chronic obstructive pulmonary disease (COPD). We examined the types of expenses for which patients with obstructive lung disease raise funds using the GoFundMe platform. METHODS: We collected a random sample of 89,645 United States-based GoFundMe campaigns posted from January 2010 to August 2020. We identified campaigns that contained the following word fragments: COPD, CPOD (allowing for misspellings), emphysema, smoker's lung, smoker lung, chronic bronchitis, asthma, inhaler, pulmonary rehab. Two coders reviewed each campaign in detail. Campaigns were included if they were for one adult with asthma, bronchiectasis, and/or COPD. We categorized financial needs using inductive summative content analysis. Codes included: disease, description of financial circumstances, expenses directly related to medical care (e.g., oxygen), and expenses indirectly related to medical care (e.g., transportation to appointments). RESULTS: We identified 184 campaigns, including people with asthma (n=144, 78%), COPD (n=49, 27%) and bronchiectasis (n=5, 3%), allowing for multiple diagnoses per patient. Half of the campaigns reported that the patient or caregiver had lost their job due to illness (n=92, 50%). One-third of campaigns (n=59, 32%) noted having insurance, while 14 campaigns (8%) mentioned being uninsured and 111 did not mention insurance (60%). Of 128 campaigns (70%) requesting money for expenses directly related to lung disease, 19% (n=35) were for hospital bills, 10% (n=19) for medications, and 3% (n=6) for oxygen. Almost half of campaigns described indirect expenses (n=88, 47%), including treatment-associated travel (n=14, 8%), food/groceries (n=16, 9%), home accessibility modifications (n=9, 5%), and utilities/electricity (n=6, 3%). Forty-five campaigns requested money for expenses directly (n=40, 22%) and indirectly (n=19, 10%) related to comorbidities, most commonly cancer, heart disease, and obesity. CONCLUSIONS: Crowdfunding campaigns detail the economic struggles of patients. Although there has been an emphasis on controlling the cost of inhalers, more common concerns in our sample were related to the cost of hospitalizations and everyday non-medical expenses. In future research, we will examine how different expenses contribute to financial need among patients with obstructive lung disease, especially among those who do not utilize crowdfunding. This information could inform future interventions aimed at mitigating financial burden in this patient population.

Background:Web-based crowdfunding is commonly used to defray medical expenses, but it is not fully known which factors determine fundraising success. Previous studies have usually focused on a single disease category at a time or a small number of mutually exclusive diseases, even though a given campaign may seek funding for multiple conditions. In addition, differences in fundraising exist according to socioeconomic status, but whether this association applies across different diseases is unclear. Thus, questions remain about how certain medical conditions and the socioeconomic context of a campaign's location interact to influence fundraising success. Objective:This study aimed to determine the impact of specific medical conditions on crowdfunding success and to evaluate if the socioeconomic environment of a campaign's location has a distinct effect on earnings. Last, we sought to understand the effect of these features on donation behavior in terms of number of donations and donation amount. Methods:Web scraping was used to collect medical crowdfunding campaigns on GoFundMe that were based in the United States and created between 2010 and 2020. Using a previously validated disease identification algorithm based on natural language processing, we identified the presence or absence of 11 broad disease categories in each campaign description. An Area Deprivation Index was calculated to represent a composite view of the socioeconomic status of each campaign's county of origin. Generalized linear models were constructed to estimate the impact of mentioning specific disease categories and the campaign's area deprivation on the amount of money raised. Results:This study analyzed 89,645 crowdfunding campaigns. We identified at least one medical condition in 82.6% (n=74,016) of campaigns. A quarter of campaigns (n=25,026, 27.9%) mentioned more than one disease category. Neoplasms were the most common condition among medical crowdfunding campaigns by a large margin (n=38,221, 43.7% of campaigns), followed by injuries and external causes (n=18,087, 20.7% of campaigns). In multivariable analysis, mentioning neoplasms, injuries and external causes, respiratory system diseases, nervous system diseases, or infections in the campaign was associated with higher total fundraising amounts. On the other hand, mentioning genitourinary, mental health, or endocrine diseases was associated with lower total fundraising amounts. Campaigns originating from less-deprived counties raised more money than those from more-deprived counties, and this effect was independent of the diseases mentioned in the campaign. The success of campaigns for higher-earning conditions and from less-deprived areas was typically due to a larger number of donations, rather than a higher donation amount. Conclusions:The medical conditions mentioned in crowdfunding campaigns matter for the fundraising success of the campaign. Importantly, certain diseases tended to receive lower total fundraising amounts. Regardless of the specific diseases mentioned in the campaign, the socioeconomic backdrop of a campaign's location had a significant impact on fundraising.

BACKGROUND:How physicians frame medication benefits and tradeoffs while engaging in shared decision-making with patients is not well described in the management of heart failure with reduced ejection fraction (HFrEF). METHODS:This qualitative, secondary analysis of recorded encounters between clinicians and patients with HFrEF sought to identify major themes regarding the communication of medication benefits and tradeoffs. Encounters occurred in 6 clinics within 2 academic health systems. English-speaking adult patients with a diagnosis of HFrEF (ejection fraction ≤40%) were enrolled. RESULTS:A total of 247 patient encounters were analyzed. Patients' mean (standard deviation) age was 62.9 (13.9) years; 70.5% were male; 64.0% were White, 26.3% Black, and 3.2% Hispanic/Latinx. Overall, 70% of encounters contained a discussion involving medication benefits. Substantial variability was observed, and 4 main themes emerged. (1) Primary benefits (increased survival, reduced hospitalizations, better quality of life) were commonly discussed, but clinicians described the magnitude in only 2 cases. (2) Adjunctive drug benefits (improved physiology, tolerability, affordability) were described nonspecifically. (3) Persuasive forms of communication were common, including direct appeals to authority/guidelines, references to pharmaceutical advertisements, and emotive language. (4) Significant heterogeneity was present in the content and character of benefit tradeoff discussions. CONCLUSIONS:Rare inclusion of medication benefit magnitude, variability in the presentation of benefits, and use of persuasive and emotive communication all challenge traditional notions of shared decision-making but are commonly encountered in clinical interactions for heart failure. Recognizing these contextual factors and evaluating which are consistent with effective decision-making in HFrEF and other chronic conditions is important and needed.

The FDA often exercises flexibility in deciding whether to approve highly promising drugs for patients in desperate need of treatment options. But it doesn't consider a drug's likely financial toxicity.

Background: We developed the Engaging Peer Mentors for Opportunity, Well-Being, and Equity Realization (EMPOWER) program to provide leadership training and peer mentoring in a virtual, scalable format. Designed to be widely accessible to women leaders in academic medicine, it combined an asynchronous online curriculum with 1 hour per month group meetings via teleconference with peers and a faculty advisor. This qualitative study assessed the program's feasibility and impact as well as identified areas for quality improvement.Methods: We conducted individual interviews with 34 program participants as well as focus groups with 14 faculty advisors. These were conducted virtually at the program midpoint and following program completion. The Framework Method informed qualitative analysis.Results: Beneficial program outcomes included knowledge acquisition/skill development, new or different ways of thinking, a sense of empowerment/self-confidence, and the clarification of personal values/goals. Monthly, 1-hour peer meetings appeared to further facilitate learning and practical application. Barriers included a lack of time to complete didactic activities and to attend group meetings, limitations of an online/virtual format, individual circumstances, and idiosyncratic group dynamics. Recommendations to improve quality and establish best practices included clear communication of well-defined aims/expectations, tailored programming, efficient use of time, minimization of labor/mental load, and enhanced online community-building.Conclusions: The benefits program participants and their faculty advisors described reinforce the value of gender-aware leadership development programs, especially those that include peer mentoring. By enhancing accessibility, engagement, and flexibility, programs such as EMPOWER can become more inclusive and effective, ensuring that all promising leaders can thrive in academic medicine.

BACKGROUND:Guideline-directed medical therapy for heart failure (HF) with reduced ejection fraction can entail high out-of-pocket (OOP) costs, prompting concerns about financial toxicity and access. OOP costs are generally unavailable during encounters. This trial assessed the impact of providing patient-specific OOP costs to patients and clinicians. METHODS:This trial was conducted between June 2021 and August 2023 at 6 clinics in 2 health systems using a stepped-wedge, clinic-level cluster-randomized design. Adult patients with HF with reduced ejection fraction (left ventricular ejection fraction ≤40%) were enrolled. The intervention was built upon the EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) checklist of approved HF with reduced ejection fraction medications. Patients and clinicians received this checklist with (intervention) or without (control) patient-specific OOP cost estimates for higher-cost medications at the time of encounter. Estimates were obtained by providing pharmacy benefit information to a financial navigation firm. Encounters were audio-recorded, and patients were surveyed 2 weeks later. The primary outcome was cost-informed decision-making, defined by mentioning HF medication cost during the encounter. The primary analysis used a generalized linear mixed model. Secondary outcomes were assessed via transcript subcoding and analysis of survey responses. RESULTS:Demographic characteristics of 247 patients (mean age, 62.9 years; 29.5% female; 26.3% Black; and 3.2% Hispanic/LatinX) treated by 39 clinicians in intervention and control periods were similar. In the primary model, the rate of cost-informed decision-making was higher in the intervention group than the control group (68% versus 49%; P=0.021). Baseline rates of cost discussions and the impact of the intervention varied across sites. When cost discussions were present, fewer discussions in the intervention group involved contingency plans to address potential costs (16.5% versus 31.9%; P=0.028). Most other secondary outcomes were not significantly different. CONCLUSIONS:Disclosing comprehensive OOP medication costs to patients with HF with reduced ejection fraction increased cost-informed decision-making. Further work is needed to optimize implementation and assess the impact on medication choices and adherence. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04793880.

Importance Prior studies have revealed gender differences in workplace assessments of physicians, but little is known about differences by physician gender in patients’ online written reviews. Objective To analyze whether patients’ perceptions of their physicians’ interpersonal manner and technical competence differ by physician gender and practicing specialty and are associated with review star ratings. Design, Setting, and Participants This cross-sectional study sampled written reviews submitted by patients between October 16, 2015, and May 27, 2020, for physicians across the US from a commercial physician rating and review website. Physicians included primary care physicians (PCPs) listed under family medicine, internal medicine, and pediatrics and surgeons listed under general surgery; orthopedic surgery; and cosmetic, plastic, and reconstructive surgery. Hand-coded reviews were used to fine-tune a natural language processing algorithm to classify all reviews for the presence and valence of patients’ comments of physicians’ interpersonal manner and technical competence. Statistical analyses were performed from July 2022 to December 2024. Exposure Female or male physician gender. Main Outcomes and Measures Outcomes included the presence and valence of interpersonal manner and technical competence comments and receipt of high star ratings. Multilevel logistic regressions analyzed differences by female or male physician gender in interpersonal manner and technical competence comments and whether those comments were associated with review star ratings. Results The analysis included 345 053 written reviews of 167 150 physicians (mean [SD] age, 55.16 [11.40] years); 60 060 physicians (35.9%) were female, and 36 132 (21.6%) were surgeons. Female physicians overall had higher odds than males of receiving any (odds ratio [OR], 1.19; 95% CI, 1.16-1.22) or negative (OR, 1.22; 95% CI, 1.18-1.26) patient comments for their interpersonal manner. Among PCPs, females had higher odds than males of receiving a negative comment for interpersonal manner (OR, 1.22; 95% CI, 1.18-1.27) and, when receiving that negative comment, had disproportionately lower odds of receiving a high star rating (OR, 0.62; 95% CI, 0.53-0.73). Female physicians overall (OR, 1.09; 95% CI, 1.05-1.13) and female PCPs (OR, 1.08; 95% CI, 1.04-1.13) had higher odds than their male counterparts of receiving a negative comment for their technical competence. When receiving a negative comment for technical competence, both female PCPs (OR, 0.60; 95% CI, 0.50-0.73) and female surgeons (OR, 0.67; 95% CI, 0.50-0.89) had disproportionately lower odds of receiving a high star rating compared with their male counterparts. Female PCPs also had lower odds than male PCPs of receiving a high star rating when receiving a positive comment for technical competence (OR, 0.82; 95% CI, 0.70-0.96). Conclusions and Relevance In this cross-sectional study of online written reviews, female and male physician gender were differently associated with patients’ perceptions of their physicians’ interpersonal manner and technical competence. The findings suggest that patients harbored negative gender biases about the interpersonal manner of female physicians, especially female PCPs, and also assessed disproportionate penalties related to technical competence for both female PCPs and female surgeons.

When patients with multimorbidity (≥ 2 chronic diseases) are diagnosed with cancer, their adherence to non-cancer medications declines. Nonadherence in this patient population has been linked to an increased risk of disease progression, hospitalization, and death. However, the reasons for declines in adherence are not well understood. To qualitatively explore barriers and facilitators of chronic medication adherence among patients with multimorbidity and active cancer. Semi-structured interviews conducted in March–November 2023. Adults aged ≥ 50 years with 2+ chronic conditions and cancer diagnosed within the past year and under active treatment at one large academic health system. We used purposive sampling to include balanced numbers of advanced (stage 3–4) and non-advanced (stage 1–2) cancers, and perceived change in chronic medication adherence after cancer diagnosis (same/better vs. worse). We asked participants to describe medication adherence barriers and facilitators, and experiences balancing cancer and non-cancer symptoms, medications, and medical appointments. We analyzed transcripts using applied thematic analysis. We interviewed 20 participants. The majority were female (14/20), had breast cancer (8/20) or lung cancer (6/20), and took 3+ medications (12/20). Half had stage 3–4 disease. Three themes emerged. First, participants felt forced to prioritize among their diseases, medications, and appointments. Many focused their energy on their cancer, putting management of their chronic diseases on pause. Second, participants’ trust in caregivers, medical teams, and their own self-confidence influenced their motivation to adhere to medications. Third, adherence was logistically difficult and depended on drug side effects, drug-disease interactions, drug-drug interactions, and conflicting recommendations from cancer and non-cancer care teams. Patients with cancer and multimorbidity must manage the demands of their cancer and non-cancer treatments simultaneously and navigate relationships with multiple healthcare professionals whose recommendations may conflict. Interventions are needed to address barriers to adherence in this population.

OBJECTIVES:The high costs of cancer care can cause significant harm to patients and society. Prostate cancer, the leading nonskin malignancy in men, is responsible for the second-highest out-of-pocket (OOP) payments among all malignancies. Multiple first-line treatment options exist for metastatic castration-resistant prostate cancer (mCRPC); although their costs vary substantially, comparative effectiveness data are limited. There is little evidence of how gross payments made by insurers and OOP payments made by patients differ by treatment and health plan type and how these payment differences relate to utilization. STUDY DESIGN:Retrospective cohort study. METHODS:We used IBM MarketScan databases from 2013-2019 to identify men with prostate cancer who initiated treatment with 1 of 6 drugs approved for first-line treatment of mCRPC. We calculated and compared gross and OOP payments and drug utilization across drug and insurance plan types. RESULTS:We identified 4298 patients who met our inclusion criteria. Insurer payments varied substantially by first-line therapy but were similar across different health plan types, except for docetaxel. OOP payments for a given first-line therapy, in contrast, varied by health plan type. Utilization of first-line therapies varied by plan type in unadjusted analyses, but not after adjusting for patient characteristics. CONCLUSIONS:The extent to which patient OOP payments for drugs reflect differences in gross payments made by insurers varies across health insurance plan types. However, even though OOP payments for the same treatment differ across plan types, treatment choice is not significantly different across type of health insurance after controlling for patient characteristics.