Identifying Medication Affordability Concerns in Primary Care: A Resident Led Quality Improvement Initiative

From the 2021 HVPAA National Conference

Tyler Greathouse (Cleveland Clinic), Manik Aggarwal, Kavya Kommaraju, Andrew Para, Agam Bansal, William Smith, William Wallace, Ruth Bell, Sudarshana Datta, Patrick Flanagan, Catherine Fleisher, Jessica Donato, Richard Cartabuke


Patient access to affordable medications is imperative to improving health outcomes in the United States. The Centers for Medicare and Medicaid Services (CMS) estimates the total cost of prescription medications in the United States as $335 billion. It is not surprising that a recent survey reported that one in four Americans had difficulty affording their medications. Treatment for type 2 diabetes mellitus (T2DM) and hypertension (HTN) form the bulk of primary care visits, and poor medication adherence in this population can lead to severe and sometimes life-threatening complications. Lack of patient-provider communication and provider knowledge regarding medication affordability are common reasons for non adherence.


To increase identification of patient concerns about medication affordability prior to initiating T2DM or HTN medications by 50% from baseline in an underserved primary care setting.


This prospective study was conducted in the primary care clinic of ten internal medicine (IM) residents over a 20-week period. The intervention group included all patients who were started on a new medication for T2DM or HTN. Our pre-intervention phase consisted of a retrospective review of office visits three months prior to the date of intervention, and evaluated the number of documented conversations about medication affordability. Our intervention was an electronic medical record (EMR) “smart phrase” that was inserted into the note templates of all participating IM residents to serve as a reminder to discuss medication affordability. The smart phrase was a two-step questionnaire aimed at identifying whether or not the patient had concerns about medication affordability, and then provided resources to the patient to help with affordability.


In the pre-intervention phase, zero patient encounters had a discussion about medication affordability prior to prescribing new T2DM or HTN medications. In the first PDSA cycle following our intervention of the EMR smart phrase, 54% of encounters (14/26 patients) had a discussion about medication affordability and provided available resources. In the second PDSA cycle, 32 new medications were prescribed and medication affordability was discussed in 81% of encounters (26/32 patients).


Our single step intervention utilizing an EMR smart phrase increased the number of discussions about medication affordability in 69% of visits between the two PDSA cycles. This low cost and easily implementable intervention served as an effective reminder to IM residents to discuss medication cost and provide resources. This intervention can serve as a starting point to identify patients at high risk of medication nonadherence due to cost and provide them with resources to increase compliance.

Clinical Implications

Early identification of financial constraints surrounding prescribed medications in the primary care setting can help increase medication compliance and ultimately improve patient health outcomes through identification of social determinants, opportunities, and targeted appropriate supportive intervention.

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