A conceptually based approach to understanding chronically ill patients’ responses to medication cost pressures
Introduction
The costs of prescription drugs pose a growing burden to health care payers and patients (Gabel et al., 2003). In the United States, the average number of prescriptions per person more than doubled between 1977 and 1998 (Schur, Doty, & Berk, 2004). $162 billion dollars were spent on prescription drugs in 2002 (a 15% increase from the prior year) (Schur et al., 2004), and that amount is expected to more than triple by the year 2012 (Heffler, Smith, Keehan, & Clemens, 2003). The proportion of personal health expenses going to prescription drugs has increased more than 10% annually every year since 1997 (Levit et al., 2003). Outcry over prescription cost pressures has played a role in national political debates and contributed to social tensions such as layoffs (Toner & Stolberg, 2002) and labor strikes (Greenhouse, 2003). Patients, clinicians, and researchers all have called for policies to minimize the impact of these costs on patients’ health and well-being (Adams, Soumerai, & Ross-Degnan, 2001; Altman & Parks-Thomas, 2002; Huskamp, Epstein, & Blumenthal, 2003; Soumerai, 2004; Soumerai & Ross-Degnan, 1999; Steinbrook, 2002).
Although patients’ out-of-pocket prescription costs are of particular concern in countries such as the US where governmental financial supports are weak, chronically ill patients in other countries also experience significant burdens from prescription medication costs (Ess, Schneeweiss, & Szucs, 2003). For example, patients throughout the European Union are responsible for at least some of their prescription medication costs, paying approximately 20% of costs in Germany and Italy, and more than half of drug costs in Finland (59%) (Noyce et al., 2000). Even in countries such as the UK in which most prescription charges are waved, both prescribers and patients are increasingly modifying their decisions about medication use based on their implications for patients’ out-of-pocket costs (Schafheutle, 2003). Studies from Germany (Krobot et al., 2004) and Japan (Hagihara, Murakami, Chishaki, Nabeshima, & Nobutomo, 2001) have documented that patients’ use of prescription medication varies according to their level of drug coverage. Similar medication policy changes can have radically different effects across countries (Furler, Rolnick, Lawday, Mak, & Einarson, 2002), and European studies also have found variable clinician responses to patients’ burdens from out-of-pocket medication costs (Hassell, Atella, Schafheutle, Weiss, & Noyce, 2003). Because physicians and patients face an increasingly complex array of potential therapeutic options for many chronic conditions, understanding how patients respond to prescription cost pressures is a global imperative.
Studies based on cross-sectional (Federman, Adams, Ross-Degnan, Soumerai, & Ayanian, 2001; Piette, Heisler, & Wagner, 2004a; Safran et al., 2002; Steinman, Sands, & Covinsky, 2001; Stuart & Grana, 1998; Tseng, Brook, Keeler, Steers, & Mangione, 2004) and longitudinal data (Brian & Gibbens, 1974; Goldman et al., 2004; Harris, Stergachis, & Ried, 1990; Johnson, Goodman, Hornbrook, & Eldredge, 1997; Martin & McMillan, 1996; Nelson, Reeder, & Dickson, 1984; Reeder & Nelson, 1985; Soumerai, Avorn, Ross-Degnan, & Gortmaker, 1987; Tamblyn et al., 2001) have documented that higher out-of-pocket medication costs, lower patient incomes, and less generous prescription benefits are each associated with lower rates of prescription drug use. There is also considerable evidence that cost-related adherence problems jeopardize patients’ health (Mojtabai & Olson, 2003; Piette, Wagner, Potter, & Schillinger, 2004d; Schoen, DiDomenico, Connor, Dischler, & Bauman, 2001; Soumerai, Ross-Degnan, Avorn, McLaughlin, & Choodnovsky, 1991). Tamblyn et al. (2001) documented that increased cost sharing among elderly and indigent patients led to significant increases in acute care use, long-term care admissions, and deaths. In a large, nationally representative longitudinal survey of older Americans (Heisler, Langa et al., 2004), patients who reported underusing their prescription drugs due to cost were almost twice as likely as other patients to experience a significant decline in their health status (32% versus 21%).
Few studies have shed light on how patients vary in their response to similar medication costs, or how clinicians and health systems can best support patients’ adherence in the face of cost pressures. The relationship between patients’ out-of-pocket medication costs and adherence is complex, and individuals’ response to cost pressures cannot be predicted solely based on their level of financial burden. Most patients report taking their medication as prescribed even in the face of high out-of-pocket costs, low incomes, and lack of prescription medication coverage. For example, Steinman and colleagues found that only 13% of older Americans with monthly prescription costs of more than $100 reported cutting back on their medication due to cost pressures (Steinman et al., 2001). More recent studies also have found that the majority of patients bear the cost of their prescription drugs, with overall rates of cost-related underuse among those without prescription coverage between 18% and 28% (Piette et al., 2004a; Safran et al., 2002). On the other hand, small increases in copayments (e.g., less than $2) can significantly reduce drug utilization rates (Harris et al., 1990; Johnson et al., 1997; Nelson et al., 1984; Reeder & Nelson, 1985), and a recent study (Piette, Heisler, & Wagner, 2004b) found that 13% of diabetes patients with moderate to high incomes ($60,000 per year or more) reported cost-related underuse despite their apparent ability to afford these treatments. These studies suggest that non-cost factors may modify patients’ likelihood of cutting back on medication use in response to financial pressures.
Section snippets
Conceptual framework
We developed a framework for understanding chronically ill patients’ medication cost problems that focuses on out-of-pocket costs as well as additional characteristics of the treatment, patient, provider, and health system. To develop the framework, we first conducted a search of English-language articles published in Medline between 1990 and 2004 (see Appendix A for search terms) to review evidence on potential pathways, such as the relationship between patient characteristics and
General and cost-related medication non-adherence
Overall rates of medication non-adherence are high—less than 50% of patients with chronic diseases take their essential medications as prescribed (Haynes, McDonald, & Garg, 2002). Studies have identified few consistent sociodemographic determinants of adherence problems (DiMatteo, 2004; Ryan, 1999; World Health Organization, 2003). Risk factors for non-adherence include low health literacy (Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs AMA, 1999; Williams, Baker,
Implications for patient care
Failure to identify patients with medication cost problems may be an important and under-recognized factor associated with poor clinical outcomes among chronically ill patients. When the health of individuals who underuse their medication due to cost does not improve, typical clinician responses, such as increasing their dose or adding augmentation therapy may exacerbate the problem by inadvertently increasing patients’ cost burden. Unfortunately, clinicians may interpret “medication failures”
Implications for medication cost policy
Health care payers have developed a variety of mechanisms to finance medication use while maintaining financial solvency (Huskamp, Deverka et al., 2003; Lutchmie et al., 1999; Schneeweiss et al., 2002). Additional creative strategies, such as linking patients’ copayments to the expected clinical benefit of a treatment (Fendrick, Smith, Chernew, & Shah, 2001), are badly needed to better target available resources while providing appropriate incentives for patients and their physicians to use
Conclusions
Medication cost problems will adversely affect the care of chronically ill patients throughout the world for the foreseeable future. Higher costs not only can lead to medication underuse, but also to other problems such as forgoing basic needs (Heisler et al., 2005) and, ultimately, poorer health outcomes. However, most patients continue using their medication as prescribed despite the cost, and some patients forgo medication due to cost when they may be able to afford those treatments. The
Acknowledgements
John Piette is a VA Research Career Scientist. Michele Heisler is a VA Career Development Awardee. The views expressed in this paper do not necessarily reflect those of the Department of Veterans Affairs.
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