How many elderly adults forgo prescription drugs because of cost?

More than one-quarter of seniors reported that they did not fill or adhere to a prescription for cost-related reasons in 2003. Among those with complex chronic illnesses, almost one-third with prescription drug coverage and more than one-half without drug coverage reported cost-related nonadherence. Four of 10 seniors reported prescription nonadherence for any reason, including two-thirds of those with complex chronic illnesses and no drug coverage.

Why is this important?

Almost 90 percent of elderly adults (ages 65 and older) take prescription drugs, and they take about five prescription drugs on average. Seniors on fixed incomes can face financial challenges paying for their drugs, which can lead them to skip doses or forgo prescriptions altogether (Safran et al. 2005).

Inadequate access and adherence to essential prescription drugs can lead to adverse health outcomes and increased use of the emergency department and admissions to the hospital and nursing home (Heisler et al. 2004a; Piette et al. 2004b; Simpson et al. 2006; Soumerai et al. 1991; 1994; Tamblyn et al. 2001).

Individuals reporting cost-related underuse of prescription drugs are likely to report medication nonadherence for other reasons (Piette et al. 2005). This association argues for considering both economic and noneconomic nonadherence issues as part of an overall strategy to help patients better manage their health.

Findings

In 2003, before implementation of the new Medicare prescription drug benefit, more than one-quarter (26%) of seniors reported that they did not fill one or more prescriptions in the past year because of its cost, or that they skipped or cut back on medication doses to make the prescription last longer (Safran et al. 2005). Cost-related nonadherence was even higher among those without prescription drug coverage (37%), low-income seniors (35%), and those with complex chronic illnesses (35%).

Four of 10 seniors, including one-half of those with complex chronic illnesses and drug coverage and two-thirds without drug coverage, reported prescription nonadherence for any reason (data not shown) (Safran et al. 2005).

Implications

These findings serve as a baseline for measuring the effects of the new Medicare prescription drug benefit in reducing cost-related prescription nonadherence for seniors. The data suggest that, even with improved drug coverage, seniors will continue to experience both cost-related and other prescription nonadherence issues.

Low-income working-age adults with chronic illnesses—both insured and uninsured—are even more likely than similarly situated seniors to report that they did not fill a prescription because of cost (Reed 2005). This suggests the need for wider attention to this issue and a better understanding of its implications on patient health.

Physicians seldom ask patients with chronic illnesses about their ability to afford a prescription (Heisler et al. 2004b), and one-third of patients with chronic illnesses who report underusing medications because of cost say that they never talked to their doctor or nurse about their lack of adherence (Piette et al. 2004a).

Improvement Ideas and Resources

Experts recommend that doctors and patients discuss prescription nonadherence more proactively (Osterberg and Blaschke 2005). Patients experiencing medication cost pressures rate their physician more highly when he or she asks whether the patient can afford a prescription and offers information about programs to help pay for medications (Piette et al. 2004a).

Interventions to improve patient adherence should address patient, provider, and system-level factors that influence patient self-management behavior (Piette et al. 2006). These include:

• enhancing physician–patient communication and patient education;
• simplifying medication regimens when appropriate;
• ensuring that patients can see a doctor when they have concerns; and
• designing appropriate drug formularies.

Some multifaceted educational and behavioral interventions have shown modest improvements in prescription adherence (Haynes et al. 2005), but more effective approaches are needed that can be adapted to everyday practice.

Measure:

The National Survey of Seniors and Prescription Drugs used validated survey questions to ask community-dwelling elderly Medicare beneficiaries about nonadherence with prescription regimens. The numerator for composite rates were constructed as follows:

• Cost-related nonadherence included respondents who reported one or more of the following: 1) not filling a prescription because of cost, 2) skipping doses to make a prescription last longer, and/or 3) taking smaller doses than prescribed to make a prescription last longer. In addition, respondents who reported using prescription drugs for one or more specific chronic conditions indicated whether they did not fill any of these prescriptions because of cost.
• Experience-related nonadherence included respondents who reported that they skipped doses or stopped taking a medicine because: 1) it was making them feel worse, and/or 2) they didn't think the medicine was helping them.
• Nonadherence due to self-assessed need included respondents who reported that they did not fill a prescription because 1) they felt they were taking too many medicines, and/or 2) they didn't think they needed the medicine.

In a multivariate analysis, cost-related nonadherence was significantly higher for patients in defined vulnerable groups after controlling for patients' sociodemographic and health characteristics (Safran et al. 2005).

Limitations:

Patient self-reports are subject to potential recall bias. The surveys did not measure the clinical significance of nonadherence; stopping medication might have been appropriate in some cases to avoid adverse drug reactions.

Source:

The National Survey of Seniors and Prescription Drugs was a nationally representative mail and telephone survey of 36,901 noninstitutionalized Medicare beneficiaries ages 65 and older, randomly sampled from each state and the District of Columbia. It was administered in English and Spanish between July 15–October 2003 and achieved a response rate of 51 percent (Safran et al. 2005).

References:

* Indicates source of data used in the chart(s).

Haynes, R. B., X. Yao, A. Degani et al. 2005. Interventions to Enhance Medication Adherence. Cochrane Database of Systematic Reviews (4): CD000011.

Heisler, M., K. M. Langa, E. L. Eby et al. 2004a. The Health Effects of Restricting Prescription Medication Use Because of Cost. Medical Care 42 (7): 626–34.

Heisler, M., T. H. Wagner, and J. D. Piette. 2004b. Clinician Identification of Chronically Ill Patients Who Have Problems Paying for Prescription Medications. American Journal of Medicine 116 (11): 753–8.

Osterberg, L., and T. Blaschke. 2005. Adherence to Medication. New England Journal of Medicine 353 (5): 487–97.

Piette, J. D., M. Heisler, R. Horne et al. 2006. A Conceptually Based Approach to Understanding Chronically Ill Patients' Responses to Medication Cost Pressures. Social Science and Medicine 62 (4): 846–57.

Piette, J. D., M. Heisler, S. Krein et al. 2005. The Role of Patient-Physician Trust in Moderating Medication Nonadherence Due to Cost Pressures. Archives of Internal Medicine 165 (15): 1749–55.

Piette, J. D., M. Heisler, and T. H. Wagner. 2004a. Cost-Related Medication Underuse: Do Patients with Chronic Illnesses Tell Their Doctors? Archives of Internal Medicine 164 (16): 1749–55.

Piette, J. D., T. H. Wagner, M. B. Potter et al. 2004b. Health Insurance Status, Cost-Related Medication Underuse, and Outcomes Among Diabetes Patients in Three Systems of Care. Medical Care 42 (2): 102–9.

Reed, M. 2005. An Update on Americans' Access to Prescription Drugs. Center for Studying Health System Change (95): 1–4.

* Safran, D. G., P. Neuman, C. Schoen et al. 2005. Prescription Drug Coverage and Seniors: Findings from a 2003 National Survey. Health Affairs Web Exclusives: W5-152–66.

Simpson, S. H., D. T. Eurich, S. R. Majumdar et al. 2006. A Meta-Analysis of the Association Between Adherence to Drug Therapy and Mortality. BMJ 333 (7557): 15.

Soumerai, S. B., T. J. McLaughlin, D. Ross-Degnan et al. 1994. Effects of a Limit on Medicaid Drug-Reimbursement Benefits on the Use of Psychotropic Agents and Acute Mental Health Services by Patients with Schizophrenia. New England Journal of Medicine 331 (10): 650–5.

Soumerai, S. B., D. Ross-Degnan, J. Avorn et al. 1991. Effects of Medicaid Drug-Payment Limits on Admission to Hospitals and Nursing Homes. New England Journal of Medicine 325 (15): 1072–7.

Tamblyn, R., R. Laprise, J. A. Hanley et al. 2001. Adverse Events Associated with Prescription Drug Cost-Sharing among Poor and Elderly Persons. Journal of the American Medical Association 285 (4): 421–9.