Nearly one in five older adults with diabetes in the survey reported cutting back on prescription medication in the prior year because of costs, and 15 percent used less of their medication at least once per month because of the cost.
By not taking their medications as prescribed, patients had poorer diabetes control, more symptoms and worse physical and mental functioning, researchers found.
"We're really just beginning to appreciate how common it is that people with chronic illnesses are cutting back on prescription medication use because of the cost. We have not yet fully estimated the impact that these costs have on other aspects of patients' lives. We may already be seeing the fallout in terms of poorer health status. While prescription drug coverage may seem expensive, a good plan may save Medicare and other health insurance companies in the long run by preventing serious health problems," says John Piette, Ph.D., a career scientist at the Ann Arbor VA Healthcare System and an associate professor of general medicine at U-M Medical School.
These findings are reported in two separate studies published this month. Piette is the lead author for both studies.
In one study, published in the February issue of Diabetes Care, researchers surveyed 875 people with diabetes across the United States who used prescription drugs to control their blood sugar. Participants were asked if they had ever taken less of their diabetes medications or any other prescription drugs in the last year because of cost concerns.
Half of the participants reported using at least seven different prescription drugs, including treatments for hypertension, high cholesterol, arthritis or depression, as well as their glucose control. More than one-quarter of those surveyed said their prescriptions cost them $50-$99 a month, while 29 percent spent $100 or more each month out-of-pocket for their prescription drugs.
As people reported using more drugs each month, it was more likely that they skipped doses to save money. People who used seven or more drugs were four times more likely than those with one or two prescriptions to cut back on their medications at least once per month. Cost-related medication adherence problems were especially common among patients without prescription drug coverage, and those who were younger than 65 (and therefore not eligible to benefit from planned Medicare drug benefit reforms).
The researchers found many doctors may be in the dark about patients' problems due to medication costs. More than one-third of patients who reported cutting back on their medication use never talked to their doctor or nurse about it. These patients often said they were never asked about possible problems paying for their prescriptions or they did not think their doctor could help with medication costs. Patients also reported feeling embarrassed or rushed for time.
"Especially when a patient is not responding to medication therapy, doctors should raise the issue of prescription drug costs. Common clinician responses, such as changing drugs or adding an additional prescription may actually make the problem worse," Piette says.
In the second study, published in the February issue of Medical Care, 766 adults with diabetes from Veterans Affairs health systems, a county health system and a university-based health system were asked about their medication use and costs. Patients who reported using less diabetes medication because of cost had higher blood glucose levels than those who took their medication as prescribed. Those who cut back on other medications had more than twice as many symptoms and scored lower on tests of physical and mental functioning.
More than half of the participants had at least three other chronic health problems, in addition to their diabetes, and these patients were especially at risk for foregoing medication because of cost problems.
Investigators found patients with access to the VA's generous prescription drug benefits were much less likely to cut back on medication use due to cost, compared to patients with any other type of health insurance. People with private insurance were twice as likely to have cost-related adherence problems with their medication as people using VA care, and Medicare or Medicaid patients were two to three times more likely to report cutting back medication than VA patients.
VA medical centers cover 100 percent of drug costs for people with low incomes or service-connected disabilities. Other VA patients pay $7 co-pays for 30-day supplies of prescription medications, with no cap on total costs or number of prescriptions. Costs above $840 in a year are waived.
Although many Medicaid and uninsured patients in the study were eligible for low-cost or free prescription drug programs, more of them reported cost-related medication problems than their VA counterparts. The researchers concluded that many of these patients may not be aware of assistance programs available to them.
The study authors suggest the VA drug coverage policy may provide a model for other government prescription drug coverage programs.
"Access to the type of prescription drug coverage available to VA patients could prevent many patients from underusing their prescription medications because of costs," Piette says. "This study shows more extensive drug coverage for people with diabetes could lead to improved health – which may lead to a reduction in overall health care costs over the long term."
Researchers also recommend social workers, nurses or pharmacists be enlisted to help link patients with sources of low-cost treatment and other forms of assistance available to them. In addition, patients can ask their doctors if each new prescription is necessary or request generic alternatives.
In addition to Piette, researchers on the Medical Care study were Todd H. Wagner, Ph.D., of VA Palo Alto Health Care System and Stanford University; and Michael B. Potter, M.D., and Dean Schillinger, M.D., of the University of California-San Francisco. Researchers on the Diabetes Care study were Piette, Wagner and Michele Heisler, M.D., MPA, an attending physician with the Department of Internal Medicine at UMHS.
Both studies were supported by grants from the Department of Veterans Affairs and the Medical Care study was also supported by the Agency for Healthcare Research and Quality.
Contact:
Nicole Fawcett, nfawcett@umich.edu, or
Mary Beth Reilly, reillymb@umich.edu
734-764-2220
Journal
Diabetes Care