Advertisement

Journal of General Internal Medicine

, Volume 22, Issue 6, pp 864–871 | Cite as

Patients At-Risk for Cost-Related Medication Nonadherence: A Review of the Literature

  • Becky A. BriesacherEmail author
  • Jerry H. Gurwitz
  • Stephen B. Soumerai
Clinical Review

Abstract

Objective

Up to 32% of older patients take less medication than prescribed to avoid costs, yet a comprehensive assessment of risk factors for cost-related nonadherence (CRN) is not available. This review examined the empirical literature to identify patient-, medication-, and provider-level factors that influence the relationship between medication adherence and medication costs.

Design

We conducted searches of four databases (MEDLINE, CINAHL, Sciences Citations Index Expanded, and EconLit) from 2001 to 2006 for English-language original studies. Articles were selected if the study included an explicit measure of CRN and reported results on covarying characteristics.

Main Results

We found 19 studies with empirical support for concluding that certain patients may be susceptible to CRN: research has established consistent links between medication nonadherence due to costs and financial burden, but also to symptoms of depression and heavy disease burden. Only a handful of studies with limited statistical methods provided evidence on whether patients understand the health risks of CRN or to what extent clinicians influence patients to keep taking medications when faced with cost pressures. No relationship emerged between CRN and polypharmacy.

Conclusion

Efforts to reduce cost-related medication nonadherence would benefit from greater study of factors besides the presence of prescription drug coverage. Older patients with chronic diseases and mood disorders are at-risk for CRN even if enrolled in Medicare’s new drug benefit.

KEY WORDS

medicare cost sharing patient compliance prescriptions 

Notes

Acknowledgements

This study was supported by grants RO1AG022362 and R01AG028745 from the National Institute on Aging (NIA). Drs. Briesacher, Soumerai, and Gurwitz are investigators in the HMO Research Network Center for Education and Research in Therapeutics, which receives funding from the US Agency for Healthcare Research and Quality (grant 2U18HS010391).

Conflict of Interest

Dr. Briesacher reported that she has received unrestricted research grants from and has been a consultant for Novartis Pharmaceuticals Corporation within the last 3 years. The other authors reported no conflicts of interest.

References

  1. 1.
    Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. J Am Med Assoc. 2002;287:337–44.CrossRefGoogle Scholar
  2. 2.
    Safran DG, Neuman P, Schoen C, et al. Prescription drug coverage and seniors: findings from a 2003 national survey. Health Aff (Millwood) 2005.Google Scholar
  3. 3.
    Heisler M, Langa KM, Eby EL, Fendrick AM, Kabeto MU, Piette JD. The health effects of restricting prescription medication use because of cost. Med Care. 2004;42:626–34.PubMedCrossRefGoogle Scholar
  4. 4.
    Soumerai SB, Pierre-Jacques M, Zhang F, et al. Cost-related medication nonadherence among elderly and disabled medicare beneficiaries: a national survey 1 year before the medicare drug benefit. Arch Intern Med. 2006;166:1829–35.PubMedCrossRefGoogle Scholar
  5. 5.
    Gibson TB, Ozminkowski RJ, Goetzel RZ. The effects of prescription drug cost sharing: a review of the evidence. Am J Manag Care. 2005;11:730–40.PubMedGoogle Scholar
  6. 6.
    Rice T, Matsuoka KY. The impact of cost-sharing on appropriate utilization and health status: a review of the literature on seniors. Med Care Res Rev. 2004;61:415–52.PubMedCrossRefGoogle Scholar
  7. 7.
    Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. J Am Med Assoc. 2001;285:421–9.CrossRefGoogle Scholar
  8. 8.
    Roblin DW, Platt R, Goodman MJ, et al. Effect of increased cost-sharing on oral hypoglycemic use in five managed care organizations: how much is too much? Med Care. 2005;43:951–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Motheral B, Fairman KA. Effect of a three-tier prescription copay on pharmaceutical and other medical utilization. Med Care. 2001;39:1293–304.PubMedCrossRefGoogle Scholar
  10. 10.
    Stuart B, Briesacher BA, Shea DG, Cooper B, Baysac FS, Limcangco MR. Riding the rollercoaster: the ups and downs in out-of-pocket spending under the standard Medicare drug benefit. Health Aff (Millwood). 2005;24:1022–31.CrossRefGoogle Scholar
  11. 11.
    Piette JD, Heisler M, Horne R, Caleb Alexander G. A conceptually based approach to understanding chronically ill patients’ responses to medication cost pressures. Soc Sci Med. 2006;62:846–57.PubMedCrossRefGoogle Scholar
  12. 12.
    Craig BM, Kreling DH, Mott DA. Do seniors get the medicines prescribed for them? Evidence from the 1996–1999 Medicare Current Beneficiary Survey. Health Aff (Millwood). 2003;22:175–82.CrossRefGoogle Scholar
  13. 13.
    Heisler M, Wagner TH, Piette JD. Clinician identification of chronically ill patients who have problems paying for prescription medications. Am J Med. 2004;116:753–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Alexander GC, Casalino LP, Meltzer DO. Patient–physician communication about out-of-pocket costs. J Am Med Assoc. 2003;290:953–8.CrossRefGoogle Scholar
  15. 15.
    Mitchell J, Mathews HF, Hunt LM, Cobb KH, Watson RW. Mismanaging prescription medications among rural elders: the effects of socioeconomic status, health status, and medication profile indicators. Gerontologist. 2001;41:348–56.PubMedGoogle Scholar
  16. 16.
    Kennedy J, Erb C. Prescription noncompliance due to cost among adults with disabilities in the United States. Am J Public Health. 2002;92:1120–4.PubMedGoogle Scholar
  17. 17.
    Kennedy J, Coyne J, Sclar D. Drug affordability and prescription noncompliance in the United States: 1997–2002. Clin Ther. 2004;26:607–14.PubMedCrossRefGoogle Scholar
  18. 18.
    Fortess EE, Soumerai SB, McLaughlin TJ, Ross-Degnan D. Utilization of essential medications by vulnerable older people after a drug benefit cap: importance of mental disorders, chronic pain, and practice setting. J Am Geriatr Soc. 2001;49:793–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Piette JD, Heisler M, Wagner TH. Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Arch Intern Med. 2004;164:1749–55.PubMedCrossRefGoogle Scholar
  20. 20.
    Schommer JC, Mott DA, Hansen RA, Cline RR. Selected characteristics of senior citizens prescription drug payment and procurement in 1998 and 2001. J Manag Care Pharm. 2003;9:408–15.PubMedGoogle Scholar
  21. 21.
    Landsman PB, Yu W, Liu X, Teutsch SM, Berger ML. Impact of 3-tier pharmacy benefit design and increased consumer cost-sharing on drug utilization. Am J Manag Care. 2005;11:621–8.PubMedGoogle Scholar
  22. 22.
    Huskamp HA, Deverka PA, Epstein AM, Epstein RS, McGuigan KA, Frank RG. The effect of incentive-based formularies on prescription-drug utilization and spending. N Engl J Med. 2003;349:2224–32.PubMedCrossRefGoogle Scholar
  23. 23.
    Goldman DP, Joyce GF, Escarce JJ, et al. Pharmacy benefits and the use of drugs by the chronically ill. J Am Med Assoc. 2004;291:2344–50.CrossRefGoogle Scholar
  24. 24.
    Balkrishnan R, Byerly WG, Camacho FT, Shrestha A, Anderson RT. Effect of prescription benefit changes on medical care utilization in a Medicare HMO population. Am J Manag Care. 2001;7:1093–100.PubMedGoogle Scholar
  25. 25.
    Love J. Filling the Rx: An Analysis of the Perceptions, Attitudes and Buying Habitts of Medicare Beneficiaries. Washington, DC: AARP; 2004:1–17.Google Scholar
  26. 26.
    Rector TS, Venus PJ. Do drug benefits help Medicare beneficiaries afford prescribed drugs? Health Aff (Millwood). 2004;23:213–22.CrossRefGoogle Scholar
  27. 27.
    Piette JD, Heisler M, Wagner TH. Problems paying out-of-pocket medication costs among older adults with diabetes. Diabetes Care. 2004;27:384–91.PubMedCrossRefGoogle Scholar
  28. 28.
    Cox ER, Jernigan C, Coons SJ, Draugalis JL. Medicare beneficiaries’ management of capped prescription benefits. Med Care. 2001;39:296–301.PubMedCrossRefGoogle Scholar
  29. 29.
    Klein D, Turvey C, Wallace R. Elders who delay medication because of cost: health insurance, demographic, health, and financial correlates. Gerontologist. 2004;44:779–87.PubMedGoogle Scholar
  30. 30.
    Mojtabai R, Olfson M. Medication Costs, Adherence, And Health Outcomes Among Medicare Beneficiaries. Health Aff. 2003;22:220–9.CrossRefGoogle Scholar
  31. 31.
    Safran DG, Neuman P, Schoen C, et al. Prescription drug coverage and seniors: how well are states closing the gap? Health Aff (Millwood). 2002;Supp Web Exclusives: W253–68.Google Scholar
  32. 32.
    Steinman MA, Sands LP, Covinsky KE. Self-restriction of medications due to cost in seniors without prescription coverage. J Gen Intern Med. 2001;16:793–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Tseng CW, Brook RH, Keeler E, Steers WN, Mangione CM. Cost-lowering strategies used by Medicare beneficiaries who exceed drug benefit caps and have a gap in drug coverage. J Am Med Assoc. 2004;292:952–60.CrossRefGoogle Scholar
  34. 34.
    Piette JD, Heisler M, Wagner TH. Cost-related medication underuse among chronically ill adults: the treatments people forgo, how often, and who is at risk. Am J Public Health. 2004;94:1782–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Piette JD, Wagner TH, Potter MB, Schillinger D. Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care. Med Care. 2004;42:102–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Piette JD, Heisler M. Problems due to medication costs among va and non-va patients with chronic illnesses. Am J Manag Care. 2004;10 (part 2):861–868.PubMedGoogle Scholar
  37. 37.
    Sharkey JR, Ory MG, Browne BA. Determinants of self-management strategies to reduce out-of-pocket prescription medication expense in homebound older people. J Am Geriatr Soc. 2005;53:666–74.PubMedCrossRefGoogle Scholar
  38. 38.
    Heisler M, Wagner TH, Piette JD. Patient strategies to cope with high prescription medication costs: who is cutting back on necessities, increasing debt, or underusing medications? J Behav Med. 2005;28:43–51.PubMedCrossRefGoogle Scholar
  39. 39.
    Piette JD, Heisler M. The relationship between older adults’ knowledge of their drug coverage and medication cost problems. J Am Geriatr Soc. 2006;54:91–6.PubMedCrossRefGoogle Scholar
  40. 40.
    Saver B, Doescherm M, Jackson E, Fishman P. Seniors with chronic health conditions and prescription drugs: benefits, wealth, and health. Value Health. 2004;7:113–143.CrossRefGoogle Scholar
  41. 41.
    Wilson IB, Rogers WH, Chang H, Safran DG. Cost-related skipping of medications and other treatments among Medicare beneficiaries between 1998 and 2000. Results of a national study. J Gen Intern Med. 2005;20:715–20.PubMedCrossRefGoogle Scholar
  42. 42.
    Taira DA, Iwane KA, Chung RS. Prescription drugs: elderly enrollee reports of financial access, receipt of free samples, and discussion of generic equivalents related to type of coverage. Am J Manag Care. 2003;9:305–12.PubMedGoogle Scholar
  43. 43.
    Piette JD, Heisler M, Krein S, Kerr EA. The role of patient–physician trust in moderating medication nonadherence due to cost pressures. Arch Intern Med. 2005;165:1749–55.PubMedCrossRefGoogle Scholar
  44. 44.
    Tseng CW, Brook RH, Keeler E, Mangione CM. Impact of an annual dollar limit or “cap” on prescription drug benefits for Medicare patients. JAMA. 2003;290:222–7.PubMedCrossRefGoogle Scholar
  45. 45.
    Newhouse JP, Manning WG, Duan N, et al. The findings of the Rand Health Insurance experiment—a response to Welch et al. Med Care. 1987;25:157–79.PubMedCrossRefGoogle Scholar
  46. 46.
    DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42:200–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Soumerai SB, Avorn J, Ross-Degnan D, Gortmaker S. Payment restrictions for prescription drugs under Medicaid. Effects on therapy, cost, and equity. N Engl J Med. 1987;317:550–6.PubMedCrossRefGoogle Scholar
  48. 48.
    DeNavas-Walt C, Proctor BD, Lee CH. Income, Poverty, and Health Insurance Coverage in the United States: 2004 Current Population Reports. Washington, DC: U.S. Census Bureau; 2005.Google Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Becky A. Briesacher
    • 1
    Email author
  • Jerry H. Gurwitz
    • 1
  • Stephen B. Soumerai
    • 2
  1. 1.Division of Geriatric Medicine and Meyers Primary Care InstituteUniversity of Massachusetts Medical School, Biotech Four, Suite 315WorcesterUSA
  2. 2.Department of Ambulatory Care and PreventionHarvard Medical School and Harvard Pilgrim Health CareCambridgeUSA

Personalised recommendations