Journal of General Internal Medicine

, Volume 16, Issue 12, pp 793–799 | Cite as

Self-restriction of medications due to cost in seniors without prescription coverage

A national survey
  • Michael A. Steinman
  • Laura P. Sands
  • Kenneth E. Covinsky

Abstract

OBJECTIVE: Little is known about patients who skip doses or otherwise avoid using their medications because of cost. We sought to identify which elderly patients are at highest risk of restricting their medications because of cost, and how prescription coverage modifies this risk.

DESIGN AND PARTICIPANTS: Cross-sectional study from the 1995–1996 wave of the Survey of Asset and Health Dynamics Among the Oldest Old, a population-based survey of Americans age 70 years and older.

MEASUREMENTS: Subjects were asked the extent of their prescription coverage, and whether they had taken less medicine than prescribed for them because of cost over the prior 2 years. We used bivariate and multivariate analyses to identify risk factors for medication restriction in subjects who lacked prescription coverage. Among these high-risk groups, we then examined the effect of prescription coverage on rates of medication restriction.

MAIN RESULTS: Of 4,896 seniors who regularly used prescription medications, medication restriction because of cost was reported by 8% of subjects with no prescription coverage, 3% with partial coverage, and 2% with full coverage (P<.01 for trend). Among subjects with no prescription coverage, the strongest independent predictors of medication restriction were minority ethnicity (odds ratio [OR], 2.9 compared with white ethnicity; 95% confidence interval [95% CI], 2.0 to 4.2), annual income <$10,000 (OR, 3.8 compared with income ≥$20,000; 95% CI, 2.4 to 6.1), and out-of-pocket prescription drug costs >$100 per month (OR, 3.3 compared to costs ≤$20; 95% CI, 1.5 to 7.2). The prevalence of medication restriction in members of these 3 risk groups was 21%, 16%, and 13%, respectively. Almost half (43%) of subjects with all 3 risk factors and no prescription coverage reported restricting their use of medications. After multivariable adjustment, high-risk subjects with no coverage had 3 to 15 times higher odds of medication restriction than subjects with partial or full coverage (P<.01).

CONCLUSIONS: Medication restriction is common in seniors who lack prescription coverage, particularly among certain vulnerable groups. Seniors in these high-risk groups who have prescription coverage are much less likely to restrict their use of medications.

Key words

insurance pharmaceutical services health services accessibility prescriptions drug fees pharmaceutical aged 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Soumerai SB, Ross-Degnan D. Inadequate prescription-drug coverage for Medicare enrollees—a call to action (published erratum appears in N Engl J Med 1999;340:976). N Engl J Med. 1999;340:722–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Lagnado L. The uncovered; drug costs can leave elderly a grim choice: pills or other needs. Wall Street Journal. November 17, 1998: A1.Google Scholar
  3. 3.
    Dustan HP, Caplan LR, Curry CL, et al. Report of the Task Force on the Availability of Cardiovascular Drugs to the Medically Indigent. Circulation. 1992;85:849–60.PubMedGoogle Scholar
  4. 4.
    Drazen JM, Bush GW, Gore A. The Republican and Democratic candidates speak on health care. N Engl J Med. 2000;343:1184–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Shih YC. Effect of insurance on prescription drug use by ESRD beneficiaries. Health Care Financ Rev. 1999;20:39–54.PubMedGoogle Scholar
  6. 6.
    Poisal JA, Chulis GS. Medicare beneficiaries and drug coverage. Health Aff. 2000;19:248–56.CrossRefGoogle Scholar
  7. 7.
    Poisal JA, Murray L. Growing differences between Medicare beneficiaries with and without drug coverage. Health Aff. 2001;20:74–85.CrossRefGoogle Scholar
  8. 8.
    Lillard LA, Rogowski J, Kington R. Insurance coverage for prescription drugs: effects on use and expenditures in the Medicare population. Med Care. 1999;37:926–36.PubMedCrossRefGoogle Scholar
  9. 9.
    Department of Health and Human Services. Report to the President: Prescription Drug Coverage, Spending, Utilization, and Prices. 2000. Available at: http://www.aspe.hhs.gov/health/reports/drugstudy.Google Scholar
  10. 10.
    Soldo BJ, Hurd MD, Rodgers WL, Wallace RB. Asset and health dynamics among the oldest old: an overview of the AHEAD study. J Gerontol B Psychol Sci Soc Sci. 1997;52:1–20.PubMedGoogle Scholar
  11. 11.
    Heeringa S. Technical Description of the Asset and Health Dynamics (AHEAD) Survey Sample Design (Public Use Version). Ann Arbor: University of Michigan Institute for Social Research; 1995.Google Scholar
  12. 12.
    Smith JP. Wealth inequality among older Americans. J Gerontol B Psychol Sci Soc Sci. 1997;52:74–81.PubMedGoogle Scholar
  13. 13.
    Hopp FP, Duffy SA. Racial variations in end-of-life care. J Am Geriatr Soc. 2000;48:658–63.PubMedGoogle Scholar
  14. 14.
    McKinley ED, Garrett JM, Evans AT, Danis M. Differences in end-of-life decision making among black and white ambulatory cancer patients. J Gen Intern Med. 1996;11:651–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Escarce JJ, Epstein KR, Colby DC, Schwartz JS. Racial differences in the elderly’s use of medical procedures and diagnostic tests. Am J Public Health. 1993;83:948–54.PubMedCrossRefGoogle Scholar
  16. 16.
    Blustein J. Drug coverage and drug purchases by Medicare beneficiaries with hypertension. Health Aff. 2000;19:219–30.CrossRefGoogle Scholar
  17. 17.
    Stuart B, Grana J. Ability to pay and the decision to medicate. Med Care. 1998;36:202–11.PubMedCrossRefGoogle Scholar
  18. 18.
    Stuart B, Zacker C. Who bears the burden of Medicaid drug copayment policies? Health Aff. 1999;18:201–12.CrossRefGoogle Scholar
  19. 19.
    Johnson RE, Goodman MJ, Hornbrook MC, Eldredge MB. The effect of increased prescription drug cost-sharing on medical care utilization and expenses of elderly health maintenance organization members. Med Care. 1997;35:1119–31.PubMedCrossRefGoogle Scholar
  20. 20.
    Tamblyn R, Laprise R, Hanley JA. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA. 2001;285:421–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Lurie N, Ward NB, Shapiro MF, Brook RH. Termination from Medi-Cal—does it affect health? N Engl J Med. 1984;311:480–4.PubMedCrossRefGoogle Scholar
  22. 22.
    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
  23. 23.
    Soumerai SB, Ross-Degnan D, Avorn J, McLaughlin T, Choodnovskiy I. Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. N Engl J Med. 1991;325:1072–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Soumerai SB, McLaughlin TJ, Ross-Degnan D, Casteris CS, Bollini P. Effects of a limit on Medicaid drug-reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. N Engl J Med. 1994;331:650–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Schweitzer SO, Shiota SR. Access and cost implications of state limitations on Medicaid reimbursement for pharmaceuticals. Annu Rev Public Health. 1992;13:399–410.PubMedCrossRefGoogle Scholar
  26. 26.
    Pedersen TR, Kjekshus J, Berg K, et al. Cholesterol lowering and the use of healthcare resources. Results of the Scandinavian Simvastatin Survival Study (published erratum appears in Circulation 1996;94:849). Circulation. 1996;93:1796–802.PubMedGoogle Scholar
  27. 27.
    Rosenheck R, Cramer J, Allan E, et al. Cost-effectiveness of clozapine in patients with high and low levels of hospital use. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia. Arch Gen Psychiatry. 1999;56:565–72.PubMedCrossRefGoogle Scholar
  28. 28.
    Gross DJ, Alecxih L, Gibson MJ, Corea J, Caplan C, Brangan N. Out-of-pocket health spending by poor and near-poor elderly Medicare beneficiaries. Health Serv Res. 1999;34:241–54.PubMedGoogle Scholar
  29. 29.
    Rogowski J, Lillard LA, Kington R. The financial burden of prescription drug use among elderly persons. Gerontologist. 1997;37:475–82.PubMedGoogle Scholar
  30. 30.
    Stuart B, Shea D, Briesacher B. Dynamics of drug coverage of Medicare beneficiaires: finders, losers, switchers. Health Aff. 2001;20:86–99.CrossRefGoogle Scholar
  31. 31.
    McArdle F, Coppock S, Yamamoto D, Zebrak A. Retiree Health Coverage: Recent Trends and Employer Perspectives on Future Benefits. Menlo Park, Calif: The Henry J. Kaiser Family Foundation; 1999.Google Scholar
  32. 32.
    Sjahid SI, van der Linden PD, Stricker BH. Agreement between the pharmacy medication history and patient interview for cardiovascular drugs: the Rotterdam Elderly Study. Br J Clin Pharmacol. 1998;45:591–5.PubMedCrossRefGoogle Scholar
  33. 33.
    Rost K, Roter D. Predictors of recall of medication regimens and recommendations for lifestyle change in elderly patients. Gerontologist. 1987;27:510–5.PubMedGoogle Scholar
  34. 34.
    West SL, Savitz DA, Koch G, Strom BL, Guess HA, Hartzema A. Recall accuracy for prescription medications: self-report compared with database information. Am J Epidemiol. 1995;142:1103–12.PubMedGoogle Scholar
  35. 35.
    McKenna MT, Speers M, Mallin K, Warnecke R. Agreement between patient self-reports and medical records for Pap smear histories. Am J Prev Med. 1992;8:287–91.PubMedGoogle Scholar
  36. 36.
    Brown JB, Adams ME. Patients as reliable reporters of medical care process. Recall of ambulatory encounter events. Med Care. 1992;30:400–11.PubMedCrossRefGoogle Scholar
  37. 37.
    Evans C, Crawford B. Patient self-reports in pharmacoeconomic studies. Their use and impact on study validity. Pharmacoeconomics. 1999;15:241–56.PubMedCrossRefGoogle Scholar
  38. 38.
    Coughlin SS. Recall bias in epidemiologic studies. J Clin Epidemiol. 1990;43:87–91.PubMedCrossRefGoogle Scholar
  39. 39.
    Norrish A, North D, Kirkman P, Jackson R. Validity of self-reported hospital admission in a prospective study. Am J Epidemiol. 1994;140:938–42.PubMedGoogle Scholar
  40. 40.
    Yaffe R, Shapiro S, Fuchseberg RR, Rohde CA, Corpeno HC. Medical economics survey-methods study: cost-effectiveness of alternative survey strategies. Med Care. 1978;16:641–59.PubMedCrossRefGoogle Scholar
  41. 41.
    Cleary PD, Jette AM. The validity of self-reported physician utilization measures. Med Care. 1984;22:796–803.PubMedCrossRefGoogle Scholar
  42. 42.
    McCall N, Rice T, Sangl J. Consumer knowledge of Medicare and supplemental health insurance benefits. Health Serv Res. 1986;20:633–57.PubMedGoogle Scholar

Copyright information

© Blackwell Science Inc 2001

Authors and Affiliations

  • Michael A. Steinman
    • 1
    • 2
    • 3
  • Laura P. Sands
    • 2
  • Kenneth E. Covinsky
    • 1
    • 2
  1. 1.the Division of GeriatricsSan Francisco VA Medical CenterSan Francisco
  2. 2.the University of California-San FranciscoSan Francisco
  3. 3.the VA National Quality Scholars ProgramSan Francisco VA Medical Center (MAS)San Francisco

Personalised recommendations