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Differentiating Between Inability to Afford Prescription Medications and 'Noncompliance'

by Susanne J. Pavlovich-Danis, R.N., M.S.N., ARNP-C

Geriatric Times May/June 2004 Vol. V Issue 3

Health care providers should not rush to label seniors as noncompliant with medication regimes until their ability to pay for medications has been assessed. Like it or not, a "financial triage" is rapidly becoming a necessity when planning care for seniors, regardless of the type of health coverage they may have. Health care providers can enhance compliance with medications among their geriatric clients through familiarity with available assistance programs and by implementing financially sensitive prescribing practices.

Seniors are three times as likely to use prescription medications as the general population, yet individuals with chronic conditions such as hypertension and hyperlipidemia are more likely to be unable to afford them (Cunningham, 2002).

The problem is more pronounced among African-American Medicare beneficiaries who, according to the Center for Studying Health System Change, are more than twice as likely as whites to report being unable to fill prescriptions (Reed et al., 2003). Even with their Medicare coverage, 16% of seniors still cannot afford medications (Steinman et al., 2001).

Seniors with diabetes are among those who do not fare well, especially when considering compliance with evidence-based recommended medications such as lipid-lowering medications (e.g., statins) and angiotensin-converting enzyme (ACE) inhibitors (Brown et al., 2003). The problem is twofold: Prescribers do not recommend these medications as often to lower-income patients, and the uninsured or underinsured may not fill prescriptions even if they are prescribed.

Barriers to Rx Compliance

Pointing the finger at prescription drug costs and decreased or absent coverage for medications is easy when trying to identify barriers to compliance. However, these factors are beyond the control of the prescribing professional.

Other factors, including preconceived prescriber bias, limited awareness of patient financial circumstances and inflexible prescribing practices, may be altered--resulting in enhanced compliance.

One of the most prevalent obstacles prescribing professionals face is preconceived bias about which patients can and cannot afford medications. Assessing ability to afford medications is further complicated by patient pride and reluctance to disclose financially sensitive information. Many health care providers are also unaware of the actual cost of many of the medications they prescribe in relation to available alternatives (Korn et al., 2003).

Prescribing professionals often dislike being told what to prescribe from managed care plans, yet recommendations from pharmaceutical industry representatives have often been accepted and have been found to highly influence prescribing habits (Monaghan et al., 2003). Selecting medications other than those considered the "newest and best" is often frowned upon or viewed as providing an inferior level of care. Keeping in mind that patients have financial constraints and accepting the fact that "something is better than nothing" may be inevitable. Being unable to afford antihypertensive medication can precipitate a cerebrovascular accident, and poor blood glucose control can accelerate renal failure or lead to amputation.

Asking the Right Questions

Screen everybody--frequently. You will be surprised at what you find. Patients who could afford their medications last year may have lost their supplemental insurance; may be paying for their prescriptions on credit cards; or may be supporting a parent, children or grandchildren.

When inquiring about your geriatric patients' ability to afford medications, it is imperative that the topic is approached with tact and respect. Focus on circumstances that may be similar to those of other patients you care for. Use empathetic and simple terms that convey your desire to obtain information as a means to plan out a medication regime that is both effective and affordable. The following questions may yield valuable information:

A sensitive triage must allow enough time for seniors to explain their circumstances. Your initial investment of time conveys respect, strengthens a trusting relationship and facilitates selection of appropriate assistance strategies.

Respect the personal nature of the information you are requesting. Seniors willing to share their concerns over incontinence or impotence may be reluctant to tell you that they cannot afford some or all of their medications. Reassure your patients that the information they share will be kept confidential. If they qualify for assistance, some patients may require help in completing forms. While this is a task that can be delegated to a compassionate and competent staff member, caution staff members and patients against providing inaccurate information that may misperceived as a fraudulent attempt to obtain assistance.

Remember that it is perfectly acceptable to document the patient's difficulty in affording medications as a factor you considered when formulating the treatment plan. Also document avenues of assistance you provided for the patient to pursue.

Help for the Asking

Patient circumstances will dictate which assistance measures are appropriate. For the severely economically challenged patient, many pharmaceutical company-sponsored programs are available. These programs typically provide brand-name drugs free or at a drastically reduced price (Table).

Patients above the threshold for company-sponsored assistance programs may require some manipulation of their medication regime to take advantage of lower-cost generic options, over-the-counter medications, coupons and rebates, and pricing battles between competing pharmacies. Often, simply evaluating their monthly medications in light of coverage caps and available alternatives may be all that is necessary.

Sometimes, it may be necessary to select drug classifications agents based on coverage. For example, some patients with diabetes may have coverage for testing supplies only if they are insulin-dependent. Perhaps a basal insulin dose might afford both better control and savings over oral agents.

Choosing the Right Words

Remember that your terminology often will be taken literally by patients. If you suggest an Accu-Chek or a OneTouch by name instead of a blood glucose meter, patients with diabetes paying out-of-pocket for their testing supplies may needlessly purchase a more expensive testing system. Conveying the acceptability of a store-brand meter and strips may result in substantial savings for your patients and enhance compliance with testing.

Samples--Friend or Foe?

Samples provide a wonderful way to assist patients in getting started on new medications without paying up-front for them. The ability to select and titrate medications without charge can be quite beneficial; however, be cautious about continually supplying medications from samples. You may be helping a few at the expense of others. Direct patients needing assistance to longer-term solutions such as patient-assistance programs. Use samples to get them started and tide them over until their personal supply arrives from the manufacturer (Pavlovich-Danis, 2003). Another potential problem with samples is the lack of labeling or instructions. This could lead to improper use, noncompliance or other, more dire outcomes.

Sample availability can influence prescribing patterns, as was found in a study of antihypertensive agent prescribing (Boltri et al., 2002). Despite recommendations based on the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, only 38% of prescriptions were for first-line medications when samples of second-line medications were available.

When patients insist on a brand-name medication or require multiple agents for the same disorder, consider the benefits of prescribing combination medications to reduce both co-pays and out-of-pocket expense.

Senior Self-Prescribing

As time passes and drug patents expire, many medications once covered as prescription drugs are made available over the counter. This can be a mixed blessing for seniors. Some may be required to pay out of pocket for medications that will no longer be covered by supplementary plans or managed care plan formularies. Prescription alternatives may result in higher tiered-level co-pays or be excluded altogether. Sometimes, paying out of pocket for an over-the-counter medication may actually be less expensive than a prescription drug co-pay. Often, selecting a medication regime requires the use of a calculator to assist patients in tailoring their medication plan based on co-pays, monthly drug expense caps and available OTC options.

On the downside, seniors may also seek relief from symptoms with OTC medications instead of visiting their health care providers, thus delaying diagnosis and more aggressive levels of care. This delay in care and any restriction in prescription drug use can lead to more expensive interventions, including unnecessary trips to the emergency department.

Helping You--Helping Me

If office space and resources permit, consider in-house dispensing of generic medications. Check state regulations regarding licensing requirements, and then locate a service provider to assist you with everything necessary to dispense and log office-dispensed medications to your own patients.

While samples may not be sold, medications dispensed by a practitioner may be sold in-office for a profit. Medications dispensed for a fee differ from free samples in that they are full prescription-size containers supplied by a drug repackager approved by the U.S. Food and Drug Administration.

Nearly all states have regulations governing this practice by physicians and nurse practitioners. While state laws vary, all drug repackagers must comply with guidelines from the FDA and the U.S. Drug Enforcement Administration. It is important for providers interested in dispensing medications for a fee to check with their state guidelines and only purchase medications for dispensing from licensed repackagers.

Consider both the generic co-pay and the out-of-pocket cost at area pharmacies when pricing your medications. As circumstances dictate, you can always lower prices.

Medicare Participants

The Medicare Prescription Drug Improvement and Modernization Act of 2003 created new "Part D" drug benefits that take effect January 2006. In the interim, discount drug cards offering some measure of assistance will be distributed, beginning in June 2004. The benefits available vary based upon income levels, with those patients least likely to afford their medications receiving the greatest assistance. Additional information regarding program details can be found at <www.medicare.gov/MedicareReform/>.

Sharing the Responsibility

Facilitating the best possible outcome with a plan of care the patient can adhere to is an obvious goal for which prescribing professionals strive. While it is crucial to select the right medication, it is equally important to assess for barriers to compliance and alter the plan of care accordingly. When coverage dictates medication choices, physicians should not feel alone or remorseful--many health care providers report their prescribing habits are heavily influenced by prescription coverage constraints (Artz et al., 2002).

Doubtful that a financial triage leading to prescription assistance can make that much difference? The clinical outcomes of one study of uninsured cardiac patients may change your mind (Schoen et al., 2001). When triaged and assisted, researchers found that medication compliance not only increased from 48.5% to 72.7%, but blood pressure and low-density lipoprotein cholesterol levels improved, as did normalized ratio (INR) testing of patients taking warfarin (Coumadin).

Enhancing compliance can be facilitated by promoting sensitive triage of financial resources available for medications, selecting medication regimes with cost-containment in mind, and keeping up-to-date with available assistance programs and measures to which patients can be directed.

Ms. Pavlovich-Danis practices in Plantation, Fla., and is nursing area chairperson and professor at the University of Phoenix, Fort Lauderdale campus.

References

Artz MB, Hadsall RS, Schondelmeyer SW (2002), Impact of generosity level of outpatient prescription drug coverage on prescription drug events and expenditure among older persons. Am J Public Health 92(8):1257-1263.

Boltri JM, Gordon ER, Vogel RL (2002), Effect of antihypertensive samples on physician prescribing patterns. Fam Med 34(10):729-731.

Brown AF, Gross AG, Gutierrez PR et al. (2003), Income-related differences in the use of evidence-based therapies in older persons with diabetes mellitus in for-profit managed care. J Am Geriatr Soc 51(5):665-670.

Cunningham PJ (2002), Prescription Drug Access: Not Just a Medicare Problem. Washington, D.C.: Center for Studying Health System Change. Available at: www.hschange.org/CONTENT/429/429.pdf. Accessed April 8, 2004.

Korn LM, Reichert S, Simon T, Halm EA (2003), Improving physicians' knowledge of the costs of common medications and willingness to consider costs when prescribing. J Gen Intern Med 18(1):31-37.

Monaghan MS, Galt KA, Turner PD et al. (2003), Student understanding of the relationship between the health professions and the pharmaceutical industry. Teach Learn Med 15(1):14-20.

Pavlovich-Danis SJ (2003), Lifeplan: when prescription blues put your patients in the red. Clinician News 7(8):8-11.

Reed MC, Hargrave JL, Cassil A (2003), Unequal Access: African-American Medicare Beneficiaries and the Prescription Drug Gap. Issue Brief No. 64. Washington, D.C.: Center for Studying Health System Change. Available at: www.hschange.org/CONTENT/586/ ?topic=topic20. Accessed April 8, 2004.

Schoen MD, DiDomenico RJ, Connor SE et al. (2001), Impact of the cost of prescription drugs on clinical outcomes in indigent patients with heart disease. Pharmacotherapy 21(12):1455-1463.

Steinman MA, Sands LP, Covinsky KE (2001), Self-restriction of medications due to cost in seniors without prescription coverage. J Gen Intern Med 16(12):793-799 [see comment].