Have you ever forgone filling a prescription because of the cost? Research finds many people, including those with insurance coverage, have for everything from drugs that manage chronic conditions to oral cancer medications.
Commonly, those who abandon their prescriptions — not picking up prescriptions approved by insurance from the pharmacy — don’t go on to get an alternate drug. As a result, medication therapy in many cases is not only delayed but halted.
Experts say the issue seems to be growing more severe as drug prices rise — about 10 percent annually in recent years, according to a Truveris National Drug Index report — and as the insured with drug benefits are increasingly being required to shoulder a greater share of that cost.
Reflecting a broader trend of patients being more likely to forgo getting drugs and medical care as their costs rise, one study in the Journal of Clinical Oncology found that as the out-of-pocket costs for new, or novel, oral cancer drugs increased, so did abandonment rates. In that research, which was first published online in December, abandonment refers specifically to not filling the initial prescription or a substitute prescription for the same drug in the 90 days after the prescription was approved by insurance, explains lead study author Jalpa Doshi, a professor of general internal medicine in the Perelman School of Medicine at the University of Pennsylvania. “When patients had to pay less than $10, about 10 percent of the patients failed to pick up their prescriptions, [and that] jumped up to 32 percent when patients were charged $100 to $500,” Doshi says. Most surprising, she says, was that nearly half (49.4 percent) of the people who were asked to pay more than $2,000 out of pocket either abandoned their prescription or refused to pick it up.
[See: 8 Questions to Ask Your Pharmacist.]
“The $2,000 out-of-pocket cost is not uncommon nowadays in the marketplace where we see a lot of high-deductible health plans. We see specialty drugs being placed on what are called these fourth or fifth specialty tiers, wherein the out-of-pocket costs for the patients are tied to high coinsurance levels of 30 percent or higher,” she says. “So being asked to pay 30 percent of the price of the drug, as opposed to a fixed copay of $100 or $50, is obviously exposing these patients to much higher out-of-pocket costs.”
While costs of cancer care can be particularly burdensome, putting innovations in treatment out of reach for many patients, experts say financial pressures lead people facing a great number of medical issues to hold off on getting prescribed medications — as Doshi and fellow researchers have found. “Our team has actually conducted studies in multiple disease areas — where there are innovative yet expensive treatments — including rheumatoid arthritis, psoriasis, multiple sclerosis and others. And in all of these cases we do find that high out-of-pocket costs are impacting initiation of medications, they’re impacting adherence to these medications once patients start,” she says. “We’ve reported in our studies often treatment interruptions — gaps in use — and even complete discontinuation of these medications.”
Frequently patients never discuss the decisions not to fill a prescription due to cost with their doctors, and health providers fail to address potential affordability concerns. However, increasingly clinicians say because of the profound impact financial constraints can have on treatment, these kinds of cost concerns are medical concerns — and should be handled as such. “I just think as physicians we need to work with the patients, because if the patients see the drug as prohibitively expensive, they’re just not going to take it,” says Dr. Mark Kelley, a pulmonologist at Massachusetts General Hospital in Boston and a senior lecturer at Harvard Medical School. Kelley is also on the board of the advocacy and education nonprofit Costs of Care, which is seeking to help lower medical costs.
He thinks that physicians should initiate the cost conversation with patients, who may be reluctant to do so. Whoever goes first, the discussion needs to happen, experts say, especially where there may be concerns about affordability — though that’s not always known until the out-of-pocket sticker shock for a new drug sets in at the pharmacy counter.
What a patient pays for a prescription drug differs by the plan, yet Kelley notes that doctors tend to prescribe many of the same medications to different patients and should become familiar with what the drugs cost. “Most doctors have a portfolio of those drugs that they prescribe day in and day out, and my dictum is ‘You should know what those costs are,'” he says. “I’m a pulmonologist and many of the drugs that I prescribe are pretty expensive — the inhalers in particular; and I know pretty much what they all cost.” Admittedly drug prices fluctuate a lot — “this is a bouncing ball,” Kelley notes; so that can make drug prices harder to follow day-to-day. “But I know from a directional vantage point, what are the most expensive and what are the least expensive,” he says.
[See: 10 Lessons From Empowered Patients.]
When it’s not clear how much a patient might pay for a drug, one workaround is calling in that prescription to a pharmacy first to check on the out-of-pocket cost — like a drug copay. “If it’s a pharmacy the patient uses all the time, they’ll have their information in the computer system. So you can ask upfront how much you’re going to have to pay,” Kelley says. If it’s prohibitively expensive, the patient and health provider can discuss lower cost alternatives, like comparable, less expensive generic drugs if available. (While there are many low cost medications available, prices even for some generics are rising, too.) If there aren’t alternatives, they can discuss other ways to deal with affordability issues, such as if that person qualifies for patient assistance programs like NeedyMeds to get drugs discounted by pharmaceutical companies.
Websites like GoodRx.com can also help people shop around for drugs, which can be helpful when paying for prescriptions in cash, since prices can vary greatly from one pharmacy to the next.
But especially when making decisions on whether to take a drug or not because of cost, patients should make sure to share their concerns with their health provider, if the clinician hasn’t already discussed options to make drugs more affordable. “It is very important for patients to talk with their health care providers about what medications they’re on, what medications they should be on — which are not always the same thing … — and how much they have to pay for those medications, and how easy or difficult that may be,” says Dr. Jeffrey Kullgren, a research scientist in the Center for Clinical Management Research at the VA Ann Arbor Healthcare System and an assistant professor of internal medicine at the University of Michigan Medical School.
In addition to increasing drug prices and plans requiring patients to pay a greater share, another major drug cost driver is the sheer number of medications some people take. That number can increase with age and in response to chronic conditions or more medically complex issues.
Experts point out that often patients, especially those seeing multiple health providers, may be continued on drugs longer than needed, which can expose some not only to additional side effects but to undue financial strain. “So it’s important then, especially if a patient’s health changes as they age, to periodically be reviewing those medications with their health care team to ensure that they are able to get the medications that are going to be the most beneficial to them, while we avoid prescribing medications to patients who are unlikely to benefit from them and for who those unneeded prescriptions can lead to cost burdens,” Kullgren says.
[See: How to Help Aging Parents Manage Medications.]
That kind of open dialogue can strengthen the doctor-patient relationship, experts say, while recognizing that if a patient can’t afford recommended drugs, it’s an impediment to optimal care — not just a pocketbook concern. “Economic risk for the patient is a health care risk,” Kullgren says. “Because if you can’t afford something, you’re not going to get it.”
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Why You Should Talk to Your Doctor About Drug Pricing originally appeared on usnews.com
