Knowledge of health care benefits among patients with depression

Navigating Poorly Charted Territory

American health care is complex, fragmented, and arcane rather than being patient centered. Many patients have considerable difficulty navigating this system. As a result, care is less timely, safe, effective, and efficient. Since navigation problems are more likely for those who are sicker and less educated, they contribute to inequity. Early solutions proposed for this problem focused on the use of yet another specialized professional, the “navigator,” to help individuals find their way through the system so they get the care they need. The author defines the patient navigation problem and its probable consequences and argues that research and action are needed to (a) document the problem empirically, (b) identify underlying organizational structures and behaviors that can make navigation easy or difficult, and (c) assess whether and how policies, regulations, and improvement strategies can influence these structures and behaviors.

Consumers' misunderstanding of health insurance

We report results from two surveys of representative samples of Americans with private health insurance. The first examines how well Americans understand, and believe they understand, traditional health insurance coverage. The second examines whether those insured under a simplified all-copay insurance plan will be more likely to engage in cost-reducing behaviors relative to those insured under a traditional plan with deductibles and coinsurance, and measures consumer preferences between the two plans. The surveys provide strong evidence that consumers do not understand traditional plans and would better understand a simplified plan, but weaker evidence that a simplified plan would have strong appeal to consumers or change their healthcare choices.

Influence of patient costs and requests on emergency physician decisionmaking

STUDY OBJECTIVES

We examine emergency physician knowledge of, attitudes about, and responses to patient cost-sharing in the emergency department (ED).

METHODS

A convenience sample of emergency physicians from an integrated delivery system completed a questionnaire including self-report questions about knowledge of and attitudes about cost-sharing and an experimental vignette. The vignette describes a patient with an uncomplicated asthma exacerbation, with a version in which she has a $100 ED visit copayment and a version in which she does not. Subjects responded with their "best judgment" of whether they would order a chest radiograph and their decision after specific patient request. We examined the frequency of responses overall and associated characteristics with chi(2) testing.

RESULTS

Of 204 respondents (349 eligible participants [58%]), 203 answered the vignette questions. No respondent reported that ordering a radiograph was clinically appropriate; however, 85% reported that they would order a radiograph if the patient requested it. There were no significant differences in the percentage of physicians ordering the test across the 2 versions. Overall, 77% of respondents reported having limited awareness of an individual patient's cost-sharing level; 67% reported that patient costs sometimes affect their clinical decisions; only 10% estimated changing their decisions in greater than 20% of encounters in which the cost-sharing level was known.

CONCLUSION

Emergency physicians are usually not aware of a patient's cost-sharing level and, in instances which they are, report that this knowledge rarely affects their clinical decisions. However, emergency physicians are responsive to patient requests, even when the treatment request differs from their clinical judgment.

The Relationship Between Older Adults' Knowledge of Their Drug Coverage and Medication Cost Problems

OBJECTIVES

To determine whether chronically ill patients have gaps in knowledge about their prescription drug coverage and establish the relationship between gaps and medication cost problems.

DESIGN

Nationwide, cross-sectional survey.

SETTING

Nationwide survey conducted via the Internet.

PARTICIPANTS

Three thousand one hundred nineteen adults aged 50 and older (1,400 of whom were aged > or = 65) who had prescription drug coverage and at least one chronic illness.

MEASUREMENTS

Patients were asked about features of their drug benefits and whether they had experienced problems due to medication costs in the prior year.

RESULTS

Twenty-five percent of respondents reported not knowing their usual prescription copayments, and 41% did not know whether there were caps on their drug coverage. Nonwhite race and lower income were independent risk factors for lack of knowledge about these aspects of pharmacy benefits. Lack of knowledge regarding the limits of coverage was associated with a greater likelihood of cutting back on medication use because of cost pressures, forgoing basic needs because of medication costs, borrowing money to pay for prescriptions, and worrying about medication costs (all P<.05).

CONCLUSION

Many older adults with prescription drug coverage do not know important features of their pharmacy benefits. Racial minorities and those with low incomes may have the greatest difficulty understanding coverage and as a result may be at greatest risk for underusing their benefits. Education about Medicare reforms and other efforts to increase prescription coverage should accompany these policies.

A conceptually based approach to understanding chronically ill patients' responses to medication cost pressures

Prescription medications enhance the well-being of most chronically ill patients. Many individuals, however, struggle with how to pay for their treatments and as a result experience problems with self-care and health maintenance. Although studies have documented that high out-of-pocket costs are associated with medication non-adherence, little research on prescription cost sharing has been theoretically grounded in knowledge of the more general determinants of patients' self-management behaviors and chronic disease outcomes. We present a conceptual framework for understanding the influence of patient, medication, clinician, and health system factors on individuals' responses to medication costs. We review what is known about how these factors influence medication adherence, identify possible strategies through which clinicians, health systems, and policy-makers may assist patients burdened by their medication costs, and highlight areas in need of further research. Although medication costs represent a burden to chronically ill patients worldwide, most patients report using their medication as prescribed despite the costs, and others report cost-related underuse despite an apparent ability to afford those treatments. The cost-adherence relationship is modified by contextual factors, including patients' characteristics (e.g., age, ethnicity, and attitudes toward medications), the type of medications they are using (e.g., the complexity of dosing and the drug's clinical target), clinician factors (e.g., choice of first-line agent and communication about medication costs), and health system factors (e.g., efforts to influence clinicians' prescribing and to help patients apply for financial assistance programs). Understanding these relationships will enable clinicians and policy-makers to better design pharmacy benefits and assist patients in taking their medication as prescribed. The next generation of studies examining the consequences of prescription drug costs should expand our knowledge of the ways in which these co-factors influence patients' responses to medication cost pressures.

The community initiative on depression: report from a multiphase work site depression intervention

OBJECTIVE

We sought to further understand depression, a common, disabling condition with considerable ramifications for the workplace, including higher costs, absenteeism, and reduced work performance.

METHODS

A multidisciplinary health care coalition recently implemented a multiphase workplace depression initiative in Kansas City. We report results from its first phase, a 22-item, self-administered survey of depression knowledge and attitudes among employees of 13 large, local work sites.

RESULTS

There were 6,399/38,945 respondents (16% response rate). Most respondents (>90%) appropriately recognized the signs and symptoms of depression. A minority (29%) would feel comfortable discussing depression with their supervisor. Sixty-two percent knew how to access company resources for depression care.

CONCLUSIONS

Employees were knowledgeable about depression but were less aware of employee-assistance programs for depression care. These findings support increased attempts to raise the awareness of depression and promote of help-seeking behavior in the workplace.

CLINICAL SIGNIFICANCE

Depression is a prevalent illness with risk for many deleterious outcomes if under-recognized or undertreated. Depression is a leading cause of work-related disability worldwide. Most people with depression are employed (an estimated 68%). Recognizing and initiating depression care in the workplace will facilitate depression treatment in clinical settings.

Cost-Sharing

BACKGROUND

The use of cost-sharing to control healthcare expenditures is increasing, but there is scant information about patients' knowledge of cost-sharing or its influence on behavior.

OBJECTIVE

The objective of this study was to evaluate what patients know about their individual levels of cost-sharing and how it influences decisions to seek care.

STUDY DESIGN

We conducted a cross-sectional telephone survey with a 69% response rate.

SUBJECTS

We studied a stratified random sample of 695 adult patients in an integrated delivery system: 266 subjects > or =65 years, 218 low-income subjects, and 211 subjects from the overall membership.

MEASURES

We used perceived and actual levels of copayments for emergency department (ED) visits, office visits, and prescription drugs; and self-reports of copayment-related behavior changes.

RESULTS

One third of subjects correctly reported their ED copayment, whereas three fourths correctly reported their prescription drug and office visit copayments. Over half of the subjects (57%) underestimated their ED copayment by $20 or more. Among patients who reported having any copayment, 11% described changing their behavior because of the copayment, ie, delayed or avoided emergency care. The perceived copayment level was strongly associated with behavior change (odds ratio, 3.9). Other significant factors included having more ED visits in the past 12 months and having a low health status.

CONCLUSIONS

Patients have less knowledge of their ED cost-sharing levels than for other services. The perceived copayment amount was strongly associated with avoidance of or delays in emergency care. Further research is needed to determine whether these responses reflect greater efficiency or harmful decisions.