Coping with prescription drug cost sharing: knowledge, adherence, and financial burden

Health insurance as a moderator in the relationship between financial toxicity and medical cost-coping behaviors: Evidence from patients with lung cancer in China

OBJECTIVE

This study investigates the relationship between financial toxicity and medical cost-coping behaviors (MCCB) in Chinese patients with lung cancer, with a particular focus on the moderating role of health insurance.

METHODS

We surveyed 218 patients with lung cancer and assessed their Comprehensive Score for Financial Toxicity (COST) and self-reported MCCB. Patients were categorized into Urban Employee's Basic Medical Insurance (UEBMI) group and Urban-Rural Resident Basic Medical Insurance Scheme (URRBMI) groups by their medical insurance, and matched for socioeconomic, demographic, and disease characteristics via propensity score.

RESULTS

Significant different characteristics were noted between UEBMI patients and URRBMI patients. Patients with UEBMI had higher COST scores but lower levels of MCCB compared to URRBMI patients in the original dataset. After data matching, multivariate logit regression analysis showed that better financial toxicity was associated with lower levels of MCCB (OR = 0.95, 95% CI: 0.92-0.99). Health insurance type did not have a direct association with cost-coping behaviors, but an interaction was observed between health insurance type and financial toxicity. Among patients with URRBMI, better financial toxicity was associated with lower levels of cost-coping behaviors (OR = 0.89, 95% CI: 0.83-0.95). Patients with UEBMI had a lower probability of engaging in any cost-coping behaviors in situations of worse financial toxicity compared to patients with URRBMI.

CONCLUSION

The findings suggest that financial toxicity is correlated with MCCB in Chinese patients with lung cancer. The type of health insurance, specifically UEBMI and URRBMI, plays a moderating role in this relationship. Understanding these dynamics is essential for developing targeted interventions and policies to mitigate financial toxicity and improve patients' management of medical costs.

Association of Branded Prescription Drug Rebate Size and Patient Out-of-Pocket Costs in a Nationally Representative Sample, 2007-2018

IMPORTANCE

Over the past decade, branded prescription drug manufacturers have substantially increased list prices while offering larger rebate payments to health care insurers. Whereas larger rebates can partially offset increases in list prices for insurers, patient out-of-pocket costs may be directly associated with list prices for individuals without insurance and indirectly associated with list prices for individuals with insurance through deductibles or coinsurance.

OBJECTIVE

To investigate the association between rebates and patient out-of-pocket costs and whether this association differs by coverage type (ie, Medicare, commercial, or uninsured) and before and after 2014.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted using data from the Medical Expenditure Panel Survey (MEPS) combined with pricing data for single-source branded drugs from SSR Health from 2007 through 2018. The study was conducted among a nationally representative sample of the noninstitutionalized civilian US population. Included individuals were respondents to MEPS with at least 1 prescription for a single-source branded drug who were covered by Medicare or commercial insurance or were uninsured during an entire year. Data analyses were conducted from August 2019 through March 2021.

EXPOSURES

Estimated rebate size.

MAIN OUTCOMES AND MEASURES

Out-of-pocket costs per prescription were calculated, adjusting for year and drug.

RESULTS

Among 38 131 individuals with at least 1 prescription, the mean age was 54 years (95% CI, 54 to 55 years), with 22 044 women (57.8%) and 29 086 White individuals (76.3%). The sample included 444 unique drugs with a survey-weighted total of 4.7 billion prescriptions. Estimated mean (SE) rebates increased from $34 ($1) per prescription in 2007 to $374 ($9) per prescription in 2018. The rebate sizes were associated with statistically significant mean out-of-pocket increases per branded prescription of $4 (95% CI, $4 to $4) from 2007 to 2013 and $11 (95% CI, $10 to $12) from 2014 to 2018. From 2014 to 2018, rebate sizes were associated with statistically significant mean increases in out-of-pocket costs per prescription of $13 (95% CI, $12 to $13) for individuals with Medicare, $6 (95% CI, $6 to $7) for individuals with commercial insurance, and $39 (95% CI, $34 to $44) for individuals without insurance. After adjusting for list prices, there was no association between rebates and out-of-pocket costs, with a change from 2014 to 2018 of -$0.01 (95% CI, -$0.04 to $0.02).

CONCLUSIONS AND RELEVANCE

These findings suggest that drug manufacturers may have provided larger rebates to insurers primarily by increasing list prices and that individuals without insurance had greater cost increases. The results emphasize the need for policy solutions that decouple list prices and out-of-pocket costs.

The Association between Medication Experiences and Beliefs and Low Medication Adherence in Patients with Chronic Disease from Two Different Societies: The USA and the Sultanate of Oman

This cross-sectional study aimed to describe the association between medication experiences and beliefs and self-reported medication adherence in patients with chronic diseases in two different samples from two different societies: the USA and the Sultanate of Oman. The Morisky Medication Adherence Score (MMAS-8) questionnaire was used to measure medication adherence. Three items (statements) were used for measuring medication experiences and beliefs variable on a four-point Likert scale adapted from the 2015 National Consumer Survey of the Medication Experience and Pharmacists’ Role (NCSME&PR). In the U.S., quantitative secondary data analysis of 13,731 participants was conducted using the 2015 NCSME&PR, a self-administered online survey coordinated by Qualtrics Panels between 28 April 2015 and 22 June 2015. The same variables were translated into Arabic, with studies conducted at the Royal Court Medical Center in Oman, and data from 714 participants were collected between 16 June 2019 and 16 August 2019. Data were analyzed using IMB/SPSS version 24.0 software. Chi-square analysis and descriptive statistics were used. The results showed that the low adherence rates for medication (MMAS-8 < 6) were 56% and 52% in Omani and U.S. groups, respectively. Approximately 90% of the U.S. and Omani participants believed that “medicines are a life-saver”; however, medication adherence was higher in Oman (30%) than in the United States (9%) for these participants. In total, 60% of the U.S. and 29% of Omani participants believed that “medicines are a burden”; however, about 60–65% of participants in both countries were in the low medication adherence group. Additionally, 63% of the U.S. and 83% of the Omani participants disagreed that “medicines do more harm than good”; however, medication adherence in the U.S. (15%) was higher than in Oman (8%). In conclusion, a decrease in low medication adherence was observed with positive medication experiences and beliefs. However, the impacts of medication experiences and beliefs on low medication adherence rates were different from one population to another. The “medication burden” statement resulted in the highest percentage of difference in terms of low medication adherence rates between those who agree and those who disagree in the U.S. group (20%), whereas the “medicines are a life-saver” statement resulted in a greater difference in the Omani group (30%). Proper communication between patients and healthcare providers based on the patient’s medication experiences and beliefs will substantially improve medication adherence.

Who Benefits from the Fixed Copayment of Medical and Pharmaceutical Expenditure among the Korean Elderly?

The Korean National Health Insurance system imposes a 30% coinsurance for outpatient medical care and prescription drugs; however, at the age of 65, the coinsurance model changes to a copayment model that offers lower fees for the elderly. Thus, this study aimed to investigate the influence of the copayment model for outpatient visits and prescription drugs on healthcare utilization among the Korean elderly. We compared total outpatient visits, total prescriptions, and out-of-pocket expenses between a case group with copayment reduction (65 years or older) and a control group without any reduction (64 years or younger). We obtained secondary data collected from seven waves of the Korea Health Panel Survey (2010-2016). Outpatient visits increased exclusively in the case group among those with lower income. After adjusting for covariates, the results of the difference-in-differences analysis showed that, compared to the control group, there was a significant increase in outpatient visits among individuals with lower income in the case group. Our study shows that cost sharing changes affect Korean patients with different income levels in different ways.

Primary medication non-adherence at Counties Manukau Health Emergency Department (CMH-ED), New Zealand: an observational study

OBJECTIVES

To measure primary medication non-adherence (failure to fill prescription medicines) in patients discharged from the emergency department (ED), and to determine whether sociodemographic factors, smoking status and access to a general practitioner affect prescription filling. Little is known about primary medication non-adherence in EDs, and less so in New Zealand (NZ). Identifying reasons for non-adherence will enable development of strategies to improve adherence and reduce morbimortality.

DESIGN AND SETTING

An observational study based on patient data from the ED of a large public hospital in South Auckland, NZ.

PARTICIPANTS

Data were collected from 1600 patients discharged between 28 April-6 May and 28 July-9 August 2014. Data were included if patients were residents within the Auckland Regional Public Health Service boundaries, admitted to ED and discharged with a prescription. Data were excluded if patients were admitted to another ward, transferred to another hospital or left the ED without seeing a doctor.

RESULTS

992 patients were included in the study, the majority were under 10 years (32.6%), of Pacific Island descent (42.8%), NZ-born (67.7%) and living in the most socioeconomically deprived areas (78.1%). Almost 50% of patients failed to fill all prescription medications. Simple linear regression analysis indicated that non-adherence was significant for those 10-24 years (n=236; adherence=47.2%; p<0.05), of NZ Māori ethnicity (n=175; 51.3%; p=0.01), unemployed (n=77; 46.8%; p<0.01), homemakers (n=66; 45.7%; p<0.01), students (n=228; 55.6%; p<0.05) and cigarette smokers (n=139; 50.3%; p<0.01). Following multivariable analysis, the strongest predictors for non-adherence were those aged between 10 and 17 years (n=116; p<0.01), the unemployed (n=77; p=0.01) and homemakers (n=66; p=0.01).

CONCLUSIONS

Age and occupation were the greater predictors of non-adherence; however, no other significant differences were found. Since this study, changes to prescription co-payments have been made. Further research is warranted to assess whether this change has more recently affected the rates of non-adherence.

Patient adherence to pharmaceutical care amid the economic crisis in Greece: Underlying priority areas for policy makers

The purpose of the study was to investigate the degree to which chronic patients adhered to medication regimens during the economic crisis in Greece. It is a quantitative cross-sectional study, with a convenience sample of 1,009 residents of Western and Northern Greece, aged ≥ 18 years, with chronic health problems. The survey was conducted between February and June 2016. Data were collected via a structured questionnaire with closed-ended questions, filled out during face to face interviews with all participants. The vast majority of respondents (94.5 %) said that they were able to buy prescribed drugs but had to economise in other ways (for example, by cutting back on clothing and travel) to cope with essential household expenses, including medication. Only 71 % of participants said they remembered to take their prescribed medications every day, following all of their physicians' recommendations. Almost 70 % of participants said that using generic medications made it easier to adhere to their treatment regimens. The results of a correlation analysis showed that patients experiencing financial hardships as a result of health problems were less likely to adhere to pharmaceutical care regiments than those who were not experiencing financial difficulties (p = 0.026). Men had a higher level of adherence than women (p = 0.001).

Adverse Childhood Experiences and Household Out-of-Pocket Healthcare Costs

INTRODUCTION

Adverse childhood experiences are associated with higher risk of common chronic mental and physical illnesses in adulthood, but little evidence exists on whether this influences medical costs or expenses. This study estimated increases in household medical expenses associated with adults' reported adverse childhood experience scores.

METHODS

Household out-of-pocket medical cost and adverse childhood experience information was collected in the 2011 and 2013 waves of the Panel Study of Income Dynamics and its linked 2014-2015 Panel Study of Income Dynamics Childhood Retrospective Circumstances Study supplement and analyzed in 2017. Generalized linear regression models estimated adjusted annual household out-of-pocket medical cost differences by retrospective adverse childhood experience count and compared costs by family type and size. Logistic models estimated odds of out-of-pocket costs that were >10% of household income or >100% of savings, as well as odds of household debt.

RESULTS

Adverse childhood experience scores were associated with higher out-of-pocket costs. Annual household total out-of-pocket medical costs were $184 (95% CI=$90, $278) or 1.18-fold higher when respondents reported one to two adverse childhood experiences and $311 (95% CI=$196, $426) or 1.30-fold higher when three or more adverse childhood experiences were reported by an adult in the household. Odds of household medical costs >10% of income, >100% of savings, and the presence of household medical debt were 2.48-fold (95% CI=1.40, 4.38), 2.25-fold (95% CI=1.69, 2.99), and 2.29-fold (95% CI=1.56, 3.34) higher when an adult in the household reported three or more adverse childhood experiences compared with none.

CONCLUSIONS

Greater exposure to adverse childhood experiences is associated with higher household out-of-pocket medical costs and financial burden in adulthood.

Patient-reported adherence to statin therapy, barriers to adherence, and perceptions of cardiovascular risk

BACKGROUND

Patient reports of their adherence behaviors, concerns about statins, and perceptions of atherosclerotic cardiovascular disease (ASCVD) risk could inform approaches for improving adherence to statin therapy. We examined these factors and their associations with adherence.

METHODS

We conducted telephone interviews among a stratified random sample of adults receiving statins within an integrated delivery system (N = 730, 81% response rate) in 2010. We sampled equal numbers of individuals in three clinical risk categories: those with 1) coronary artery disease; 2) diabetes or other ASCVD diagnosis; and 3) no diabetes or ASCVD diagnoses. We assessed 15 potential concerns about and barriers to taking statins, and perceived risk of having a heart attack in the next 10 years (0-10 scale). We calculated the proportion of days covered (PDC) by statins in the last 12 months using dispensing data and used multivariate logistic regression to examine the characteristics associated with non-adherence (PDC<80%). Analyses were weighted for sampling proportions.

RESULTS

Sixty-one percent of patients with PDC<50% reported not filling a new prescription, splitting or skipping statins, or stopping refilling statins in the last 12 months vs. 15% of those with PDC≥80% (p<0.05). The most commonly reported concerns about statins were preferring to lower cholesterol with lifestyle changes (66%), disliking medications in general (59%), and liver or kidney problems (31%); having trouble remembering to take statins (9%) was the most common reason for taking less than prescribed. In multivariate analyses, clinical risk categories were not significantly associated with odds of non-adherence; however, those with higher perceived risk of heart attack were less likely to be non-adherent.

CONCLUSIONS

Patient-reported medication-taking behaviors were correlated with statin PDC and those with lower perceived cardiovascular risk were less likely to be adherent. These findings highlight the importance of eliciting from and educating patients on their adherence behaviors and ASCVD risks.

Associations Between Medicare Part D and Out-of-Pocket Spending, HIV Viral Load, Adherence, and ADAP Use in Dual Eligibles With HIV

BACKGROUND

The implementation of Medicare part D on January 1, 2006 required all adults who were dually enrolled in Medicaid and Medicare (dual eligibles) to transition prescription drug coverage from Medicaid to Medicare part D. Changes in payment systems and utilization management along with the loss of Medicaid protections had the potential to disrupt medication access, with uncertain consequences for dual eligibles with human immunodeficiency virus (HIV) who rely on consistent prescription coverage to suppress their HIV viral load (VL).

OBJECTIVE

To estimate the effect of Medicare part D on self-reported out-of-pocket prescription drug spending, AIDS Drug Assistance Program (ADAP) use, antiretroviral adherence, and HIV VL suppression among dual eligibles with HIV.

METHODS

Using 2003-2008 data from the Women's Interagency HIV Study, we created a propensity score-matched cohort and used a difference-in-differences approach to compare dual eligibles' outcomes pre-Medicare and post-Medicare part D to those enrolled in Medicaid alone.

RESULTS

Transition to Medicare part D was associated with a sharp increase in the proportion of dual eligibles with self-reported out-of-pocket prescription drug costs, followed by an increase in ADAP use. Despite the increase in out-of-pocket costs, both adherence and HIV VL suppression remained stable.

CONCLUSIONS

Medicare part D was associated with increased out-of-pocket spending, although the increased spending did not seem to compromise antiretroviral therapy adherence or HIV VL suppression. It is possible that increased ADAP use mitigated the increase in out-of-pocket spending, suggesting successful coordination between Medicare part D and ADAP as well as the vital role of ADAP during insurance transitions.

Estimating the Impact of Adherence to and Persistence with Atypical Antipsychotic Therapy on Health Care Costs and Risk of Hospitalization

STUDY OBJECTIVE

To estimate the impact of adherence to and persistence with atypical antipsychotics on health care costs and risk of hospitalization by controlling potential sources of endogeneity.

DESIGN

Retrospective cohort study using medical and pharmacy claims data.

DATA SOURCE

Humana health care insurance database.

PATIENTS

A total of 32,374 patients with a diagnosis of schizophrenia or bipolar disorder and who had a prescription for noninjectable atypical antipsychotics (aripiprazole, asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, or ziprasidone), after a washout period of at least 180 days during which there was no use of any atypical antipsychotics, between January 2007 and June 2013.

MEASUREMENTS AND MAIN RESULTS

The effects of adherence (proportion of days covered by all atypical antipsychotic prescription fills) to and persistence (time from initiation to discontinuation of therapy) with atypical antipsychotics on outcomes (all-cause total health care costs, medication costs, medical services costs, and inpatient admissions) were examined. To exclude potential bias due to mutual causality between drug use patterns and health care utilization, the effects of adherence and persistence measured in the first year on outcomes measured in the second year were investigated. Instrumental variable regressions using reimbursement rate and mail order as instrumental variables were conducted to correct potential endogeneity due to omitted variable bias. Being adherent decreased total costs by $19,497 (p<0.05), increased medication costs by $8194 (p<0.001), decreased medical services costs by $27,664 (p<0.001), and reduced hospitalization risk by 27% (p<0.001). Being persistent decreased individual total costs by $23,927 (p<0.05), increased medication costs by $10,278 (p<0.001), and decreased medical services costs by $34,178 (p<0.001). We could not identify a significant association between persistence and the risk of hospitalization.

CONCLUSION

Good adherence to and persistence with atypical antipsychotics led to lower total costs than poor adherence and persistence. Thus efforts should be made to improve adherence and persistence in patients taking atypical antipsychotics.

Health Care Utilization and Treatment Persistence Associated with Oral Paliperidone and Lurasidone in Schizophrenia Treatment

BACKGROUND

Oral paliperidone and lurasidone are new second-generation antipsychotics (SGAs). Empirical evidence on the comparative costs and persistence of these 2 agents are absent in the literature.

OBJECTIVE

To assess health care use and persistence associated with the 2 new agents oral paliperidone and lurasidone and other SGAs.

METHODS

Schizophrenia patients who initiated SGA therapy were identified in the January 2007-June 2013 claims databases of a large managed care organization. Multivariate regressions using aripiprazole as the comparator were conducted. Ordinary least squares regressions were used to estimate the total medical and pharmacy costs associated with each drug. Poisson regressions were conducted to evaluate the frequency of hospitalizations and emergency department (ED) visits associated with each drug. A censored regression model was used to evaluate the comparative persistence. Sensitivity analyses using generalized linear models, two-part models, hurdle models, and instrumental variable regressions were also performed.  

RESULTS

Compared with aripiprazole, paliperidone was not associated with significantly different total costs, yet lurasidone was associated with lower total costs (-$7,052; 95% CI = -$9,221, -$4,882). Lurasidone was also associated with significantly lower medical services costs (-$5,025; 95% CI = -$7,096, -$2,955), drug costs (-$2,026; 95% CI = -$2,695, -$1,357), hospital costs (-$3,026; 95% CI = -$4,731, -$1,321), outpatient costs (-$1,999; 95% CI = -$2,536, -$1,463), and ED costs (-$2,284; 95% CI = -$3,069, -$1,499), whereas paliperidone did not have significant effects on any types of costs. Paliperidone users had fewer ED visits (-0.25; 95% CI = -0.42, -0.08), while lurasidone users had fewer hospitalizations (-5.98; 95% CI = -6.61, -5.35) and fewer ED visits (-2.51; 95% CI = -2.92, -2.10). Both paliperidone and lurasidone were associated with lower levels of treatment persistence.

CONCLUSIONS

Paliperidone does not associate with lower total costs compared with commonly used SGAs, whereas lurasidone is associated with lower total health costs. Thus, high access fees of lurasidone are not necessarily a major concern in prescription.

Employee knowledge of value-based insurance design benefits

BACKGROUND

Value-based insurance designs (VBD) incorporate evidence-based medicine into health benefit design. Consumer knowledge of new VBD benefits is important to assessing their impact on health care use.

PURPOSE

To assess knowledge of features of a VBD.

METHODS

The eligible study population was employees receiving healthcare benefits in an integrated care system in the U.S. Pacific Northwest. In 2010, participants completed a web-based survey 2 months after rollout of the plan, including three true/false questions about benefit design features including copays for preventive care visits and chronic disease medications and premium costs. Analysis was completed in 2012. Knowledgeable was defined as correct response to all three questions; self-reported knowledge was also assessed.

RESULTS

A total of 3,463 people completed the survey (response rate=71.7%). The majority of respondents were female (80.1%) Caucasians (79.6%) aged 35-64 years (79.0%), reflecting the overall employee population. A total of 45.7% had at least a 4-year college education, and 69.1% were married. About three quarters of respondents correctly answered each individual question; half (52.1%) of respondents answered all three questions correctly. On multivariate analysis, knowledge was independently associated with female gender (OR=1.80, 95% CI=1.40, 2.31); Caucasian race (OR=1.72, 95% CI=1.28, 2.32); increasing household income (OR for ≥$100,000=1.86, 95% CI=1.29, 2.68); nonunion job status (OR compared to union status=1.63, 95% CI=1.17, 2.26); and high satisfaction with the health plan (OR compared to low satisfaction=1.26; 95% CI=1.00, 1.57).

CONCLUSIONS

Incomplete knowledge of benefits is prevalent in an employee population soon after VBD rollout.

Chronic conditions, financial burden and pharmaceutical pricing: insights from Australian consumers

Objective To explore the perceptions of Australian consumers and carers about the financial burden associated with medicines used for the treatment of chronic conditions. Method Semi-structured interviews were undertaken with individuals (n = 97) who identified as having a chronic condition(s) (n = 70), cared for someone with a chronic condition(s) (n = 8), or both (n = 19). Participants included individuals identifying with an Aboriginal or Torres Strait Islander (n = 23) or Culturally and Linguistically Diverse (n = 19) background. Data were analysed using the constant comparison method and reported thematically. Results Participants described substantial costs associated with medicines use, along with aggravating factors, including the duration and number of medicines used, loss of employment, lack of pricing consistency between pharmacies and the cost of dose administration aids. Consequences included impacts on medicine adherence, displacement of luxury items and potentially a reduced financial incentive to work. Understanding and beliefs related to pharmaceutical pricing policy varied and a range of proactive strategies to manage financial burden were described by some participants. Conclusions The financial burden associated with medicines used for the management of chronic conditions by Australian consumers is substantial. It is compounded by the ongoing need for multiple medicines and indirect effects associated with chronic conditions, such as the impact on employment. What is known about the topic? Medicines are a common form of treatment in chronic conditions. The financial burden related to medicines use, including co-payments, is associated with reduced adherence and other cost-coping strategies. Out of pocket costs for prescription medicines are relatively high in Australia compared with some other countries, including New Zealand and the United Kingdom. Australian consumers with chronic illness are likely to be at particular risk of financial burden associated with medicines use. What does this paper add? This paper explores the perceptions of consumers and carers around the financial burden associated with the use of medicines for the treatment of chronic conditions in Australia. It draws on the experiences and perceptions of a diverse group of consumers in Australia who identify as having, or caring for someone with, a chronic condition(s). What are the implications for practitioners? Health professionals who assist consumers to manage their medicines need to be aware of the potential for financial burden associated with medicines use and its potential impact on adherence. There is a need for health professionals to educate and assist consumers with chronic conditions to ensure they can navigate the health system to maximum benefit and receive financial entitlements for which they are eligible.

Is infertility associated with childhood autism?

Concerns persist about a possible link between infertility and risk of autism spectrum disorders (ASD). Interpretation of existing studies is limited by racial/ethnic homogeneity of study populations and other factors. Using a case-control design, we evaluated infertility history and treatment documented in medical records of members of Kaiser Permanente Northern California. Among singletons (349 cases, 1,847 controls), we found no evidence to support an increase in risk of ASD associated with infertility. Among multiple births (21 cases, 54 controls), we found an increased risk associated with infertility history and with infertility evaluations and treatment around the time of index pregnancy conception; however, small sample size and lack of detailed data on treatments preclude firm interpretation of results for multiple births.

The affordability of prescription medicines in Australia: are copayments and safety net thresholds too high?

Objective. To create and report survey-based indicators of the affordability of prescription medicines for patients in Australia. Method. A cross-sectional study of 1502 randomly selected participants in the Hunter Region of NSW, were interviewed by telephone. Main outcome measure. The self-reported financial burden of obtaining prescription medicines. Results. Data collection was completed with a response rate of 59.0%. Participants who had received and filled at least one prescription medicine in the previous 3 months, and eligible for analysis (n=952), were asked to self-report the level of financial burden from obtaining these medicines. Extreme and heavy financial burdens were reported by 2.1% and 6.8% of participants, respectively. A moderate level of burden was experienced by a further 19.5%. Low burden was recorded for participants who said that their prescription medicines presented either a slight burden (29.0%) or were no burden at all (42.6%). Conclusion. A substantial minority of participants who had obtained prescription medicines in the 3 months prior to survey experienced a level of financial burden from the cost of these medicines that was reported as being moderate to extreme. What is known about the topic? The Australian National Medicines Policy aims to, amongst other things, facilitate access to medicines at a cost that is affordable to individuals and the community. Copayments combined with the safety net and brand price premium are the main determinants of the amount that patients pay for PBS listed prescription medicines. Previous surveys have reported on selected aspects of medicine affordability in Australia and have shown some groups in the population experience difficulty with the cost of their medicines. What does this paper add? This paper develops and reports on a set of indicators that can be used to periodically measure the level of self-reported financial burden experienced by Australians when obtaining prescription medicines. The analysis assesses affordability issues for both general patients and patients who are able to access prescription medicines using a concession card. What are the implications? Our research suggests that, as they stand, the copayment and safety net thresholds are not protecting nearly one-third of Australian patients from financial burden. Ongoing monitoring and evaluation is required to ensure the copayment and safety net thresholds do not jeopardise the National Medicines Policy’s principle of equitable and affordable access to medicines.

The experience of Massachusetts shows that consumers will need help in navigating insurance exchanges

In 2022 twenty-five million people are expected to purchase health insurance through exchanges to be established under the Affordable Care Act. Understanding how people seek information and make decisions about the insurance plans that are available to them may improve their ability to select a plan and their satisfaction with it. We conducted a survey in 2010 of enrollees in one plan offered through Massachusetts's unsubsidized health insurance exchange to analyze how a sample of consumers selected their plans. More than 40 percent found plan information difficult to understand. Approximately one-third of respondents had help selecting plans-most commonly from friends or family members. However, one-fifth of respondents wished they had had help narrowing plan choices; these enrollees were more likely to report negative experiences related to plan understanding, satisfaction with affordability and coverage, and unexpected costs. Some may have been eligible for subsidized plans. Exchanges may need to provide more resources and decision-support tools to improve consumers' experiences in selecting a health plan.

COBRA ARRA subsidies: was the carrot enticing enough?

OBJECTIVE

To help preserve continuity of health insurance coverage during the recent recession, the American Recovery and Reinvestment Act provided a 65 percent Consolidated Omnibus Budget Reconciliation Act (COBRA) premium subsidy for workers laid off in 2008-2010. We examined COBRA enrollment levels with the subsidy and the health, access, and financial consequences of enrollment decisions.

STUDY DESIGN/DATA COLLECTION

Telephone interviews linked with health system databases for 561 respondents who were laid off in 2009 and eligible for the COBRA subsidy (80 percent response rate).

PRINCIPAL FINDINGS

Overall, 38 percent reported enrolling in COBRA and 54 percent reported having some gaps in insurance coverage since being laid off. After adjustments, we found that those who had higher cost-sharing, who had higher incomes, were older, or were sicker were more likely to enroll in COBRA. COBRA enrollees less frequently reported access problems or that their health suffered because of poor access, but they reported greater financial stress due to health care spending.

CONCLUSION

Despite the substantial subsidy, a majority of eligible individuals did not enroll in COBRA, and many reported insurance coverage gaps. Nonenrollees reported more access problems and that their health worsened. Without a mandate, subsidies may need to be widely publicized and larger to encourage health insurance enrollment among individuals who suffer a negative income shock.

Coping strategies used by patients infected with hepatitis C virus who are facing medication costs

BACKGROUND

The prevalence of infection with hepatitis C virus (HCV) is increasing worldwide. Antiviral therapy, prescription and nonprescription medications, and nondrug therapies to treat HCV infection and to manage associated adverse effects are costly.

OBJECTIVE

To determine whether individuals infected with HCV attending a hepatology clinic were negatively affected by the costs of prescription medications, and if so, to determine coping strategies they adopted.

METHODS

Patients infected with HCV attending Hepatology Services, a clinic within the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, were interviewed as part of an exploratory study (April 2 to July 8, 2008). The interview was based on a validated survey adapted for Nova Scotia. Information collected included demographic characteristics; types of prescription, nonprescription, and complementary medications used by patients; and strategies patients adopted to pay their medication costs.

RESULTS

Fifty patients (age 33-64 years) participated in the interviewer-administered survey, including 35 (70%) men and 19 people (38%) with household income less than $30 000. Frequently used medications were antidepressants (19 patients [38%]), antihypertensive agents (12 [24%]), anxiolytics (10 [20%]), and nonsteroidal anti-inflammatory drugs (10 [20%]). More than half (29 [58%]) were concerned about having sufficient money to pay for their medications. Coping strategies adopted in response to costs of prescription medications were either self-initiated or undertaken in consultation with physicians and/or other health care professionals. Sixteen (32%) of the respondents expressed the belief that physicians usually do not consider patients' concerns about affordability when prescribing medications. Seven (14%) indicated they would seek help from a pharmacist to buy low-cost substitutes for their medications.

CONCLUSION

This study highlighted a range of coping strategies adopted by patients infected with HCV in response to medication costs. It underscores that cost may limit access to essential medications within this patient population, even in a publicly funded health care system. Some of the coping strategies adopted might reduce patients' persistence and adherence with medication therapy, which could lead to adverse health outcomes. Hospital and community pharmacists need to be aware of the challenges faced by patients in terms of paying for medications and should consider possible proactive responses to address potentially detrimental coping strategies.

How patient cost-sharing trends affect adherence and outcomes: a literature review

OBJECTIVE

We sought to assess the relationship between patient cost sharing; medication adherence; and clinical, utilization, and economic outcomes.

METHODOLOGY

We conducted a literature review of articles and abstracts published from January 1974 to May 2008. Articles were identified using PubMed, Ovid, medline, Web of Science, and Google Scholar databases. The following terms were used in the search: adherence, compliance, copay, cost sharing, costs, noncompliance, outcomes, hospitalization, utilization, economics, income, and persistence.

RESULTS

We identified and included 160 articles in the review. Although the types of interventions, measures, and populations studied varied widely, we were able to identify relatively clear relationships between cost sharing, adherence, and outcomes. Of the articles that evaluated the relationship between changes in cost sharing and adherence, 85% showed that an increasing patient share of medication costs was significantly associated with a decrease in adherence. For articles that investigated the relationship between adherence and outcomes, the majority noted that increased adherence was associated with a statistically significant improvement in outcomes.

CONCLUSION

Increasing patient cost sharing was associated with declines in medication adherence, which in turn was associated with poorer health outcomes.

Medication cost problems among chronically ill adults in the US: did the financial crisis make a bad situation even worse?

A national internet survey was conducted between March and April 2009 among 27,302 US participants in the Harris Interactive Chronic Illness Panel. Respondents reported behaviors related to cost-related medication non-adherence (CRN) and the impacts of medication costs on other aspects of their daily lives. Among respondents aged 40-64 and looking for work, 66% reported CRN in 2008, and 41% did not fill a prescription due to cost pressures. More than half of respondents aged 40-64 and nearly two-thirds of those in this group who were looking for work or disabled reported other impacts of medication costs, such as cutting back on basic needs or increasing credit card debt. More than one-third of respondents aged 65+ who were working or looking for work reported CRN. Regardless of age or employment status, roughly half of respondents reporting medication cost hardship said that these problems had become more frequent in 2008 than before the economic recession. These data show that many chronically ill patients, particularly those looking for work or disabled, reported greater medication cost problems since the economic crisis began. Given links between CRN and worse health, the financial downturn may have had significant health consequences for adults with chronic illness.

Beliefs that influence cost-related medication non-adherence among the "haves" and "have nots" with chronic diseases

BACKGROUND AND OBJECTIVE

Some patients continue taking their medication as prescribed despite serious financial pressures, while others with the ability to pay forego treatment due to cost concerns. The primary goal of this study was to explore how patients' beliefs about the necessity of treatment and treatment side effects, influence cost-related non-adherence (CRN).

METHODS

27,302 participants in the Harris Interactive Chronic Illness Panel completed an internet survey. The current study focused on two subsamples representing: (a) the most economically-vulnerable survey respondents (ie, individuals with household incomes of US$25,000 per year or less and monthly out-of-pocket medication costs of at least US$60, n = 1321); and (b) respondents who were the most likely to have the financial resources to pay for medications (ie, those with incomes of US$125,000 or more and monthly medication costs of less than US$60.00, n = 1195). Multivariate models were constructed for each group to determine the independent impact on CRN of perceived need for medications and side-effect concerns. Increased risk for CRN associated with depression and asthma diagnoses also was examined.

RESULTS

Twenty-one percent of economically vulnerable respondents reported continuing to take their medication as prescribed despite serious cost pressures, while 14% of high-income respondents reported CRN despite apparently manageable out-of-pocket costs. Both low perceived need for medications and concerns about side-effects affected CRN risk in low-income and high-income groups. Within groups of both low-income and high-income respondents, depression and asthma significantly increased patients' odds of reporting CRN.

CONCLUSION

Beyond objective financial measures, CRN is influenced by patient beliefs, which can influence the perceived value of prescription drugs. Addressing these beliefs, as well as the unique adherence concerns of patients with depression and asthma, could decrease CRN rates even if cost pressures themselves cannot be reduced.

Factors influencing cost-related nonadherence to medication in older adults: a conceptually based approach

OBJECTIVE

Although multiple noncost factors likely influence a patient's propensity to forego treatment in the face of cost pressures, little is known about how patients' sociodemographic characteristics, physical and behavioral health comorbidities, and prescription regimens influence cost-related nonadherence (CRN) to medications. We sought to determine both financial and nonfinancial factors associated with CRN in a nationally representative sample of older adults.

METHODS

We used a conceptual model developed by Piette and colleagues that describes financial and nonfinancial factors that could increase someone's risk of CRN, including income, comorbidities, and medication regimen complexity. We used data from the 2004 wave of the Health and Retirement Study and the 2005 HRS Prescription Drug Study to examine the influence of factors within each of these domains on measures of CRN (including not filling, stopping, or skipping doses) in a nationally representative sample of Americans age 65+ in 2005.

RESULTS

Of the 3071 respondents who met study criteria, 20% reported some form of CRN in 2005. As in prior studies, indicators of financial stress such as higher out-of-pocket payments for medications and lower net worth were significantly associated with CRN in multivariable analyses. Controlling for these economic pressures, relatively younger respondents (ages 65-74) and depressive symptoms were consistent independent risk factors for CRN.

CONCLUSIONS

Noncost factors influenced patients' propensity to forego treatment even in the context of cost concerns. Future research encompassing clinician and health system factors should identify additional determinants of CRN beyond patients' cost pressures.

Generic-only drug coverage in the Medicare Part D gap and effect on medication cost-cutting behaviors for patients with diabetes mellitus: the translating research into action for diabetes study

OBJECTIVES

To examine the association between drug coverage during the Medicare Part D coverage gap and medication cost-cutting behaviors of beneficiaries with diabetes mellitus who use and do not use insulin.

DESIGN

The study was cross-sectional.

SETTING

A network-model health system.

PARTICIPANTS

2007 survey of Medicare Advantage Part D (MAPD) and Prescription Drug Plan (PDP) beneficiaries who entered the gap by October 2006 (N=1,468, 57% response rate).

MEASUREMENTS

The primary predictor variable was no gap coverage versus generic-only gap coverage. Seven cost-cutting behaviors were examined as dependent variables, including cost-related nonadherence (CRN) to any medication. Covariates included race or ethnicity, education, health status, income, and comorbidities, as well as generic medication use in the first quarter. Logistic regression models were constructed using nonresponse weights to generate predicted percentages.

RESULTS

In multivariate analyses, beneficiaries taking insulin were less likely to report CRN if they had generic-only gap coverage than if they had no gap coverage (16% vs 29%, P=.03). No differences in CRN according to type of gap coverage were seen between beneficiaries not taking insulin.

CONCLUSION

Medicare beneficiaries using insulin are at high risk of CRN. Generic-only coverage during the gap is associated with an attenuated risk of CRN in insulin users, possibly because of savings on other, generic medications. Future research should evaluate CRN within alternative benefit designs covering selected brand name medications, such as insulin, during the gap.

Medication nonfulfillment rates and reasons: narrative systematic review

BACKGROUND

The literature on nonfulfillment of prescription medications spans over three decades of work. There is a wide variation in reported nonfulfillment rates, but no previous study has systematically reviewed this literature to explore the reasons behind this variation.

OBJECTIVE

The objective of this study was to review estimates of medication nonfulfillment rates and published reasons for nonfulfillment and explore whether nonfulfillment rates vary by study variables.

METHODS

Articles were identified through searches conducted on MEDLINE, CINAHL, Psych Info, and EMBASE, and review of relevant reference citations. Methodological variables, nonfulfillment rate, and unit of analysis (i.e., patient or prescription) were abstracted from each article selected for review. Mean and median nonfulfillment rates for groups categorized by unit of analysis and selected methodological variables (method for assessing nonfulfillment, sample characteristics, disease subgroup, sample size, country of data collection, recall period or time allowed before classifying as nonfulfillment, and year of study) were calculated. Reasons for nonfulfillment were abstracted from all articles that included a relevant discussion.

FINDINGS

A total of 79 studies reporting pure nonfulfillment rates (59 at the patient level and 20 at the prescription level) and six studies reporting nonfulfillment rates in combination with nonpersistence rates were included. There was a wide variation in nonfulfillment rates reported by the studies - from 0.5% to 57.1%. The three primary reasons for nonfulfillment identified from this review were perceived concerns about medications, lack of perceived need for medications, and medication affordability issues.

CONCLUSION

To the best of the authors' knowledge, this study is the first narrative systematic review on nonfulfillment of prescription medications. Despite the wide variation in individual study rates, the mean and median rates across different modes of data collection and sources of data were in a relatively narrow range (11% to 19%) and surprisingly close to the overall mean (16.4%) and median (15%.0) rates for all studies. The reasons for nonfulfillment identified through this review address barriers to nonfulfillment at the patient, physician, and health system level and thus bear important implications for policy makers.

Cost-related medication nonadherence among beneficiaries with depression following Medicare Part D

CONTEXT

Cost-related medication nonadherence (CRN) was problematic for Medicare beneficiaries with depressive symptoms before Medicare Part D.

OBJECTIVE

To estimate changes in CRN and forgoing basic needs to pay for drugs among Medicare beneficiaries with and without depressive symptoms following Part D implementation.

DESIGN AND SETTING

The authors compared changes in outcomes between 2005 and 2006 before and after Part D with changes between 2004 and 2005 using logistic regression to control for demographic characteristics, health status, and historical trends.

PARTICIPANTS

The community-dwelling sample of the Medicare Current Beneficiary Survey (N = 24,234).

MAIN OUTCOME MEASURES

Self-reports of CRN (skipping or reducing doses and not obtaining prescriptions) and spending less on basic needs to afford medicines.

RESULTS

The unadjusted annual prevalence of CRN among beneficiaries with depressive symptoms was 27% (2004), 27% (2005), and 24% (2006), compared with 13%, 12%, and 9% among beneficiaries without depressive symptoms. The annual prevalence of spending less on basic needs was 22% (2004), 23% (2005), and 19% (2006), compared with 8%, 9%, and 5% among beneficiaries without depressive symptoms. Controlling for historical changes and demographic characteristics, CRN did not decline among beneficiaries with depressive symptoms compared with beneficiaries without depressive symptoms (ratio of Part D changes 0.98; 95% confidence interval [CI], 0.73-1.32). Respondents with depressive symptoms seemed less likely to spend less on basic needs compared with individuals without depressive symptoms (0.70; 95% CI, 0.49-1.01); however, this difference was not statistically significant.

CONCLUSIONS

Despite a Medicare Part D goal to improve medication adherence among mentally ill beneficiaries, the disparity in economic access to medications between beneficiaries with and without depressive symptoms did not improve after the start of Part D.