Cost keeps many from taking their meds

Along with a database on drug interactions, Melvyn L. Sterling, MD, keeps a list in his handheld computer showing what local pharmacies are charging for the drugs he prescribes.

"I look at that and I tell patients which pharmacies are more or less expensive," the Orange, Calif.-based internist and chair of the AMA Council on Scientific Affairs said.

Conversations about the affordability of prescriptions are important, but they are also somewhat rare. According to a study in the Sept. 13 Archives of Internal Medicine, two-thirds of chronically ill patients 50 and older who underuse prescriptions to save money never tell their physicians about their intent in advance and 35% never discuss the issue at all.

While researchers said the study indicated a need for doctors to spend more time talking with patients, they said it also showed how physicians can use electronic medical records or work with a team of social workers, nurse-care managers, pharmacists and drug companies to help patients manage their prescriptions.

The study, funded by the Dept. of Veterans Affairs and the Agency for Healthcare Research and Quality, also showed how financial barriers add to the cost of care when chronic conditions are not managed and complications require hospitalization.

AHRQ spokeswoman Karen Migdail defined poor quality health care as the "misuse, underuse or overuse" of medications, treatments or procedures. By this definition, she said underusing prescriptions for financial reasons is definitely a quality issue. "People are not getting what they need."

Michael O. Fleming, MD, president of the American Academy of Family Physicians, agreed. "There isn't any question that it's a quality issue," he said. "To control my patient's diabetes, I have to prescribe the right medicine, but unless they take the right medicine, we haven't gotten anywhere and that's not quality."

Dr. Fleming also said a lack of communication between primary care doctors and specialists compounds the problem. "I've seen patients taking two of the same medication because the specialists didn't realize it," he said. "And I've added to medication because I didn't think it was controlling my patient's condition when the problem was with the patient not taking the medication as prescribed."

Dr. Fleming added that it's cheaper to manage a patient's hypertension than it is to treat the patient after a stroke.

The study presented a bad news-good news scenario, said its lead author, John D. Piette, PhD, a VA career scientist and associate professor at the University of Michigan in Ann Arbor. "Although we identified that a large number of chronically ill patients don't take their medications like they're supposed to, it is addressable and that's a positive sign," Dr. Piette said.

He said patients often make their medication-rationing choices based on misinformation, so primary care doctors need to talk to patients about what each of their medications does and how it affects their health.

"Traditionally, [physicians] felt this was not their role," Dr. Piette said.

He acknowledged that physicians might have only seven minutes to spend with a patient who has six different health problems. For that reason, Dr. Piette said physicians have to discard the old model that includes a doctor working in isolation and determining the best course of treatment without factoring in costs.

"People really need to talk to each other," Dr. Piette said. "Social workers or nurse-care managers can take pressure off the docs in helping patients deal with this issue."

Another positive sign was that 72% of patients who did discuss costs with their doctors found it helpful, he said. The results of these talks included the physician dispensing free samples, changing to a less expensive or generic brand, giving information about assistance programs and discussing which drugs should never be skipped.

Dr. Fleming said the study shows the need for EMRs, for patients to have one primary care physician who keeps track of all aspects of their care and for a rational, national policy on prescription drugs.

As a long-term solution, Dr. Sterling suggested more health education for the public because that may make some prescriptions unnecessary.

"If they're not obese, the likelihood of diabetes goes way down," Dr. Sterling said. "If they don't smoke, pulmonary problems and many different types of cancer are unlikely."