Physicians feeling pressure from patients’ financial problems

The patient in front of William B. White, MD, an internist in Farmington, Conn., was being treated for hypertension, but he was worrying more about financial pressure than blood pressure. The patient, who worked for a small factory and had a health insurance deductible of $2,500, asked Dr. White: Are those lab tests really necessary? Could I take fewer medications?

“At least he was up-front about the issue,” said Dr. White, chief of the hypertension and clinical pharmacology division at the University of Connecticut and president-elect of the American Society of Hypertension. “There are many others who just simply don’t show up for their appointments.”

Data released April 4 by the IMS Institute for Healthcare Informatics indicates that fewer patients are visiting their doctors, and that those who do are cutting what they spend on prescriptions. Physicians say patients who do come are more likely to ask about cheaper alternatives — like Dr. White’s patient. Or, patients just might take it upon themselves to find alternatives as they struggle with higher co-pays, deductibles and general economic problems as the effects of the 2007-09 recession linger.

“The end of the recession has not delivered recovery to many people,” said Michael Kleinrock, IMS’ director of research development and the primary author of “The Use of Medicines in the United States: Review of 2011.” “Patients are spreading out repeat visits and self-medicating with over-the-counter drugs.”

Visits to physician offices declined 4.7% in 2011, according to IMS. That follows a 4.2% drop in 2010 and is the fourth decline in five years. The numbers are based on a national sample of 4,100 physicians reporting on two days of office activity per quarter.

IMS’ report is consistent with others, such as those from the Kaiser Family Foundation and Chase health industry analyst John Rex, that have described a drop in office visits. These reports have cited the sluggish economy as the major factor, though none has specifically surveyed patients. However, a Commonwealth Fund survey, released November 2011, found 42% of “sicker” adults reporting cost-related access problems in the previous year.

IMS’ report found a 1.1% decline in retail pharmacy prescription spending and average per-capita use falling from 11.5 prescriptions per person in 2010 to 11.3 in 2011. The drop in prescriptions may be due in part to increasing use of combination pills and 90-day rather than 30-day prescriptions for drugs treating chronic conditions. But researchers believe strained finances are the most significant factor, even though the Patient Protection and Affordable Care Act allowed people 26 and younger to stay on their parents’ insurance and increased subsidies to help fill the Medicare Part D “doughnut hole.”

Prescription spending by insured 19- to 25-year-olds went up 2%, but seniors cut back. Patients 65 and older spent 3.1% less out of pocket, including a 4.3% drop for those 65 to 69 years old, the biggest decline by age group.

The biggest class of drugs to decline were those treating hypertension, which have the most on-therapy patients, 42.4 million, more than double second-place lipid inhibitors. The 65-and-older group received 7,074 prescriptions for antihypertensives per 1,000 people in 2010, but this declined to 6,745 per 1,000 in 2011. This was despite declines in drug co-pays required from Medicare beneficiaries because the health reform law provided additional subsidies for Part D. Such seniors spent $10.8 billion out of pocket for medications in 2009 and $11.5 billion in 2010 but only $9.7 billion in 2011 because of the change in Medicare drug benefits.

“Most of those over 65 are on a fixed income,” Kleinrock said. “Despite the subsidy, they think it’s too much.”

The IMS report said nonemergency hospital admissions were down 0.1% in 2011, but emergency admissions were up 7.4%. That’s a sign of patients putting off treatment or not taking medications because of financial concerns, the report said.

“People are not all of a sudden getting healthier,” said Larry Levitt, senior vice president of the Kaiser Family Foundation. “It suggests people are putting off care, and they’re showing up sicker.”

What’s a physician to do?

No one knows how to persuade patients who aren’t coming in to do so, but physicians have several suggestions about making it more likely that patients concerned about money will comply with recommendations for prevention and treatment.

People who work on patient-physician communication issues suggest explaining the value of a medication, test or procedure. This may need to happen at every visit if a patient doesn’t ask.

“Patients need to understand what the expectations are, what’s going to change and what’s going to improve,” said Barry Make, MD, a pulmonologist with National Jewish Health in Denver. “Patients will only do something if they understand what it is for, but patients are often reluctant or ashamed or embarrassed to ask.”

Physicians recommend making it clear that some negotiation is possible if cost is a significant concern. This does not necessarily mean lowering the price of a particular service. For example, patients who should be seen every three months may be stretched out to every four.

Doctors may be able to steer patients to lower-cost resources by writing prescriptions for drugs that can be filled for $4 at some big-box pharmacies. Physicians also can guide patients to various drug assistance programs or discount programs run by certain groups.