Adherence
Aina Abell
In a recent study published in Circulation, researchers found that one in eight patients with atherosclerotic cardiovascular disease (ASCVD) in the United States did not adhere to their medications because of cost.
Of the 14,279 individuals surveyed by Khera and colleagues, 1,774 reported not taking their medications as prescribed to save money. This translates to 12.6% of adult patients with ASCVD nationally.
“We see this almost every day in the clinic I work in,” said Lisa Cillessen, PharmD, who’s a clinical assistant professor at University of Missouri–Kansas City School of Pharmacy and an ambulatory care pharmacist at Jordan Valley Community Health Center, a federally qualified health center that serves a primarily underserved and low-income population. “A lot of patients just simply don’t pick up their medications because of the cost, and even if they are able to pick them up, they stretch them out.”
It’s also not uncommon to see patients abandon their prescriptions, said Cillessen, who was not involved in the study.
“Sometimes, patients come in to pick up four or five medications, and they can’t afford that cost, so they just leave the prescription at the pharmacy,” she said. “Or maybe they’re taking half tablets [instead of the whole tablet] to make sure they do not run out of their medication.”
A pervasive problem
According to the study, among nonadherent patients, 8.6% skipped doses, 8.8% took a lower dose than prescribed, and 10.5% delayed filling their prescriptions. Those who were nonadherent because of cost were also 10.8 times more likely to request low-cost medications and 9.9 times more likely to use alternative, nonprescription therapies.
Khera and colleagues found that patients younger than 65 years were three times more likely to not take their medications as prescribed to save money; nearly 20% were nonadherent compared with 6.2% of patients 65 years and older. Among the younger individuals, one in four women, one in three patients from low-income families, and more than one-half of all patients without health insurance reported cost-related nonadherence.
Race and level of education did not seem to influence the results.
But even for Americans with insurance, affording medications can be a struggle. In a January 2020 survey by NPR, the Harvard T.H. Chan School of Public Health, and the Robert Wood Johnson Foundation, many patients reported that their insurance plans sometimes don’t cover their medication or may only cover generic versions. In these cases, nearly half of these patients simply don’t fill their prescription.
While the majority of Americans have health insurance that includes prescription medication coverage, the survey noted that more than one-third of adults across all income groups were told their prescriptions would not be covered.
This was most common among lower-income individuals who earned less than $35,000 per year—49% reported being denied coverage compared with 32% of middle-income (earning between $35,000 and $99,999 per year) and 41% of the highest-income (the top 1%, earning at least $500,000 per year) adults.
Of patients who were denied coverage, 51% of lower-income, 48% of middle-income, 41% of higher-income (earning between $100,000 and $499,999 per year), and 18% of the highest-income individuals ultimately did not fill their prescription.
Bold solutions
“The out-of-pocket cost of medications is a huge issue for millions of high-risk patients with cardiovascular diseases, such as heart attacks, stroke, angina, and other conditions,” said senior author of the Circulation study, Khurram Nasir, MD, MPH, MSc, chief of the division of cardiovascular prevention and wellness and codirector of the Center for Outcomes Research at Houston Methodist DeBakey Heart & Vascular Center in Texas, in a statement.
This is especially true for people younger than 65 years who may not have access to public insurance. The researchers wrote that access to Medicare likely contributed to the lower rates of cost-related nonadherence in patients 65 years and older.
While young-er patients are more likely to be actively employed, have fewer medical comorbidities, and therefore may be in a better financial position to afford their medications, they were still three times more likely to forego taking their medications as prescribed because of cost, the authors wrote. This suggests that the issue requires grander action that may influence health care policies.
“As health care providers, we should … consider advocating for changes in national health care policy, such as capping out-of-pocket expenses for low-income families,” said Nasir in the statement. This includes potentially expanding insurance protection offered to the Medicare population to those younger than 65 years, the authors wrote.
The patient always comes first
Community pharmacists can help in a number of ways when a patient can’t afford their medication. One big thing they can do is know what resources are available.
“For example, almost any medication that’s brand name has some sort of patient assistance program,” said Cillessen. “If the pharmacist notices that somebody’s not picking up their inhaler or their insulin [because of cost], point that patient to those resources.”
Pharmacists can also check the cash price of the medication. “Sometimes, the cash price is actually cheaper than going through the insurance,” said Cillessen, as is the case for medications on $3 or $4 lists.
Patients could also use discount cards, said Cillessen, but pharmacists should treat these as a last resort. “Discount cards typically end up hurting pharmacies a little bit more than cash paying options,” she said, “so, if I can find [another solution], I prefer to do that.”
It also helps to be aware of the kinds of federally qualified health centers in the area, said Cillessen.
“Those are going to provide health care at some sort of discounted rate, oftentimes a sliding scale fee. Then, they’re able to actually partner with community pharmacies to run a 340B program that provides medications at discounted rates.”
Pharmacists can also check if other pharmacies have medications available for lower costs. “I know as pharmacists, we don’t want to drive business away from our own place,” said Cillessen, but the patient always come first.
“We need to consider, ‘Is my patient being taken care of?’ If they’re not going to pick up their medication from my pharmacy, can we at least get them to pick it up from somewhere else?”
Know community resources
It’s important to educate patients on other community resources, as well, not just those for medications and prescriptions.
Many low-income or underserved patients who are struggling to afford their medications are probably struggling with other things, too, said Cillessen. This may include rent, utilities, transportation, and food.
“I’m lucky that the clinic I work in is very integrated,” said Cillessen. On top of the medical and health services they provide, Jordan Valley Community Health Center also has community health workers, lawyers, and social workers who can help patients apply for food stamps, figure out housing and utilities, or provide advice and support with landlord issues or domestic abuse.
“Patients will pay for their health care last because they feel like they have these other things they have to take care of,” Cillessen said. But that’s why it’s important for pharmacists to ask patients questions and be aware of other community resources that are available.
“[For example], I know we send a lot of patients to community gardens to help out with food costs,” said Cillessen. Or if your pharmacy is in a grocery store, it’s also helpful for pharmacists and technicians to know if the store doubles up on food stamps.
“Being able to educate your patient and say, ‘Oh, did you know if you go buy healthy foods, you can double your food stamps for the month?’—even small things like that are always beneficial,” said Cillessen.