Cost-related medication underuse is big problem

Identify issues at discharge

There is a large body of evidence that some people will avoid taking medication to save money, and this can lead to acute episodes that land patients in the hospital. The key is to identify this and other silent obstacles at discharge and provide patients with solutions that will improve their care transition.

"I’m a hospitalist, and I practice inpatient medicine, so it struck me that inpatients might be a high-risk group of individuals, who are sicker on average, and who might provide a cohort for understanding that kind of behavior," says Niteesh Choudhry, MD, PhD, associate professor of medicine at Harvard Medical School in the division of pharmacoepidemiology and pharmacoeconomics, Brigham and Women’s Hospital in Boston.

"We often prescribe medications to patients when they leave, and these are new medications, so this might be an opportunity to understand and intervene at the time of giving new medication prescriptions," he says.

Investigators surveyed a group of inpatients, focusing on people who had prescription drug coverage through managed care companies and large health insurers, he says.

"In essence, they have pretty good insurance, and even amongst these individuals one-quarter of them reported underutilization in the prior year," Choudhry says.

The study found that 23% of patients reported cost-related underuse of medications in the year prior to admission, and nearly all study participants endorsed at least one strategy that would make their medication more affordable. Plus, only 16% of the patients who were prescribed medication at discharge said they knew how much they would pay for it at the pharmacy, and almost no one had talked with their inpatient or outpatient providers about the costs of their new prescriptions.1

Researchers identified four different types of behavior that were attributed to cost-related nonadherence, including these:

• Patients did not fill a prescription because of cost.

• Patients skipped doses to make medication last longer.

• Patients took less medication than prescribed to make it last longer.

• Patients split pills to make them last longer.

Most of the people who underutilized their medication fell into the first category of not filling the prescription because of cost, Choudhry notes.

There are many other reasons why patients are nonadherent with their medication and treatment, including the logistics of not being able to access the pharmacy or doctor’s office or feeling that the pill burden is too high. These also need to be addressed. But cost is one of the biggest factors, Choudhry says.

"There is a huge amount of literature describing this phenomenon, and what we’ve seen over and over and across health care settings is that the average adherence in prescribed therapies is the 50% to 60% range," he adds. "So we’re left with this huge problem of nonadherence."

One way hospital discharge planners can address this problem is by talking with patients and families about both the therapeutic reasons for taking their medication as prescribed and the expected costs of the drugs. During this conversation, the discharge team might learn of potential adherence obstacles and can address them upfront.

"We need to ask patients whether they take their medication and how often they take their medication, and if they don’t take their medication, we need to ask them what we can do to make that not happen in the future," Choudhry says.

"Recognize it’s a problem, give patients more information, and communicate with patients, their community providers, and the inpatient team," Choudhry suggests. "This won’t solve the problem or make them more likely to afford medication, but it will allow providers to reinforce the need for those medications that are especially important and allow for discussions about alternatives."

For example, the discharge team could help the patient reduce out-of-pocket spending by recommending switches to generic drugs when this alternative is feasible, he adds.

"If we know there’s a generic drug that’s much cheaper, and we know the patient won’t take the branded drug due to costs, then bring up the generic option," he says. "Many large pharmacy chains have cheaper drugs that are all generics."

Patients might have to pay $4 out-of-pocket and cannot file this with their insurance company, but the cost is far less than their $10 to $30 copay for the branded drug.

"Sometimes, generic drugs are not an alternative," Choudhry says. "But I’d be willing to venture that if you forced many of us to think about medications, and we understood how difficult it is for patients to prescribe these then we might change our opinion about which branded drugs are essential and which are not."

Another strategy is for the discharge team, with collaboration with the outpatient provider, to do a medication review and look critically at the patient’s expected pill burden once he or she returns home.

"You need to look at the medications at discharge in the context of other medications the patient already is taking," Choudhry says. "On average, people take 5.5 medications, which could cost them more than $700 a year in copays, which is a lot of money for people who might make $20,000 to $30,000."

This medication review also could result in taking some medications off the list because of redundancy or because a prescription was continued even after the symptoms or problem had disappeared.

Pharmacists either in the community or hospital could be involved in this process, as well, he says.

"Pharmacists are highly effective in interventions, so this doesn’t have to be done by a physician," he adds.

For hospitals that have to use pharmacist time efficiently, one strategy might be to have pharmacist-led medication reviews for high-risk patients, including those who have conditions like heart failure that often lead to readmissions, Choudhry suggests.

"If heart failure patients don’t take their diuretics or ace inhibitors, for example, then they’re very likely to come back to the hospital," he says.

The hospital discharge team also could target other conditions that Medicare has selected as being at high risk for readmissions, including heart disease and pneumonia, he adds.

"The pharmacist could review existing medications and make sure patients understand why they are taking them," Choudhry says. "The pharmacist could talk with patients about the newly prescribed medications and tell them what to expect and what their costs might be."

Also, the pharmacist could give feedback to the team and help the team make choices, such as changing a prescription from an antibiotic that is extremely expensive and which the patient cannot afford to an alternative that will achieve the same outcomes.

"We want our patients to get better, and all of us do this work for that reason," Choudhry says.

"Often, what we do is help them get better by prescribing medication because we’re pill doctors by practice," he explains. "But if we’re not thinking about how they will use the medications when they leave the hospital then that undermines the efforts we’re making to help them get better."


1. Choudhry NK, Saya UY, Shrank WH, et al. Cost-related medication underuse: prevalence among hospitalized managed care patients. J Hosp Med. 2011;Oct 3.[Epub ahead of print].