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Patients who cut corners on drugs don't tell doctors

Rising costs are forcing many to reduce doses or skip them entirely. Physicians don't bring up the issue; often, neither do patients.

September 20, 2004|Melissa Healy | Times Staff Writer

For patients and their doctors these days, the rising cost of prescription drugs is often the fabled elephant in the room -- a looming presence, unacknowledged.

Both parties know that a drug's cost and an insurer's reimbursement rate affect whether patients will follow their physicians' advice and take medications as prescribed. After all, patients often skimp -- or skip out -- on taking the drugs because they are having trouble paying for them.

Now a study has found that, in two-thirds of these cases, patients do not tell their doctor in advance. And more than a third of those who skimp never tell their doctors at all, even during a later visit.

Physicians, it seems, are no more eager to discuss the issue with their patients, said the researchers, from the University of Michigan. Among the patients who never talked to their doctor about cutting back on medications, two out of three said that no one on their medical team had inquired whether they were having trouble paying for their medicines or whether they were skimping to cut costs. Nearly half of the patients who kept mum were too embarrassed to discuss the issue, and more than half assumed their doctors or nurses could do nothing to help.

The silence is deafening, said John Piette, lead author of the study, which appeared in the Sept. 13 issue of the Archives of Internal Medicine, and it is hurting the patients whose medical conditions are most fragile. These chronically ill patients -- people with conditions like asthma, heart disease, diabetes, high blood pressure and ulcers -- are the ones who most need to take their medications regularly and in the doses prescribed. The vast majority of those patients surveyed were on three or more prescription drugs when they started to skip doses or delay on refills to save money, Piette found.

"In regard to healthcare costs, when doctors don't ask and patients don't tell, opportunities to help are missed and patients are at risk for underusing medications and services," wrote Dr. Alex D. Federman of Mount Sinai School of Medicine in New York, in an editorial accompanying Piette's study.

Piette and his colleagues identified a group of 4,079 Americans between 50 and 64 who took prescription drugs for at least one chronic health condition, and surveyed them about their medication use in the last 12 months. They zeroed in on 660 patients who acknowledged skimping on medications one or more times during that period because of cost concerns, and who had seen their doctor in the course of the study period.

Patients across all income levels, age groups and genders reported they were shy about discussing the hardships of their drug costs with doctors. But Piette found that nonwhite patients and those with a high school education or less were the least likely to confide in their doctor when they began cutting back on medications because of costs.

The University of Michigan study is the third analysis released in less than a year that documents the toll of rising drug costs on the health of patients and details the difficulty of doctor-patient communication in this area.

In May, a Rand Corp. study, published in the Journal of the American Medical Assn., found that when the co-pay shouldered by younger patients with chronic illnesses doubled, those patients cut back on their medications by as much as 23%. And the health results were striking: As these patients scaled back their medications, their visits to emergency rooms rose 17% and hospital stays went up 10%.

A UCLA study published in the JAMA's Aug. 25 issue found that when seniors used up their annual insurance drug benefits before the end of the year, about one in four said they used less of, stopped or did not start a prescribed medication because of the burden of out-of-pocket costs.

Dr. Carol Mangione, an internal medicine specialist at UCLA and senior author of that study, said that the growing evidence that patients are skimping on their medications because of cost concerns means it's time for doctors to start the conversation.

"We have to change the culture a little bit here, and the onus is more on the doctor than on the patient," Mangione said. Though physicians are well aware of the rising cost of medications -- "we're consumers too," Mangione said -- most are not well equipped and are too pressed for time to help patients sort out the cost of prescriptions, much less the complexities of their insurance coverage.

There are, however, many inexpensive computer-based tools and programs that can help doctors initiate a decision-making process in which patient and doctor can compare trade-offs in a drug's effectiveness, side effects, convenience and cost.

That's new territory for most doctors, who have been trained to prescribe the medication or therapy that is probably best to treat a patient's illness, not to consider a potentially less effective or convenient one that might be cheaper or more likely to be covered.

In light of the new evidence, Mangione said, it's time to get over that.

"The most expensive drug might be the best choice," said Mangione, who has been seeing patients for 15 years, "but not if it's being taken half the time."

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