- As healthcare professionals continue to push for better chronic disease management, they continue to face high healthcare costs as a primary medication adherence barrier.
Numerous studies have indicated that drug costs serve as the biggest barrier to medication adherence.
A 2017 report from Consumer Reports Best Buy Drugs found that 14 percent of patients do not fill their prescriptions because of medication costs.
One-quarter of patients are paying more for their medications than they did one year ago. Seventy-four percent of those patients said that they received no prior warning of a drug price increase, and 24 percent say they likely will not be able to continue paying for their medications in the future.
Other studies indicate that drugs are cost prohibitive even for patients with serious illnesses such as cancer.
A 2018 study published in the Journal of Clinical Oncology revealed that 32 percent of cancer patients with between $100 and $500 in out-of-pocket drug costs didn’t fill their prescriptions. Fifty percent of those facing $2,000 or more in out-of-pocket drug costs did not fill their prescriptions.
Approximately one in eight cancer patients face over $2,000 in out-of-pocket drug costs, the researchers said.
Fostering medication adherence is critical to successful chronic disease management. But as more patients face high out-of-pocket medication costs, the task of medication adherence will remain challenging. Below, PatientEngagementHIT.com outlines how healthcare professionals can address cost as a medication adherence barrier.
Identifying cost as an issue
Talking about cost of healthcare is hard. Patients are often prideful and resistant to admitting any cost barriers. For providers, prying into this aspect of their patients’ personal lives can be daunting. But getting to the bottom of cost issues is crucial to understanding a patient’s medication adherence barriers.
Building trust between patient and provider can help alleviate any awkwardness that may seep into conversations about cost.
“Medication adherence is certainly a very important part of taking care of patients today,” Stuart Goldberg, MD, a practicing oncologist, said in an interview with PatientEngagementHIT.com. “It starts with, hopefully, getting trust between you and the patient, that when the patient comes in to see you for their appointment they will give you a true answer.”
To uncover any cost barriers his patients, most of whom have cancer, experience, Goldberg assumes a patient is struggling to make ends meet. After all, medications are expensive, and it is reasonable that a patient may be struggling to pay for them.
If the patient is ambivalent about drug costs, or says cost is not an issue, he marks this as a red flag. Nearly all patients experience a financial cost pinch, he said, so when a patient says cost is not an issue, Goldberg wonders if the patient is taking the medication at all and begins interventions from there.
Clinicians treating patients with other chronic illnesses employ similar strategies. David Weinstock, MD, a primary care provider at Massachusetts-based Grove Medical Associates, leans on his interpersonal skills to uncover cost barriers.
“Patients don’t always like to admit that they’re having trouble with payments,” Weinstock explained in a previous interview.
“The way to overcome these barriers is by working with the patients. I usually ask them more than if they’re taking their pills. I try to get a little more information from patients like if they’re taking pills, how they’re getting them, where they’re getting them.”
Accessing subsidies, cost-cutting tools
Once a clinician has identified cost as a medication adherence barrier, they can look into cost assistance programs to help patients manage the financial side of their conditions.
Goldberg works to leverage his connections as a doctor to help patients overcome cost. When Goldberg helps cut costs, it deters patients from taking matters into their own hands and forgoing their treatment.
“There are a lot of different things that patients do to get around the costs,” Goldberg explained. “One of them, unfortunately, is saying ‘I’m doing okay on a pill a day, so maybe I’ll do okay on a pill every other day, and that way I don't have to pay as much for my drugs.’”
Goldberg looks into generic alternatives or less intensive regimens that could save patients money.
Weinstock follows a similar route. After directing his patients to generic alternatives or pharmacies that are known for having lower rates, he’ll prioritize certain medications if the patient’s financial situation remains dire.
This strategy may run counter to many clinicians’ intuition. If a patient is seriously ill, it seems natural that they access the most effective treatment possible for their condition.
But Goldberg says affordability needs to be top concern.
“If you don't take the medicine, it doesn’t matter. You can pick the best treatment but if the patient doesn’t pick it up from the pharmacy because they can’t afford it, that doesn’t help the patient,” Goldberg said. “If the patient does pick it up and she doesn't take the pill, that doesn’t help the patient either.”
Data shows that these approaches can work. A 2017 study published in the Journal of Clinical Oncology revealed that access to drug subsidies increased medication adherence by over 60 percent.
As clinicians continue to encounter patients who struggle to meet the financial demands of their care management, they should tap these subsidy opportunities. However, clinicians and patients alike will need the industry to create these opportunities as well as lower overall drug pricing.
Leading industry efforts to address drug costs
Cutting prescription drug spending cannot and should not fall entirely on providers. Addressing high drug costs from an industry level will help address this barrier and ideally eliminate a need for patients to access drug subsidies and other cost-assistance programs.
Industry leaders have largely shifted their focus to cutting drug costs in the past year. In May 2018, the Trump Administration published its drug pricing blueprint, which called on drug manufacturers to drive price transparency for consumers, as well as proposed reforms for the Medicare 340B program and Medicare Part D.
“One of my greatest priorities is to reduce the price of prescription drugs. In many other countries, these drugs cost far less than what we pay in the United States,” the President said in a speech announcing the blueprint. “That is why I have directed my Administration to make fixing the injustice of high drug prices one of our top priorities. Prices will come down.”
Since then, HHS has taken many steps toward what it says will lower drug costs. These actions may either cut out-of-pocket spending for patients directly or create cost savings for payers that would ideally be passed onto patients.
Those proposals have not come without controversy. Industry leaders representing vulnerable patient groups have stated that plans to shift Medicare Part B drugs to Medicare Part D could actually create cost increases for patients and limit their access to treatment.
Other industry measures have sought to increase price transparency for patients purchasing their medications. In October 2018, HHS released a proposal calling on all drug manufacturers to publish their drug list prices in all direct-to-consumer (DTC) advertisements.
“This historic proposal is an important way to create new incentives for drug companies to start lowering their list prices, rather than raising them,” Azar said in a public statement. “President Trump’s drug-pricing blueprint called for HHS to consider how to accomplish this goal, and now we are following through on this measure to better inform patients, help them lower their drug costs, and reduce unreasonable spending in Medicare and Medicaid.”
The proposal faced considerable pushback from industry trade groups, who argued both on first amendment grounds and on the grounds that list prices are not actually helpful for patients.
Patients often do receive the drug subsidies discussed above and receive at least partial payer assistance when purchasing drugs. The list price, which does not take those factors into account, is not an accurate price point for patients to make healthcare decisions, these groups reasoned.
As these debates continue, medical professionals will need to bear in mind the ultimate beneficiary of these programs: the patient. Efforts to address drug costs must prioritize patients’ abilities to afford their medications and the consequences of cost-prohibitive pricing models.