Medication adherence: The impact of cost

Medication adherence is fundamental to achieving and maintaining optimal patient outcomes. Examining scientific literature pertaining to medication adherence, RxLive identified causative factors and categorized them into six major buckets: cost; side effects; skills; understanding and knowledge; social and behavioral factors; and access to care and burden of regimen. Suggested pharmacist interventions for each bucket are available from the RxLive platform drop-down menu that can further assist pharmacists to help patients achieve positive health outcomes from improvement in medication adherence.

Poor medication adherence accounts for approximately 13% of healthcare expenditures or $290 billion annually (see page 2 in link). Sub-optimal clinical benefits from low medication adherence, resulting in increased morbidity and mortality and increased avoidable healthcare costs. Cost-related medication nonadherence (CRN) is multifactorial, associated with the availability of financial resources and patient-related factors that affect how finite funds are allocated.

Cost: Influence on medication adherence

High out-of-pocket medication costs reduce adherence, effectively worsening outcomes by not filling prescriptions, delaying refills, skipping doses, and taking less medication because of financial concerns. Concerns about medication affordability can drive a patient to seek lower-cost therapies, use alternative ones, or buy medication from unreliable online sources or from sources outside of the country.  

The National Health Interview Survey (NHIS) began to include questions pertaining to CRN as prescription drug costs and medication nonadherence rates continued to rise, finding that patient populations particularly affected were the chronically ill, elderly and poor. There was a positive correlation of CRN and food insecurity, with approximately 1/3 of chronically ill survey participants unable to afford medication, food or both.  Lack of availability or immediacy of healthcare benefits or other assistance programs are related to a greater decrease in medication adherence in any population group. Circulation reported that those aged 65 or older with Medicare benefits had lower CRN than those younger than 65 without healthcare benefits. In addition, JAMA published that patients with diabetes who participated in the Supplemental Nutrition Assistance Program (SNAP) were more adherent than those who didn’t receive financial assistance.

Polypharmacy additionally contributes to CRN; the cost associated with multiple medications can be an immense burden on patients and a deterrent to adherence. According to the Centers for Disease Control and Prevention (CDC), 12.6% of persons reported using five or more prescription drugs in the past 30 days prior to the survey. Those with chronic conditions, typically including the elderly, have increased rates of polypharmacy, affecting medication adherence from numerous patient-related factors including cost. Some of these costs are avoidable when duplicate medications are prescribed, causing unneeded financial constraints on patients.

How pharmacists can identify cost as a barrier to medication adherence

Cost-related barriers to medication adherence aren’t always obvious. Pharmacists can interpret potential obstacles related to cost by listening for verbal cues from patients such as inquiring about the cost of the medication during prescription drop-off, asking for generics or the costs of alternative medications, or if the pharmacy accepts coupons for the prescription.

Monitoring medication filling patterns can signal nonadherence, particularly for those on chronic medications, prompting the pharmacist to further explore the root of the poor adherence. Refills that are consistently made at later than expected times based on the prescription directions is a sign pointing to cost-related factors, indicating that the patient is skipping doses or attempting to make the medication last longer.

Pharmacists can also identify patient financial challenges through direct questioning. Many people harbor embarrassment concerning their financial status and will not offer information without prompting. When an expensive medication is prescribed, pharmacists can ask the patient in a non-critical, empathetic manner if the medication is within their prescription budget. This opens the door for finding less-expensive options that will increase the likelihood of adherence to the prescribed therapy.

How pharmacists can improve medication adherence in regards to cost

CRN can be reduced by decreasing financial pressure as well as by modifying attitudes and beliefs that impact patient cost decisions. Pharmacist can employ several strategies to overcome patient cost-related barriers to medication adherence.

  • Pharmacist-provided medication therapy management (MTM), as offered by RxLive, is a method to reduce patient costs by evaluating which medications can be stopped with minimal risk to health and the presence of duplicate therapy. Lifestyle changes can also be evaluated and recommendations made to improve health and eventually reduce the need for certain costly medications.
  • Ongoing patient counseling and follow-up by the same pharmacist allows for reinforcement of the necessity of medication adherence for optimal patient outcomes. This is especially important for those who find difficulty perceiving the long-term effects that could result from medication regimen deviation in chronic disease states such as hypertension, where patients don’t feel the effects of the medications they’re taking. However, they do experience immediate and significant effects from their current financial pressures, contributing to CRN through prioritization of other expenses over medications.
  • Identification of alternative, less-expensive medications or insurance formulary medications can be presented to the prescriber for approval. If brand drugs aren’t medically necessary, generic medications can be provided. If no generic is available, less-expensive, brand-name alternatives should be sought.
  • Pharmacists can discuss with the patient’s provider about pill splitting as one method to reduce patient costs. Higher doses of some medications exhibit little or no price difference for higher dosages, allowing in some circumstances for the tablet to be split in half with a pill cutter to obtain two doses from one tablet.
  • Pharmacists can provide patients with sources of prescription medication financial assistance. Patient assistance programs (PAPs) are established by pharmaceutical companies to subsidize discounted or free medications to people qualifying for financial assistance. Nonprofit organizations, such as Needy Meds and RxAssist, offer PAPs searchable databases.
  • Many free prescription discount cards are available online, and pharmacists can refer patients to such discount cards. These can be especially useful to patients with high insurance deductibles who need some financial relief until their deductible is met and benefits are payable, or for those without insurance coverage. Coupons for brand-name drugs are also available from sources such as GoodRx, pharmaceutical companies online or from life science reps. Pharmacists can identify such coupons for patients paying large out-of-pocket amounts for prescription medications. To learn more about the pros and cons of when to use discount programs and when it may not be the best choice, see our blog.
  • Pharmacies can create a patient-resource document providing federal assistance programs, nonprofit assistance programs, and coupon sources for those that have cost-related barriers to medication adherence.

Summary

Medication adherence is affected by cost and the ability of patient’s to pay for expensive prescription medications. Attitudes and beliefs also impact whether finite financial resources are allocated to prescription medications, forcing patients into prioritizing limited resources.

Pharmacists are in a unique position to identify cost barriers by being directly involved in both healthcare and patient financial medication transactions, and through the examination of medication-filling trends. Because of pharmacists’ familiarity with drug pricing, understanding brand versus generic medications, possessing drug substitution knowledge, and having access to coupons and awareness of prescription drug financial assistance programs, they can employ several strategies to help lessen patients’ financial burden of attaining medications and improve medication adherence as a result.

References

Pharmacies: Improving Health, Reducing Costs. National Association of Chain Drug Stores

Association Between Supplemental Nutrition Assistance Program Participation and Cost-Related Medication Nonadherence Among Older Adults with Diabetes. JAMA

Attitudes, Beliefs, and Cost-Related Medication Nonadherence Among Adults Aged 65 or Older with Chronic Diseases; National Health Interview Survey; Therapeutic Drug Use. Centers for Disease Control and Prevention (CDC)

Cost-Related medication Nonadherence in Adults with Atherosclerotic Cardiovascular Disease in the United States. Circulation

Author avatar
Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.