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When Money is Tight (Jul-04)

Because of the high cost of many prescription drugs, some people take fewer pills than prescribed. What are the health implications?

Imagine that four months ago, you started getting chest pains whenever you exerted yourself physically, and at the time you decided this was serious enough to see a doctor. After your doctor examined you and ran some tests, you were told that you have angina, a kind of heart disease. This disease can develop when the coronary arteries become narrow and clogged from high cholesterol and the heart can't get the oxygen that it needs. Your doctor helped you plan some lifestyle changes to treat your condition. You have been very devoted to the new way of life, eating healthier and doing the proper kinds of exercise regularly. Also, part of your treatment involves regularly taking the medication that your doctor prescribed for you. You were told to take one pill each day.

The trouble is your prescription drug insurance is limited and you find yourself having to pay the majority of the cost for the angina medication out of pocket. What's more, you have been struggling just to break even every month after accounting for all of your living expenses. Now you are worried about being able to afford the medication if you take it as regularly as prescribed. A pill a day may be doctor's orders, but it is getting costly for you.
 
Would you take the pill as often as prescribed or would you skip some days to try to save money?
 
  • I would take the pill every day as prescribed.
  • I would skip some days to save some money.

How do your answers compare?

You have to save money somehow, right? Perhaps you would just have to cut back on other expenses in your life, but apparently you felt the medication had to be taken as prescribed. Research has found, however, that especially among the elderly, a significant portion of the population reports restricting medications due to cost. An important question is whether this leads to adverse health outcomes. Policy debates have been largely divided on this issue.

Do those who restrict their medications due to cost experience adverse health outcomes?

A research team led by Dr. Michele Heisler and Dr. Kenneth Langa conducted a study to investigate this question. Prior to this study, no one had examined this question by studying the same individuals at different points in time to see if those who restricted medication due to cost were more likely to develop adverse health outcomes. The researchers obtained nationally representative data that was the result of nearly 8000 interviews. Each respondent was interviewed in 1995 or 1996 and then re-interviewed in 1998. At both times, individuals were asked about cost-related medication restriction and about their health. The health questions assessed overall health, angina and other cardiovascular diseases, diabetes, arthritis, and depression.

The researchers found that cost-related medication restriction was associated with almost twice the odds of experiencing a significant decline in overall health. The association between restricting medication due to cost and poor health outcomes was strongest for those who had cardiovascular disease. Of these individuals, those who restricted their medication had a 50% increased odds of suffering angina and a 51% increased odds of having a stroke. Aren't you glad on the previous page you said you wouldn't restrict your angina medication?

Those who had arthritis or diabetes and restricted their medication due to cost did not report worse disease-related outcomes at the second interview. For arthritis, this might have been because of equally effective over-the-counter pain medications, and for diabetes, higher rates of kidney disease would likely require a longer period of follow-up to detect. When looking at age as a factor, the results showed that older adults experienced significant declines in overall health, worse cardiovascular outcomes, and increased depression. The study showed that younger people who restrict are also at risk for a decline in their health.

One limitation of this study is the lack of data about how often individuals restricted medications. If an individual restricted only once or twice, it is not clinically plausible that this would have led to an adverse health outcome. Also, the data on health outcomes were self-reported, and thus subject to bias. Previous studies, however, have shown excellent agreement between medical records and self-reports for conditions such as hypertension, diabetes, and stroke.

Implications on policy

This study provides evidence that, contrary to some claims, adults with chronic illnesses who restrict medications due to cost experience adverse health outcomes. As drug costs continue to escalate and individuals continue to lack full prescription coverage from their health insurance, it will be increasingly important for healthcare systems and physicians to develop strategies to screen patients for cost-related underuse of medications and to provide assistance to these patients. Moreover, insurance companies will need to create benefit packages that provide appropriate coverage, taking into account the cost of prescription medications.

For more information see:

Michele Heisler, Kenneth M. Langa, Elizabeth L. Eby, A. Mark Fendrick, Mohammed U. Kabeto, John D. Piette. The Health Effects of Restricting Prescription Medication Use Because of Cost. Medical Care, 42(7). 2004.

We are delighted to officially announce that Raymond De Vries will be joining Angie as the new Co-Director of the Center. Ray has been an active faculty member of CBSSM for several years.  He is a Professor in the Departments of Medical Education, Obstetrics and Gynecology, and Sociology, as well as a visiting Professor at Maastricht University in the Netherlands.  He is particularly interested in the regulation of science; clinical trials of genetic therapies and deep brain stimulation; international research ethics; and the social, ethical, and policy issues associated with maternity care.

Scott Kim recently stepped down from the Co-Directorship of CBSSM to take on a new position as Senior Investigator in the Department of Bioethics at the National Institutes of Health.  He continues to assist with various CBSSM-related research projects.

 

Fri, February 14, 2014

Dr Peter Ubel, the previous director of CBDSM, discusses health care policy in his Forbes article "Is The Profit Motive Ruining American Healthcare?" He says, "when we debate healthcare costs in the U.S., we need to be clear on whether we are focusing on profits, per se, or instead on the simple fact that everyone in the healthcare industry – from for-profit insurance companies to private practice physiotherapists – understandably need to focus on their own bottom lines," 
 

Fri, February 28, 2014

Brian Zikmund-Fisher was quoted in a Scientific American article about risk communication of certain chemicals in the lives of expectant parents. He explains, “Look at your life and the choices you make, and do things that can make you safer easily, but don't overreact to anything ... There are very, very few things out there that have such huge effects on our lives or our baby's lives that one teeny bit of exposure is going to make a difference.”

Thu, May 22, 2014

Susan Dorr Goold, M.D., M.H.S.A., M.A. is the senior author on an article receiving the annual “Professionalism Article Prize” by the ABIM Foundation. Jon C. Tilburt, M.D., M.P.H. of the Mayo Clinic is the study’s first author.

This award recognizes outstanding contributions to the field of medical professionalism. The article “Views of U.S. Physicians About Controlling Health Care Costs” was published in the Journal of the American Medical Association in July 2013.

Research Topics: 
Thu, May 22, 2014

CBSSM faculty member Susan Dorr Goold M.D., M.H.S.A., M.A. was interviewed by the LA Times about doctors assisting with prison executions despite ethics rules.

“Physicians are healers. That knowledge should be used only for healing, not executions,” said Dorr Goold, professor of internal medicine and health management and policy at the University of Michigan who is the Chair of AMA’s Council on Ethical and Judicial Affairs. “Participation as a physician is not ethical.”

Read the full LA Times story here.

Research Topics: 
Wed, June 04, 2014

A recent study, “Influence of “GERD” Label on Parents’ Decision to Medicate Infants” by CBSSM faculty Brian Zikmund-Fisher, Angela Fagerlin, and Beth Tarini was featured in a recent New York Times article. Laura Scherer, previous CBSSM postdoctoral fellow and current Assistant Professor at University of Missouri was lead author on the study.

Research Topics: 
Wed, June 04, 2014

 The Visualizing Health Project was recently featured in “Seeing Is Believing: Infographics Revolutionizing The Patient Experience” (Forbes). Robert Wood Johnson Foundation (RWJF) and the University of Michigan Center for Health Communications Research (CHCR) joined forces for “Visualizing Health,”  a project examining how data visualization for risk behavior can be applied. Their premise is that people need to be able to understand and respond to multiple types of health risk information. CBSSM’s Angela Fagerlin, Brian Zikmund-Fisher, Nicole Exe, and Knoll Larkin were involved this project.

CBSSM Seminar: Barbara Koenig, PhD

Thu, October 23, 2014, 3:00pm to 4:00pm
Location: 
NCRC 16-266C

Barbara Koenig, PhD
Professor of Medical Anthropology & Bioethics Dept. of Social & Behavioral Sciences
Institute for Health & Aging, UCSF

“Revisiting the “Race” Issue in Genomics”

Summary: Throughout the post-genomic era, efforts to categorize human populations according to geographical ancestry have been contentious. How does genetic variation map on to social categories of difference? How can researchers seeking to understand health disparities—or to interrogate diseases associated with particular genetic variants—pay attention simultaneously to race as social identity, and biological characteristic?

CBSSM Seminar: Stephanie Kukora, MD

Wed, November 05, 2014, 3:00pm to 4:00pm
Location: 
NCRC 16-266C

Stephanie Kukora, MD
Neonatal-Perinatal Medicine Fellow

"Choosing Wisely: using past medical decisions in allocating scarce ECMO resources"

This talk will examine the ethical complexities of distributing limited ECMO resources to a growing population of eligible patients across the age spectrum and varying prognosis, describe the ramifications of influenza vaccine refusal among otherwise healthy adults, and explore the moral permissibility of allocating scarce ECMO resources based on previous medical decision-making, such as declining the seasonal influenza vaccine.

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