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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.

Fri, July 26, 2013

Susan Goold is the senior author in a newly published study in JAMA, in which 2,500 U. S. physicians were asked about their views on 17 specific strategies to reduce health care spending, including proposed policies in the Patient Protection and Affordable Care Act. They were also surveyed on their perceived roles and responsibilities in addressing health care costs as care providers.

The vast majority of U.S. physicians (85 percent) agreed that trying to contain costs was a responsibility of every physician but most respondents prioritized patients’ best interests over cost concerns. Most surveyed physicians supported cost-containment initiatives aimed at improving the quality and efficiency of care, such as promoting chronic disease care coordination and limiting corporate influence on physician behavior. Substantial financing reforms, however, were much less popular among physicians. Examples include bundled payments, penalties for readmissions, eliminating fee-for-service reimbursement and other Medicare pay cuts. Physicians also believed that patients, pharmaceutical companies, and malpractice lawyers shared as much or more of the responsibility for containing escalating healthcare costs.

Jon C. Tilburt, M.D., M.P.H., of the Mayo Clinic, Rochester, Minn., was lead author of the study.

Tilburt JC, Wynia MK, Sheeler RD, Thorsteinsdottir B, James KM, Egginton JS, Liebow M, Hurst S, Danis M, Goold S (2013). Views of US Physicians About Controlling Health Care Costs. JAMA 310 (4): 380-388.

Funded by Robert Wood Johnson Foundation

Funding Years: 2014 - 2016.

The Robert Wood Johnson Foundation Clinical Scholars Program at the University of Michigan has established a rigorous curriculum, with enhanced and mentored research practicum and exciting opportunities to engage in community-based and partnered participatory research. The curriculum is based on adult learning theory and integrates research theory and practical applications. This curriculum will fulfill requirements for a Master's Degree in Health and Health Care Research, a degree program that was designed specifically to meet the needs of the Clinical Scholars at the University of Michigan. These above courses make up the central components of the first year of Clinical Scholars Program at the University of Michigan. The second year of the Clinical Scholars Program is primarily devoted to research, with the Scholars' Research Committee continuing as an advisory committee. Education in the second year focuses more closely to each Scholar's specific needs. In the second year the Scholars also participate in a "Work-in-Progress Seminar" led by one of the Program Directors. Throughout all years of the program, Scholars participate in the Clinical Scholars noon health Seminar. This is a weekly 1.5 hour seminar which will alternate between presentation of research findings by Scholars, faculty, or invited guests, and presentations about health policy by Michigan faculty and invited guests. All Scholars are expected to attend the seminar each week, as well as the CSP Leadership, most Core Faculty, and selected guests.

PI(s): Rodney Hayward

Co-I(s): Matthew Davis, Gary Freed, Mary Ellen Heisler, Timothy Hofer, Joel Howell, Theodore Iwashyna, Eve Kerr, Joyce Lee, Richard Lichtenstein, Laurence McMahon Jr, Caroline Richardson, Mary AM Rogers, Sanjay Saint, Antonius Tsai, Michael Volk, Sara Waber

Tue, January 03, 2017

Reshma Jagsi was recently interviewed for a Marketplace (NPR) piece on the JAMA Internal Medicine study, "Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians" which found that elderly patients cared for by female doctors fare better than those treated by men.

Scott Roberts and co-authors found that customers who receive direct-to-consumer genetic health data were not alarmed by results, but generally found the information useful. CBSSM faculty Wendy Uhlmann and Michele Gornick were co-authors on the study.

Click here to read more.

 

 

Research Topics: 
Wed, March 01, 2017

Interim co-director, Brian Zikmund-Fisher, as well as former co-director, Angela Fagerlin, were recently featured in the Wall Street Journal article, "How to Get Patients to Take More Control of Their Medical Decisions."

CBSSM's Co-Director Raymond De Vries' article, "Giving (Bits of) Your Self to Medicine" was published in Medicine at Michigan. In this article, Dr. De Vries discusses biobank consent and moral concerns related to biobank research.

Click here for the full article.

Research Topics: 
Mon, March 20, 2017

A 2014 Reshma Jagsi study of the Long-Term Impact of Chemotherapy on Breast Cancer Survivors was cited by NPR piece, "As Drug Costs Soar, People Delay Or Skip Cancer Treatments."

We are pleased to announce that Reshma Jagsi, M.D., D.Phil., has been appointed director of the Center for Bioethics and Social Sciences in Medicine.

CBSSM is one of the premier intellectual gathering place of clinicians, social scientists, bioethicists and all others interested in improving individual and societal health through application of social science and bioethics methods to health research, education and public outreach. The center also serves as the home of the Program in Clinical Ethics.

Click here for more details.

Tue, May 23, 2017

CBSSM Director, Reshma Jagsi's recent JAMA Oncology article, "From Muslim Registries to Radical Health Care Reform—Caring for Patients in an Era of Political Anxiety" was cited in the New York Times article, "An Expert in Fear."

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