Orlando Harmon
Non-adherence to medication is a common and costly problem, with research showing that the primary factor impacting medication adherence is cost. This is particularly true for seriously ill patients, who are faced with high out-of-pocket costs, leading to difficulties in affording their prescriptions. As a result, patients may resort to cost-saving measures such as cutting pills or delaying refills, which can have negative consequences for their health. While there are strategies to help patients save money on prescriptions, such as patient assistance programs and manufacturer copay programs, insurance companies also play a role in determining medication adherence by influencing the affordability and accessibility of medications.
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What You'll Learn
- High out-of-pocket costs reduce the likelihood of patients initiating treatment
- Patients may delay refills, stop treatment, skip doses, or cut pills to save money
- Patient education and behavioural support can improve medication adherence
- Healthcare affordability crisis impedes adherence to prescribed treatments
- Patients can request an exception to get a prescription drug covered
High out-of-pocket costs reduce the likelihood of patients initiating treatment
High out-of-pocket costs can cause patients to delay or forgo care, leading to financial distress and even bankruptcy. This is a common problem, with over a quarter of Americans reporting financial strain due to medical bills, and about half of US adults saying it is difficult to afford healthcare costs.
The high cost of healthcare is a burden on US families, and this influences decisions about insurance coverage and care-seeking behaviours. In fact, lowering out-of-pocket healthcare costs is the public's top healthcare priority, according to KFF polling. Despite this, cost-sharing is increasing, and high out-of-pocket costs are a daily challenge for both physicians and patients. Every treatment decision can have financial implications for patients, and this can impact their health.
Physicians can help patients navigate the trade-offs related to out-of-pocket costs, to ensure the best financial and medical outcomes. However, many physicians do not consider a patient's out-of-pocket costs when making clinical decisions, and this can create a barrier to care. Some physicians believe that cost should not be a factor when deciding on a treatment plan, and that beneficial treatments should not be withheld because of cost. However, this viewpoint typically applies when physicians deny care to conserve societal resources, rather than an individual's financial resources.
Discussing out-of-pocket costs with patients can be challenging for physicians, and these conversations may be brief. However, they can be a helpful tool in addressing patients' financial distress. Strategies to reduce out-of-pocket costs include patient assistance programs, manufacturer copay programs, and generic or alternative medications.
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Patients may delay refills, stop treatment, skip doses, or cut pills to save money
When patients are faced with high medication costs, they may choose to delay refills or stop treatment altogether. This can occur when patients are unable to afford the full cost of their prescription medication. For example, if their insurance plan no longer covers a particular medication, they may be left with the full financial burden. In such cases, patients may choose to delay refilling their prescription or stop taking the medication altogether. This can have significant consequences for their health, as it may lead to a worsening of their condition or the development of new complications.
Additionally, patients may choose to skip doses or cut pills in half to make their medication last longer and reduce their overall expenses. While this may seem like a practical solution, it can be detrimental to their health. Skipping doses or reducing the dosage without medical advice can decrease the medication's effectiveness and increase the risk of side effects. It can also lead to the development of drug resistance, making it harder to treat the condition in the future.
To address these challenges, patients can explore various cost-saving strategies. They can discuss generic or alternative medication options with their doctor, as these tend to be more affordable. Patient assistance programs and manufacturer copay programs are also available to help reduce out-of-pocket expenses, especially for costly brand-name drugs. Shopping around on the health insurance marketplace during the open enrollment period can help identify plans that cover their specific medication needs. Additionally, patients can work with their healthcare provider to submit an appeal or request an exception from their insurance company, demonstrating the medical necessity of the medication.
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Patient education and behavioural support can improve medication adherence
Patient education is key to improving medication adherence. Providing clear medication-related information to patients is essential to improving adherence, including addressing key information such as what the medication is, why it is being taken, when to take it, how to take it, and how long for. This can be supplemented by providing detailed written information about the medication, such as medication charts or drug cards. Educating patients about common side effects of drugs and how to prevent adverse reactions can also help alleviate fears and concerns.
Behavioural support can also improve medication adherence. Interventions that include team-based or coordinated care have been shown to increase adherence rates. In a study, patients assigned to team-based care were significantly more adherent with their medication regimen 12 months after hospital discharge (89%) compared with patients not receiving team-based care (74%). Patients reported that team-based care improved their comfort in asking clarifying questions, raising concerns about their medication regimen, and collaborating in developing their treatment plan.
Lowering economic barriers to prescribed medications also improves adherence rates. Successful strategies to improve medication adherence include reducing barriers to obtaining medication, including cost reduction and efforts to retain or re-engage patients in care.
Patient-specific tailored approaches to identifying reasons for nonadherence and aligning intervention efforts to address identified needs are also important. Interventions to improve medication adherence could be more effective if the patient's health literacy, cultural background, and language preference and proficiency are taken into account when designing communication and patient education materials.
Finally, improving providers' education can also influence patients' ability to adhere to prescribed medications. As catalysts for medication adherence, providers must be well-informed about the characteristics of the drug options available for the illness being managed, including the pharmaceutical formulation, dosage, size, frequency of use, and the dosage forms of the drug.
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Healthcare affordability crisis impedes adherence to prescribed treatments
The high cost of healthcare and prescription medication is a significant concern for many, with serious consequences for patients' health and well-being, as well as the wider economy. This is particularly true for those on low incomes, who are often unable to afford medication and face difficulties in meeting basic needs such as food, clothing, housing, and transportation.
The COVID-19 pandemic has exacerbated these issues, with a notable increase in the cost of healthcare and prescription medication. This has disproportionately impacted those on lower incomes, with many having to choose between spending on basic needs or medication. A study found that 64% of economically vulnerable patients with incomes of less than $25,000 per year did not take their medications as prescribed.
The inability to afford medication can lead to negative health outcomes, as patients may be forced to reduce spending on chronic disease management, causing health conditions to worsen over time. Additionally, patients may be unaware of more affordable options or may struggle with complicated medication regimens, further impacting their ability to adhere to prescribed treatments.
To address these issues, several strategies have been proposed, including placing a cap on out-of-pocket prescription costs, expanding the Low-Income Subsidy Program, and providing patient education and behavioral support. Patients can also explore alternative options, such as generic medications, patient assistance programs, and manufacturer copay programs, to reduce their medication costs.
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Patients can request an exception to get a prescription drug covered
The doctor must indicate that the non-formulary drug is necessary for treating the patient's condition because all covered Part D drugs on any tier would not be as effective or would have adverse effects. They can also state that the number of doses under a dose restriction has been or is likely to be less effective, or that the alternative(s) listed on the formulary or required to be used in accordance with step therapy has been or is likely to be less effective or has adverse effects.
If the patient's doctor feels that the patient not having the medication could put them in serious harm, an "urgent" or expedited request can be filed, and a decision would be made by the health plan within 24 hours. If the patient's formulary exception is denied by their health plan, they may have the right to appeal and ask for a reconsideration. They can call their health plan regarding the denial and find out if they have appeal rights and what the timeline is for submission.
If the patient's insurance company denies their appeal, they can file for an independent review through their state's insurance regulator. This can be done through an external review process by the federal Department of Health and Human Services (HHS) or a private review organization. There is usually no cost when HHS handles it, but it may cost up to $25 through a private organization or the patient's state.
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Frequently asked questions
Insurance companies are usually not informed of a patient's non-adherence to medication unless they request an exception or appeal for coverage of a certain medication, in which case the patient's medical provider would need to provide a supporting statement explaining the necessity of the medication.
Non-adherence to medication can be due to several reasons, including concerns about side effects, complicated medication regimens, and high out-of-pocket costs.
To improve medication adherence, patient education and behavioural support initiatives, such as text message reminders, can be implemented. Additionally, helping patients afford their prescriptions, such as through subsidies or cost-sharing, is crucial for long-term adherence.
If your insurance doesn't cover your medication, you can explore alternative medications or generics that may be more affordable. You can also look into patient assistance programs or manufacturer copay programs that can help with medication costs. If you need a specific medication, you can request an exception from your insurer and provide the necessary supporting documentation.
To request an exception or appeal, you or your medical provider will need to contact your insurance company and provide supporting documentation explaining the medical necessity of the medication. The specific process may vary depending on your insurer, but it often involves submitting a letter of appeal or application.
