Steven L. Smith, Ph.D.

Assistant Professor Grand Valley State University School of Social Work

Background

 In U.S., those over age 65 comprise 42% of prescription drug market (AARP, 2002).

 Medicare Part D in 2006 helped, but an array of costs for elders still exists; copayments, deductibles, supplemental coverage, coverage gaps (donut hole), leaves older adults at high financial risk.

Background

 So called “donut hole” in Medicare Part D, began in 2006 when elder’s outlays for Rx reached $2,250 and ended at $5,100.

 While these numbers have varied some from year to year, and the health reform bill last year begins to address a small portion of this amount, it will be 2020 before this is eliminated.

Background

 Communication between elders and providers has historically been poor.

 Heisler, Wagner and Piette in 2004 reported only 16% of elders stated that their provider asked whether they could afford their medications.

Background

   Tseng, Dudley and Brook et al. in 2007, in a study of 1100 elders, found that 81% wanted their MD to ask them whether they could afford their medications, and only 17% stated their MD asked them about cost and affordability.

2/3 had difficulty paying for medication and 1/4 decreased medication use.

Because many elders had difficulty asking MDs for cost-cutting help, study suggested providers need to actively initiate those conversations with elders.

Background

 Piette, Heisler and Wagner, in a 2004 cross sectional study of 875 older adults with diabetes found that 19% reported cutting back on medications due to cost and that women were 1.8 time more likely to cut back then were men.

 37% of elders in that study reported never talking to their MD about the medication cost problem.

Background

 Most common reasons for not discussing according to the elders in that study:  Providers never asked them (70%)  Felt provider could not help them (50%)  Felt not important enough to mention (39%)  Felt embarrassed (35%)  Insufficient time during visits to discuss costs (30%)

Background

 In 2007, Beran, et al. asked 678 MDs about their role with elder patients related to medication cost.

 2/3 believed out of pocket costs were important factors when prescribing.

 Fewer than half reported having conversations with elder patients in the 30 days prior to the study.

 MDs felt that elders raised the issue more often than the doctors did.

 MDs often prescribed generics if available, or used samples in the office of newer, expensive medications.

Background

  Khosravi in 2003 stated that while some Americans travel to Canada or Mexico to fill prescriptions, this is often not viable for poor elders without the resources to take such trips. FDA warns that it is illegal to re-import medications and advises against the practice, however postal inspectors (internet orders from overseas) and border agents often exercise discretion if the drug does not post a risk, there is only a 90 day supply, and there is a prescribing U.S. MD.

Methods

 My survey posed questions about beliefs and practices regarding the cost of prescription medications.

 112 elders at three different senior centers in Michigan took part; one in Portage and two near Detroit.

Demographics

 112 Respondents  59.8% Female  Mean age = 76 years old  50% lived alone; 41% lived with one other  Income:  15% Low income (135% or less of FPL)  57% Moderate (135% - 399% FPL)  11% High income (400% + of FPL)  17% Unknown/did not answer

Discussion

  Population in this study has some similarities to larger national studies, but some important differences.

Income, % female, mean age were all similar to larger studies. The number of white elders was higher in my study, primarily because I asked the Michigan OSA for 2 other senior centers to match the demographic characteristics from the senior center in my area. At the time, this was to control for confounding variables in comparing participants between centers.

Results

 12% reported having to make a decision at some point about purchasing Rx or having enough money for other routine costs of living.

 40% reported worrying about their ability to pay for prescription medication.

 75% had discussed Rx costs with MD at some point in the past, yet 40% stated they would consider taking less medication if they needed to make Rx last longer.

Results

 Over 3/4 believed it was legal to purchase Rx by travelling to another country, or to purchased from overseas via an internet pharmacy.

 However, over 90% had ONLY purchased medication at a US pharmacy, in spite of close proximity to Detroit or having internet options available.

Discussion

 There was no significant difference between the senior centers in the attitudes or practices of the elders regarding crossing the border to purchase medications, whether in person or via the internet.

 In my study, 21% of elders had never discussed medication cost issues with their MD, compared with 37% in the 2004 Piette study. This is a troubling statistic.

Discussion

 Elders in moderate income group reported the greatest problems paying for medications.

 13% of moderate income elders reported cutting back on medication due to cost considerations at some point in the past., compared with 19% in the larger, national Piette study regarding elder diabetics.

Implications

 Physicians may need to: ○ Consider broaching issue of medication affordability every time they write Rx to begin to impact on fact that elders have difficulty bringing up this topic.

○ Leaving adequate time with the elder patient for this conversation, given that talking about financial concerns is not easy.

Implications

 Physicians may need to:  Reconsider whether pharmaceutical samples are the best approach for elder patients with financial difficulties. When samples are done, will they be able to afford the latest and greatest?

 If efficacy means that the latest and greatest (and costly) Rx is clearly superior, does the pharma company offer significant subsidies? Does the elder need someone to help them with the application and coordination with the pharma company?

Implications

 Physicians may need to:  Consider the trade-off between generics and newer, more expensive medications. Can a combination of generics approximate the results of a newer, more expensive drug?

 Are their larger dosages that could be cut/split, especially with generics, in order to help elders with affordability? Of course, there are potential ethical considerations if mistakes are made in this regard, but what is the tradeoff between this and affordability and staying on medication?

Implications

 Social workers, family members, helping professions should consider: ○ Having financial discussions with the elder to ensure that they are raising questions with MD regarding all available prescribing options.

○ Advocating with the doctor through phone calls, letters, emails to inform them of the affordability issue if it exists for the elder.

Implications

 Social workers, family members, helping professions should consider: ○ Assistance with applications to pharma companies for assistance with costs.

○ Assessing if medications are being taken as prescribed. Family members could assist with splitting medications as necessary if assistance is needed with this.

Questions?