Patient adherence may depend on the answer to this question, so it must be asked.
Fam Pract Manag. 2006 Apr;13(4):67-69.
You’re finishing up your visit with Mrs. Allen. She’s been your patient for more than 15 years. You’ve been treating her hypertension and type-2 diabetes for most of that time. Until recently, she was able to control both with some of the newer medications for these diseases. Over the past year, however, both her hypertension and diabetes have been sliding out of control. Her weight has remained stable, and she swears she’s been following the diet the dietician recommended. You’ve added some newer medications to no avail. You are becoming increasingly frustrated and angry over your failure to help this kind lady control her medical problems.
While going over the instructions on how to take the latest hypoglycemic you are prescribing, you notice a few small holes in her sweater and that the cuffs of her blouse are fraying. Then you see the safety pin holding her glasses together. It’s a busy day, so you finish the prescription, answer her final questions and move to the next patient. You feel sure the newest medication will get her diabetes under control. You leave the room feeling you have done a good job for her, answering all her questions.
What you didn’t do was ask a very important question – one that may hold the answer to why Mrs. Allen’s hypertension and diabetes are getting out of control. You failed to inquire whether she could afford the medications you so hopefully prescribed.
Exploring your options
“Are you able to pay for your medications?” is a question many physicians never ask their patients, yet the answer may have a significant impact on patients’ conditions. One study of 660 older adults with chronic diseases found that each respondent admitted to underusing their medications during the previous year because they couldn’t afford them.1 Two-thirds of these patients never told their doctor that they couldn’t afford their medications. If we don’t ask, most patients won’t tell.
As their physicians, we let these patients down in many ways. Almost 60 percent of these patients thought there was nothing their doctors could do to help them get the medications they needed.1 Of the patients who did discuss this sensitive topic with their doctor, nearly three-fourths found the discussion helpful. However, around one-third said their doctors didn’t make any changes to generic or less expensive medications.
It’s not only the elderly who can’t afford their medications. Many people with jobs do not have health insurance. A Kaiser Family Foundation study found that 80 percent of people without health insurance come from working families.2 Many small businesses don’t offer health insurance to their employees, and many employees who have the option to buy health insurance at work can’t afford to. More and more, health care and health insurance costs must be borne by the individuals.
Physicians can and should take steps to make sure their patients, regardless of age or employment status, get the medications they need. There are several ways you can help – even from the examination room.
Consider non-medicinal treatments. Be sure you have fully explored lifestyle changes with your patients. Weight loss, smoking cessation, exercise, relaxation, etc. – all are important, inexpensive and can make a big difference. But lifestyle changes can go only so far.
Prescribe generics. When it’s possible, prescribing generics can save big bucks. They can cost up to 90 percent less than the brand-name version of the same drug, and they are just as effective.
Try older drugs first. The pharmaceutical manufacturers try hard to convince patients and doctors that the latest medications are better than older products. Sometimes it’s true, but frequently the newer drugs aren’t that much better and are definitely more expensive. Some of the newer drugs are more effective for certain patients, but try the older, more established and usually less expensive drugs first.
Learn drug prices. Be honest: Do you know the price of the medications you prescribe? You may know the costs of medications you or your family members take, but can you list the prices for your top 10 prescribed medications? Check them out; you may be surprised.
Reconsider your favorite medications. All doctors have “favorite” drugs they prescribe, but are these drugs’ perceived benefits so great that they justify a higher price compared to similar, less expensive drugs in the same class? A less expensive drug in the same class could work just as well. If your patients can’t afford your favorite drug, maybe it’s time to consider another.
Prescribe half a pill. The price of some medications doesn’t increase very much for a higher-dose pill. For example, if a 20 mg tablet costs less than twice as much as a 10 mg tablet and can be easily split, then the 20 mg tablets are a better deal.
Keep up-to-date with pharmaceutical patient assistance programs (PAPs). The majority of pharmaceutical companies have these programs, which are designed to help those who have no insurance coverage for medications. According to Billy Tauzin, CEO and president of the Pharmaceutical Research and Manufacturers of America (PhRMA), PAPs sponsored by PhRMA member companies gave away more than $4 billion worth of drugs, filling more than 22 million prescriptions in 2004.
All the programs require some physician involvement. For some, all you have to do is provide a prescription or sign a form; for others you have to complete significant portions of a form or call the company. Most of the programs send the medications to a doctor’s office and require that the office give the medication to the patient. This creates more paperwork and takes time for your office staff, but your patients will appreciate your help.
More on PAPs
PAPs are constantly changing: Drugs are added to or deleted from programs, requirements change, application forms are revised, etc. Staying on top of these changes will help you answer patients’ questions when they arise.
There are many sources of information on these programs. Some of the drug companies have their information on their Web sites. This is fine if you prescribe medications made by only one or two companies, which most of us do not. There are also books that contain this information. One of the better ones is Drugs For Less by Michael P. Cecil, MD. Written primarily for patients, it covers many techniques patients can use to lower medication costs. However, because PAPs change frequently, any book runs the risk of the content becoming quickly outdated. The Internet is one of the most reliable places to find the latest information on PAPs because it’s easy for Web sites to be updated as new information becomes available. Here are four Web sites worth reading:
NeedyMeds (http://www.needymeds.com) is a nonprofit organization that provides information on PAPs and other sources of assistance. Its site is designed for easy use, and the information is updated regularly. It also contains other sources of help for those who can’t afford their medications.
The Partnership for Prescription Assistance (http://www.pparx.org) is run by PhRMA and provides information for patients, patient advocates and providers. The Web site allows users to access more than 475 public and private PAPs.
RxAssist (http://www.rxassist.org) is supported by the Robert Wood Johnson Foundation and has the same type of information as NeedyMeds, though it takes a few steps to reach it.
RxHope (http://www.rxhope.com) is a private company supported by PhRMA that provides a Web portal for physicians to manage their PAPs and sample applications online. Their system allows for the patient information to be managed by the doctor, from completion of applications and reminders for reorders to notification of the PAP status.
Why you should help
The role of the physician is changing. For many patients, we have to go beyond diagnosing and treating. We have to be cognizant of our patients’ financial and insurance status. If we don’t ask patients whether they can afford their medications and help them obtain affordable medications, then we could be wasting our time and theirs with ongoing office visits.
About the Author
Dr. Sagall is a board-certified family physician in Philadelphia and the president and co-founder of NeedyMeds, a nonprofit organization that provides information on pharmaceutical patient assistance programs and other patient resources. He is also a consultant to RxHope, an Internet-based patient assistance and sampling portal. Author disclosure: Dr. Sagall is president of NeedyMeds and a consultant to RxHope.
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1. Piette JD, Heisler M, Wagner TH. Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Arch Intern Med. 2004;164:1749–1755.
2. Kaiser Family Foundation. Health Insurance Coverage in America: 2004 Data Update. November 2005. Available at: http://www.kff.org/uninsured/upload/Health-Coverage-in-America-2004-Data-Update-Report.pdf. Accessed March 22, 2006.
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