Skip to main content
SpringerLink
Log in

Self-restriction of medications due to cost in seniors without prescription coverage

A national survey

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

OBJECTIVE: Little is known about patients who skip doses or otherwise avoid using their medications because of cost. We sought to identify which elderly patients are at highest risk of restricting their medications because of cost, and how prescription coverage modifies this risk.

DESIGN AND PARTICIPANTS: Cross-sectional study from the 1995–1996 wave of the Survey of Asset and Health Dynamics Among the Oldest Old, a population-based survey of Americans age 70 years and older.

MEASUREMENTS: Subjects were asked the extent of their prescription coverage, and whether they had taken less medicine than prescribed for them because of cost over the prior 2 years. We used bivariate and multivariate analyses to identify risk factors for medication restriction in subjects who lacked prescription coverage. Among these high-risk groups, we then examined the effect of prescription coverage on rates of medication restriction.

MAIN RESULTS: Of 4,896 seniors who regularly used prescription medications, medication restriction because of cost was reported by 8% of subjects with no prescription coverage, 3% with partial coverage, and 2% with full coverage (P<.01 for trend). Among subjects with no prescription coverage, the strongest independent predictors of medication restriction were minority ethnicity (odds ratio [OR], 2.9 compared with white ethnicity; 95% confidence interval [95% CI], 2.0 to 4.2), annual income <$10,000 (OR, 3.8 compared with income ≥$20,000; 95% CI, 2.4 to 6.1), and out-of-pocket prescription drug costs >$100 per month (OR, 3.3 compared to costs ≤$20; 95% CI, 1.5 to 7.2). The prevalence of medication restriction in members of these 3 risk groups was 21%, 16%, and 13%, respectively. Almost half (43%) of subjects with all 3 risk factors and no prescription coverage reported restricting their use of medications. After multivariable adjustment, high-risk subjects with no coverage had 3 to 15 times higher odds of medication restriction than subjects with partial or full coverage (P<.01).

CONCLUSIONS: Medication restriction is common in seniors who lack prescription coverage, particularly among certain vulnerable groups. Seniors in these high-risk groups who have prescription coverage are much less likely to restrict their use of medications.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Soumerai SB, Ross-Degnan D. Inadequate prescription-drug coverage for Medicare enrollees—a call to action (published erratum appears in N Engl J Med 1999;340:976). N Engl J Med. 1999;340:722–8.

    Article  PubMed  CAS  Google Scholar 

  2. Lagnado L. The uncovered; drug costs can leave elderly a grim choice: pills or other needs. Wall Street Journal. November 17, 1998: A1.

  3. Dustan HP, Caplan LR, Curry CL, et al. Report of the Task Force on the Availability of Cardiovascular Drugs to the Medically Indigent. Circulation. 1992;85:849–60.

    PubMed  CAS  Google Scholar 

  4. Drazen JM, Bush GW, Gore A. The Republican and Democratic candidates speak on health care. N Engl J Med. 2000;343:1184–9.

    Article  PubMed  CAS  Google Scholar 

  5. Shih YC. Effect of insurance on prescription drug use by ESRD beneficiaries. Health Care Financ Rev. 1999;20:39–54.

    PubMed  CAS  Google Scholar 

  6. Poisal JA, Chulis GS. Medicare beneficiaries and drug coverage. Health Aff. 2000;19:248–56.

    Article  CAS  Google Scholar 

  7. Poisal JA, Murray L. Growing differences between Medicare beneficiaries with and without drug coverage. Health Aff. 2001;20:74–85.

    Article  CAS  Google Scholar 

  8. Lillard LA, Rogowski J, Kington R. Insurance coverage for prescription drugs: effects on use and expenditures in the Medicare population. Med Care. 1999;37:926–36.

    Article  PubMed  CAS  Google Scholar 

  9. Department of Health and Human Services. Report to the President: Prescription Drug Coverage, Spending, Utilization, and Prices. 2000. Available at: http://www.aspe.hhs.gov/health/reports/drugstudy.

  10. Soldo BJ, Hurd MD, Rodgers WL, Wallace RB. Asset and health dynamics among the oldest old: an overview of the AHEAD study. J Gerontol B Psychol Sci Soc Sci. 1997;52:1–20.

    PubMed  Google Scholar 

  11. Heeringa S. Technical Description of the Asset and Health Dynamics (AHEAD) Survey Sample Design (Public Use Version). Ann Arbor: University of Michigan Institute for Social Research; 1995.

    Google Scholar 

  12. Smith JP. Wealth inequality among older Americans. J Gerontol B Psychol Sci Soc Sci. 1997;52:74–81.

    PubMed  Google Scholar 

  13. Hopp FP, Duffy SA. Racial variations in end-of-life care. J Am Geriatr Soc. 2000;48:658–63.

    PubMed  CAS  Google Scholar 

  14. McKinley ED, Garrett JM, Evans AT, Danis M. Differences in end-of-life decision making among black and white ambulatory cancer patients. J Gen Intern Med. 1996;11:651–6.

    Article  PubMed  CAS  Google Scholar 

  15. Escarce JJ, Epstein KR, Colby DC, Schwartz JS. Racial differences in the elderly’s use of medical procedures and diagnostic tests. Am J Public Health. 1993;83:948–54.

    Article  PubMed  CAS  Google Scholar 

  16. Blustein J. Drug coverage and drug purchases by Medicare beneficiaries with hypertension. Health Aff. 2000;19:219–30.

    Article  CAS  Google Scholar 

  17. Stuart B, Grana J. Ability to pay and the decision to medicate. Med Care. 1998;36:202–11.

    Article  PubMed  CAS  Google Scholar 

  18. Stuart B, Zacker C. Who bears the burden of Medicaid drug copayment policies? Health Aff. 1999;18:201–12.

    Article  CAS  Google Scholar 

  19. Johnson RE, Goodman MJ, Hornbrook MC, Eldredge MB. The effect of increased prescription drug cost-sharing on medical care utilization and expenses of elderly health maintenance organization members. Med Care. 1997;35:1119–31.

    Article  PubMed  CAS  Google Scholar 

  20. Tamblyn R, Laprise R, Hanley JA. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA. 2001;285:421–9.

    Article  PubMed  CAS  Google Scholar 

  21. Lurie N, Ward NB, Shapiro MF, Brook RH. Termination from Medi-Cal—does it affect health? N Engl J Med. 1984;311:480–4.

    Article  PubMed  CAS  Google Scholar 

  22. Soumerai SB, Avorn J, Ross-Degnan D, Gortmaker S. Payment restrictions for prescription drugs under Medicaid. Effects on therapy, cost, and equity. N Engl J Med. 1987;317:550–6.

    Article  PubMed  CAS  Google Scholar 

  23. Soumerai SB, Ross-Degnan D, Avorn J, McLaughlin T, Choodnovskiy I. Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. N Engl J Med. 1991;325:1072–7.

    Article  PubMed  CAS  Google Scholar 

  24. Soumerai SB, McLaughlin TJ, Ross-Degnan D, Casteris CS, Bollini P. Effects of a limit on Medicaid drug-reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. N Engl J Med. 1994;331:650–5.

    Article  PubMed  CAS  Google Scholar 

  25. Schweitzer SO, Shiota SR. Access and cost implications of state limitations on Medicaid reimbursement for pharmaceuticals. Annu Rev Public Health. 1992;13:399–410.

    Article  PubMed  CAS  Google Scholar 

  26. Pedersen TR, Kjekshus J, Berg K, et al. Cholesterol lowering and the use of healthcare resources. Results of the Scandinavian Simvastatin Survival Study (published erratum appears in Circulation 1996;94:849). Circulation. 1996;93:1796–802.

    PubMed  CAS  Google Scholar 

  27. Rosenheck R, Cramer J, Allan E, et al. Cost-effectiveness of clozapine in patients with high and low levels of hospital use. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia. Arch Gen Psychiatry. 1999;56:565–72.

    Article  PubMed  CAS  Google Scholar 

  28. Gross DJ, Alecxih L, Gibson MJ, Corea J, Caplan C, Brangan N. Out-of-pocket health spending by poor and near-poor elderly Medicare beneficiaries. Health Serv Res. 1999;34:241–54.

    PubMed  CAS  Google Scholar 

  29. Rogowski J, Lillard LA, Kington R. The financial burden of prescription drug use among elderly persons. Gerontologist. 1997;37:475–82.

    PubMed  CAS  Google Scholar 

  30. Stuart B, Shea D, Briesacher B. Dynamics of drug coverage of Medicare beneficiaires: finders, losers, switchers. Health Aff. 2001;20:86–99.

    Article  CAS  Google Scholar 

  31. McArdle F, Coppock S, Yamamoto D, Zebrak A. Retiree Health Coverage: Recent Trends and Employer Perspectives on Future Benefits. Menlo Park, Calif: The Henry J. Kaiser Family Foundation; 1999.

    Google Scholar 

  32. Sjahid SI, van der Linden PD, Stricker BH. Agreement between the pharmacy medication history and patient interview for cardiovascular drugs: the Rotterdam Elderly Study. Br J Clin Pharmacol. 1998;45:591–5.

    Article  PubMed  CAS  Google Scholar 

  33. Rost K, Roter D. Predictors of recall of medication regimens and recommendations for lifestyle change in elderly patients. Gerontologist. 1987;27:510–5.

    PubMed  CAS  Google Scholar 

  34. West SL, Savitz DA, Koch G, Strom BL, Guess HA, Hartzema A. Recall accuracy for prescription medications: self-report compared with database information. Am J Epidemiol. 1995;142:1103–12.

    PubMed  CAS  Google Scholar 

  35. McKenna MT, Speers M, Mallin K, Warnecke R. Agreement between patient self-reports and medical records for Pap smear histories. Am J Prev Med. 1992;8:287–91.

    PubMed  CAS  Google Scholar 

  36. Brown JB, Adams ME. Patients as reliable reporters of medical care process. Recall of ambulatory encounter events. Med Care. 1992;30:400–11.

    Article  PubMed  CAS  Google Scholar 

  37. Evans C, Crawford B. Patient self-reports in pharmacoeconomic studies. Their use and impact on study validity. Pharmacoeconomics. 1999;15:241–56.

    Article  PubMed  CAS  Google Scholar 

  38. Coughlin SS. Recall bias in epidemiologic studies. J Clin Epidemiol. 1990;43:87–91.

    Article  PubMed  CAS  Google Scholar 

  39. Norrish A, North D, Kirkman P, Jackson R. Validity of self-reported hospital admission in a prospective study. Am J Epidemiol. 1994;140:938–42.

    PubMed  CAS  Google Scholar 

  40. Yaffe R, Shapiro S, Fuchseberg RR, Rohde CA, Corpeno HC. Medical economics survey-methods study: cost-effectiveness of alternative survey strategies. Med Care. 1978;16:641–59.

    Article  PubMed  CAS  Google Scholar 

  41. Cleary PD, Jette AM. The validity of self-reported physician utilization measures. Med Care. 1984;22:796–803.

    Article  PubMed  CAS  Google Scholar 

  42. McCall N, Rice T, Sangl J. Consumer knowledge of Medicare and supplemental health insurance benefits. Health Serv Res. 1986;20:633–57.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. the Division of Geriatrics, San Francisco VA Medical Center, San Francisco, Calif

    Michael A. Steinman MD & Kenneth E. Covinsky MD, MPH

  2. the University of California-San Francisco, San Francisco, Calif

    Michael A. Steinman MD, Laura P. Sands PhD & Kenneth E. Covinsky MD, MPH

  3. the VA National Quality Scholars Program, San Francisco VA Medical Center (MAS), San Francisco, Calif

    Michael A. Steinman MD

Authors
  1. Michael A. Steinman MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Laura P. Sands PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kenneth E. Covinsky MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael A. Steinman MD.

Additional information

Presented as an oral presentation at the American Geriatrics Society Annual Meeting, Chicago, May, 2001; the Society of General Internal Medicine Annual Meeting, San Diego, May, 2001; and the Northern California Epidemiology Network Conference, Berkeley, February, 2001.

Dr. Steinman was supported in part by the VA National Quality Scholars Fellowship Program. Dr. Covinsky was supported in part by an Independent Scientist Award from the Agency for Healthcare Research and Quality (K02HS00006-01) and is a Paul Beeson Faculty Scholar in Aging Research.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Steinman, M.A., Sands, L.P. & Covinsky, K.E. Self-restriction of medications due to cost in seniors without prescription coverage. J GEN INTERN MED 16, 793–799 (2001). https://doi.org/10.1046/j.1525-1497.2001.10412.x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1046/j.1525-1497.2001.10412.x

Key words

Search

Navigation