Transcript Canadian Prescription Purchasing Practices and Health Care

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?