Senior citizens cutting back on medications due to high costs

A new prospective study shows for the first time what many senior citizens who struggle to pay for their prescription drugs might suspect: Cutting back on your medications now because of cost means your health might suffer down the line.

The findings are based on an in-depth study over a three-year period of nearly 8,000 older adults who were regularly taking prescription medicines at the beginning of the study. By the end of the study, those who said they had had to cut back on their prescriptions because of cost were 76 percent more likely to have suffered a significant decline in their overall health, and 50 percent more likely to have had a heart attack, stroke or chest pain episode, than those who had not cut back.

These differences in health outcomes between the two groups held true even after factors such as age, race, income, education, smoking, alcohol use, obesity and co-existing health problems were taken into account.

In addition to the overall and heart-related differences, participants with depression who were over age 70 when the study began were more likely to have had a significant worsening of their depression by the end of the study if they had cut back on their medicines due to cost. But even the younger participants, who were in their 50s or early 60s when the study began, were more likely to suffer a health decline or a heart event if they had under-used their medications because of cost.

The findings are the first to show a real harm to health over time from restricting prescriptions due to cost. Made by a team from the University of Michigan and the VA Ann Arbor Healthcare System and based on nationally representative data from the U-M Institute for Social Research, they will be published in the July issue of Medical Care, a journal of the American Public Health Association. The study was funded by the National Institute on Aging.

"Medications have been getting more and more effective at preventing or slowing the progression of health problems, but at the same time patients have increasingly been bearing the costs," says lead author Michele Heisler, M.D., M.P.A., a VA research scientist and lecturer at the U-M Medical School. "In our study about 10 percent of participants said they had cut back on their prescriptions due to cost, but we had a large enough group and a long enough follow-up time to see that they had significantly worse health outcomes than those who had not, even after three years."

Heisler hopes the findings will help inform policies on prescription coverage both before and during Americans' Medicare years, and shape the debate on whether short-term drug spending might lead to long-term savings by averting health problems.

One proposal, championed by co-author and U-M professor of internal medicine and public health Mark Fendrick, M.D., is the benefit-based co-pay, which would make patients' share of the cost of a drug lower for those who stand to benefit most from that drug. For instance, a heart attack survivor would pay less for a cholesterol-lowering drug than someone with no history of heart attack.

For now, Heisler and her co-authors also note that the findings show how important it is for doctors to ask their patients if they'll have any trouble paying for the drugs they are prescribed. In another paper published in February, she and her colleagues showed that 75 percent of patients who were having trouble paying for their drugs hadn't been asked by their doctors if they could pay for them.

And, she emphasizes, patients with concerns about costs shouldn't be shy about speaking up to their doctors. "Our results indicate you may be putting your health at risk by letting financial considerations limit your medications," she says. "There are national, state and local programs, generic drugs and other ways to cut costs, but you should explore every option before cutting back – and don't hesitate to enlist your doctor's help in reducing your medication expenses." In addition to her research, Heisler sees patients as a member of the U-M Division of General Medicine faculty.

The researchers credit the rich ISR data for allowing them to draw conclusions with confidence. The study is based on the Health and Retirement Study (HRS), of people who were between the ages of 51 and 61 in 1992, and the Asset and Health Dynamics among the Oldest Old (AHEAD) survey, of those who were age 70 and older in 1992. These two long-term in-depth surveys interviewed thousands of older Americans, first in 1992, then again in 1995 or 1996, and a third time in 1998.

Taken together, the data provided an excellent chance to take a long-term (longitudinal), rather than cross-sectional, look at the relationship between cost-related prescription behavior and health.

"Other studies have suggested that this effect might exist, but only by looking at a snapshot of a population at a moment in time," says senior author John Piette, Ph.D., a VA Career Scientist and U-M associate professor of general medicine. "It's not possible to randomize people to cut back on their necessary medications, so this is the next best thing. We were able to look at relationships within subgroups of patients and see clinically plausible outcomes."

At the start of the study, those who later reported they had cut back on their medications because of cost were more likely to be uninsured or to have health insurance that didn't cover prescription drugs. They were also younger, less educated, and more likely to be female or non-white.

About the same proportion of the two groups of patients started out with a history of heart disease, diabetes, high blood pressure or stroke. This put them at high risk for later heart-related illness or crisis, but such problems can often be prevented with medications. The study looked for signs that the patients who restricted their drugs experienced more preventable heart-related problems.

By the end of the study, and after adjusting for many other potentially confounding factors, 11.9 percent of those who said they had restricted medications due to cost had suffered angina (chest pain), which is usually caused by clogged heart arteries. That's compared with 8.2 percent of those who hadn't cut back. In addition, 7.8 percent of those who had cut back suffered a non-fatal heart attack or stroke by the end of the study, compared with 5.3 percent of those who hadn't.

Among the AHEAD participants who were aged 72 and older when the study began, those who had depression at the start of the study and had trouble paying for medications later were 16 percent more likely than others to experience a worsening of their depression on a standard diagnostic scale by the end of the study. Among HRS participants, the two groups had no major difference.

There were also no significant differences between the two groups of all participants in onset or worsening of diabetes, or arthritis, after adjusting for other factors.

Heisler and her colleagues speculate that longer-term observation will be needed to assess any impact in these areas; they hope to analyze data from the year 2000 soon, when it becomes available.

The ISR surveys also routinely ask participants to rate their overall health, as excellent, very good, good, fair or poor. At the start of the study period, 5,650 of the participants said they were in good health or better. But by the end, many reported a major decline in their self-reported health status. In all, 32.1 percent of those who started out in good health but had cut back on medications characterized their health as fair or poor by the end of the study. By contrast, only 21.2 percent of those who had reported no cutbacks experienced such a decline.

The authors say that the addition of prescription drug benefits to Medicare, starting with credits and discount cards this month, may make some difference for many seniors who have had trouble paying for their drugs. But they note that it will take a while to see the impact on seniors' health.

And, they note, adults who were in their 50s when the study started were most likely to say they had cut back on prescriptions due to cost. Structuring drug benefits for this age group to reduce this trend, and making drug coverage available for those pre-Medicare older adults who do not otherwise have it may help prevent later problems, the authors suggest.

"A lot of critics are saying it's too expensive to provide or improve drug coverage, but studies like this show that the downstream costs from adverse health outcomes later may be more expensive than the upstream costs now," says Heisler. "It may be pay now, or pay more later."

In addition to Heisler, Fendrick and Piette, the study authors include Kenneth Langa, M.D., Ph.D., an assistant professor of general medicine and ISR researcher; and Elizabeth Eby, M.P.H, and Mohammed Kabeto, M.S., who performed the data analysis. Heisler, Piette, Langa and Eby are members of the VA Center for Practice Management and Outcomes Research at the VA Ann Arbor Healthcare System. Heisler and Piette are members of the Michigan Diabetes Research and Training Center. Heisler is a VA Career Development awardee.