This study had three important findings. First, 27% of seniors who skipped doses or stopped taking a medicine because of side effects or poor perceived efficacy did not tell their physician. Second, 39% of seniors who reported cost-related nonadherence had not talked with their physicians about it. Third, physician–patient dialogue about medication costs was associated with patients’ being switched to lower cost medications.
Recent data suggest that patients often do not report medication-related symptoms to physicians, and that physicians do not always respond when they do.23,24
We show that this problem is widespread among U.S. elderly. The confluence of the factors we describe—multiple chronic conditions, use of numerous medications, a variety of prescribing physicians, lack of regular review of medications, and poor communication about medication side effects and perceived efficacy—places seniors at risk for both suboptimal clinical outcomes and adverse drug events. We believe that it is important for physicians to routinely initiate discussions about medication adherence and problems paying for medications, and for patients to routinely volunteer such information, even if not asked.
have previously shown that cost-related medication nonadherence is common among seniors. However, only 2 studies have examined physician–patient dialogue about cost-related nonadherence. Alexander et al.14
found that although physicians and patients are willing to discuss medication costs, only 35% of physicians and 15% of patients report doing so. Piette et al.13
conducted an online survey of persons over age 50 participating in a web-based consumer information and marketing network, and found that 35% of those reporting cost-related nonadherence had not discussed it with their physician. The rates of physician–patient dialogue about cost-related medication nonadherence that we report are similar to those found by Piette et al.,13
but we sampled Americans 65 years and older in all 50 states, and sampled seniors from low-income neighborhoods, making our results generalizable to community-dwelling elderly nationwide.
The finding that physician–patient dialogue about costs was associated with switches to lower cost medications suggests that such discussions are worth having. Many of these switches may have been generic substitutions and others may have been therapeutic substitutions. Whereas patients sometimes do not want to be changed to generic drugs,26–28
the FDA guarantees the therapeutic equivalence of generics29
and generic substitution is a safe way to reduce costs. Physicians have a number of other cost-reducing strategies at their disposal, including within-class drug switches, between-class drug switches, dose reductions, and use of samples. In addition, physicians can help patients prioritize which medications are most important and help design safe and effective, or at least optimal, alternative strategies. None of these strategies, however, can be implemented if physicians and patients are not routinely discussing medication use and medication costs.
There are several study limitations. Our response rates were lower than anticipated, and respondents were more likely than nonrespondents to be white and to have higher incomes. Piette et al.13
found that neither race nor income was associated with physician–patient adherence-dialogue, and we do not suspect that nonresponse biased our analytic findings. Because of social desirability effects (the desire not to admit socially undesirable behaviors such as nonadherence), the levels of nonadherence and dialogue about nonadherence that we report may underestimate true levels. Finally, given the cross-sectional nature of our data, we cannot definitively know the temporal ordering of events related to medication discussions and switching to lower cost medications. It is possible that in some cases, a switch leads to medication discussion rather than the reverse. A longitudinal study design would be needed to verify the sequencing of these effects.
In conclusion, the suboptimal physician–patient communication about medications identified in this study is an important clinical backdrop against which the new Medicare drug benefit will be implemented. Prescription drug plans will have to employ similar cost-containment techniques to those currently used by commercial health insurance plans, including formularies, premiums, deductibles, copays, and drug tiers. Physicians will need to work closely with seniors and their families to identify clinically appropriate substitutes if available plans do not cover the drugs patients are currently using. Whereas collaboration with pharmacists may be useful because of a paucity of well-designed studies, relatively little is known about the effectiveness of this strategy.30–32
These and other challenges will require not only that physicians and patients educate themselves about the new drug benefit and coverage rules of the new Medicare PDPs, but will also require that substantial time and effort be dedicated to physician–patient communication about medication management.
Early experiences with Part D have been mixed.33
With technical problems caused problems with the automatic enrollment of some dual eligibles (those eligible for both Medicaid and Medicare) into PDPs,34
there have been reports of seniors being unable to obtain key medications.35,36
Early anecdotal reports suggest that seniors are using a variety of sources to obtain information and for informed decision making, including calling Medicare, surfing the internet, and asking relatives, friends, pharmacists, and health care providers.17
However, with these challenges come new opportunities. It should be possible for plans to use pharmacy claims to inform physicians about patients’ medication use and adherence. For example, drug plans could provide physicians with both medication lists and refill rates in the hopes of triggering more timely and effective discussions about coping with complex drug regimens.
These findings paint a sobering picture of prescription medication taking for America’s seniors. Most seniors have multiple chronic diseases, take multiple prescription medication, have more than one prescribing physician, and use multiple pharmacies. In these circumstances the need for improved physician–patient communication about medications is pressing. Technology aimed at improving the accuracy and timeliness of medication information, such as electronic medical records and electronic prescribing, can support the efforts of physicians and patients in this effort. But more and better talk is urgently needed. Quality measurement and quality improvement initiatives that focus on prescription-medication-related communication might speed progress in this area.