Patients are facing prescription drug benefits that require increasing out-of-pocket costs and that are more complex in structure. We found that patients typically know whether they have any prescription drug cost sharing, but have limited knowledge of important details, such as whether they have tiered copayments or an annual benefit cap. While patients generally know their generic drug copayment, many underestimate their costs for brand name drugs. Few patients know both the structure and amounts of their cost sharing.
Despite limited knowledge, nearly one in four patients report changing their behavior in response to their perceived level of prescription drug cost sharing. Over one in 10 patients report decreasing their drug adherence because of costs, nearly one in 10 report borrowing money or going without some necessity because of drug costs, and nearly one in five report engaging in some other cost-coping behavior. These reports of increased financial burden are surprising given that all patients in this study had comprehensive health insurance, and none were on Medicaid. The strong association between lower household income and reports of financial burden points to the need to adapt cost sharing policies to lessen the burden for patients with lower income or wealth. Not surprisingly, patients who have greater levels of drug cost sharing (generic copayment) or additional cost sharing structures (which could represent higher drug costs such as tiered copayments or a benefit cap) are more likely to report these behaviors.
Our findings about cost-related decreased adherence are consistent with other findings of decreased drug utilization with increased cost sharing in multiple delivery settings and in several drug classes (Stuart and Zacker 1999
; Mojtabai and Olfson 2003
; Taira et al. 2003
; Hsu et al. 2004
; Piette and Heisler 2004
; Piette et al. 2004
; Reed et al. 2005
). The decreased adherence raises concerns about whether these choices might put patients at increased risk of worse health outcomes. While our study focuses on patients' self-reported behavior in response to prescription drug cost sharing, it complements recent results from a study examining automated data for a large population over age 65 within the same IDS which show consistent negative clinical and economic consequences from decreased adherence observed in response to the drug benefit cap (Hsu et al. 2006
This study has the unique ability to examine both self-reported and actual drug cost sharing. Patients' limited knowledge of their drug cost sharing increases the importance of examining both perceived cost sharing amounts and their impacts. More importantly, additional effort is needed to provide patients with adequate knowledge of their costs and of the range of alternatives if cost sharing is to create an effective incentive without concomitant undesired effects. Improving provider awareness of patient costs may also help them to actively assist patients in adapting to costs without making unsafe choices about avoiding prescription drugs.
Several other studies also found limited understanding about health coverage details (Cafferata 1984
; McCormack 2002
; Hsu et al. 2004
; Reed et al. 2005
), suggesting a need to educate patients if they are to be judicious consumers. Similar to an earlier study, higher complexity of the benefit structure results in a lower proportion of persons who correctly understood their benefits () (Marquis 1983
). More informed patients might be better able to plan for costs or explore alternatives such as asking their physician for more affordable options. The need for better information and education might become particularly pronounced as the complexity of drug benefits and the amount of cost sharing both increase. For example, Medicare beneficiaries face a range of cost sharing amounts and structures that change with the yearly cumulative amount of drug expenditure (Stuart et al. 2005
). Early reports suggest some confusion among these beneficiaries about their plan options alone (Kaiser Family Foundation 2005
It is important to note that our study focused on patients enrolled in a prepaid, integrated delivery system with a high level of care coordination, and with low levels of brand-name drug use. In other less coordinated care settings, the likelihood of poor drug adherence may even be higher. The drug cost sharing levels in this study also are arguably more modest and less complex than those in other plans available in the market (e.g., benefit caps and gaps, deductibles, larger numbers of tiers), including the cost sharing in many Medicare Part D drug plans. If faced with higher levels of cost sharing and more complex cost sharing structures, patients might reduce their drug adherence and use other coping behaviors more often than we observed.
Overall, our findings suggest that patients have limited knowledge of their drug benefits. Despite this limited knowledge, many patients report changing their drug use behavior in response to cost sharing, some taking less medication than prescribed, and some reporting that the drug costs create a substantial financial burden. The full economic and health implications of these behaviors are important to explore further, particularly for population groups that might be vulnerable to adverse effects.