Cost-related Medication Nonadherence and Its Risk Factors Among Medicare Beneficiaries.
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ABSTRACT: Background
Unaffordability of medications is a barrier to effective treatment. Cost-related nonadherence (CRN) is a crucial, widely used measure of medications access.Objectives
Our study examines the current national prevalence of and risk factors for CRN (eg, not filling, skipping or reducing doses) and companion measures in the US Medicare population.Research design
Survey-weighted analyses included logistic regression and trends 2006-2016.Subjects
Main analyses used the 2016 Medicare Current Beneficiary Survey. Our study sample of 12,625 represented 56 million community-dwelling beneficiaries.Measures
Additional outcome measures were spending less on other necessities in order to pay for medicines and use of drug cost reduction strategies such as requesting generics.Results
In 2016, 34.5% of enrollees under 65 years with disability and 14.4% of those 65 years and older did not take their medications as prescribed due to high costs; 19.4% and 4.7%, respectively, experienced going without other essentials to pay for medicines. Near-poor older beneficiaries with incomes $15-25K had 50% higher odds of CRN (vs. >$50K), but beneficiaries with incomes <$15K, more likely to be eligible for the Part D Low-Income Subsidy, did not have significantly higher risk. Three indicators of worse health (general health status, functional limits, and count of conditions) were all independently associated with higher risk of CRN.Conclusions
Changes in the risk profile for CRN since Part D reflect the effectiveness of targeted policies. The persistent prevalence of CRN and associated risks for sicker people in Medicare demonstrate the consequences of high cost-sharing for prescription fills.
SUBMITTER: Nekui F
PROVIDER: S-EPMC7735208 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND:Despite the rollout of Medicare Part D, cost-related nonadherence (CRN) among older adults remains a problem. OBJECTIVES:To examine the rate and correlates of self-reported CRN among a population of older persons with diabetes. RESEARCH DESIGN:Cross-sectional. SUBJECTS:A total of 1264 Part D patients with diabetes, who entered the coverage gap in 2006. MEASURES:Initial administrative medication lists were verified in computer-assisted telephone interviews, in which participants brought their medication bottles to the phone. Medications were classified into cardiometabolic (diabetes, hypertension, cholesterol-lowering), symptom relief, and "other." Participants were asked if they had any CRN during 2006, and if so to which medication/s. We used the person-medication dyad as the unit of analysis, and tested a multivariate random effects logistic regression model to analyze the correlates of CRN. RESULTS:Approximately 16% of participants reported CRN. CRN was more frequent for cholesterol-lowering medications (relative risk, 1.54; 95% confidence interval, 1.01-2.32) compared with medications taken for symptom relief. CRN was reported less frequently with increasing age above 75 years, compared with patients between 65 and 69. In addition, compared with those with incomes of ?$40,000, CRN risk for those with incomes of <$25,000 was markedly higher (relative risk, 3.05; 95% confidence interval, 1.99-4.65). CONCLUSIONS:In summary, we found high rates of CRN among Medicare beneficiaries with diabetes, particularly those with lower incomes. We observed more frequent CRN for cholesterol-lowering medications as compared with medications for symptom relief. Efforts to ensure medication affordability for this population will be important in boosting adherence to key medications.
| S-EPMC3780603 | biostudies-literature
Project description:Background: Many patients face a financial burden due to their medications, which may lead to poor health outcomes. The behaviors of non-adherence due to financial difficulties, known as cost-related medication non-adherence (CRN), include taking smaller doses of drugs, skipping doses to make prescriptions last longer, or delaying prescriptions. To date, the prevalence of CRN remains unknown, and there are few studies about the association of CRN on self-reported healthcare utilization (Emergency room (ER) visits and outpatient visits) and self-reported health outcomes (health status and disability status) among older adults taking antidepressants. Objectives: The objectives were to 1) examine the CRN prevalence, and 2) determine the association of CRN on self-reported healthcare utilization and self-reported health outcomes. Methods: This study was a cross-sectional study of a sample of older adults from the Medicare Current Beneficiary Survey (MCBS) who reported having used antidepressants in 2017. Four logistic regressions were implemented to evaluate the association of CRN, and self-reported healthcare utilization and self-reported health outcomes. Results: The study identified 602 participants who were Medicare beneficiaries on antidepressants. The prevalence of CRN among antidepressant users was (16.61%). After controlling for covariates, CRN was associated with poorer self-reported outcomes but not statistically significant: general health status [odds ratio (OR): 0.67; 95% confidence interval (CI): 0.39-1.16] and disability status (OR: 1.34; 95% CI: 0.83-2.14). In addition, CRN was associated with increased outpatient visits (OR: 1.89; 95% CI: 1.19-3.02), but not associated with ER visits (OR: 1.10; 95% CI: 0.69-1.76). Conclusion: For Medicare beneficiaries on antidepressants, CRN prevalence was high and contributed to more outpatient visits. The healthcare provider needs to define the reasoning for CRN and provide solutions to reduce the financial burden on the affected patient. Also, health care providers need to consider the factors that may enhance patient health status and healthcare efficiency.
| S-EPMC8688804 | biostudies-literature
Project description:Up to 32% of older patients take less medication than prescribed to avoid costs, yet a comprehensive assessment of risk factors for cost-related nonadherence (CRN) is not available. This review examined the empirical literature to identify patient-, medication-, and provider-level factors that influence the relationship between medication adherence and medication costs.We conducted searches of four databases (MEDLINE, CINAHL, Sciences Citations Index Expanded, and EconLit) from 2001 to 2006 for English-language original studies. Articles were selected if the study included an explicit measure of CRN and reported results on covarying characteristics.We found 19 studies with empirical support for concluding that certain patients may be susceptible to CRN: research has established consistent links between medication nonadherence due to costs and financial burden, but also to symptoms of depression and heavy disease burden. Only a handful of studies with limited statistical methods provided evidence on whether patients understand the health risks of CRN or to what extent clinicians influence patients to keep taking medications when faced with cost pressures. No relationship emerged between CRN and polypharmacy.Efforts to reduce cost-related medication nonadherence would benefit from greater study of factors besides the presence of prescription drug coverage. Older patients with chronic diseases and mood disorders are at-risk for CRN even if enrolled in Medicare's new drug benefit.
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Project description:ObjectiveTo explain the association of out-of-pocket (OOP) cost, community-level factors, and individual characteristics on statin therapy nonadherence.Data sourcesBlueCross BlueShield of Texas claims data for the period of 2008-2011.Study designA retrospective cohort of 49,176 insured patients, aged 18-64 years, with at least one statin refill during 2008-2011 was analyzed. Using a weighted proportion of days covered ratio, differences between adherent and nonadherent groups are assessed using chi-squared tests, t-tests, and a clustered generalized linear model with logit link function.Principal findingsStatin therapy adherence, measured at 48 percent, is associated with neighborhood-level socioeconomic factors, including race/ethnicity, educational attainment, and poverty level. Individual characteristics influencing adherence include OOP medication cost, gender, age, comorbid conditions, and total health care utilization.ConclusionsThis study signifies the importance of OOP costs as a determinant of adherence to medications, but more interestingly, the results suggest that other socioeconomic factors, as measured by neighborhood-level variables, have a greater association on the likelihood of adherence. The results may be of interest to policy makers, benefit designers, self-insured employers, and provider organizations.
| S-EPMC5517674 | biostudies-literature
Project description:ObjectiveTo identify factors associated with the cost of treating high-cost Medicare beneficiaries.Data sourcesA national sample of 1.6 million elderly, Medicare beneficiaries linked to 2004-2005 Community Tracking Study Physician Survey respondents and local market data from secondary sources.Study designUsing 12 months of claims data from 2005 to 2006, the sample was divided into predicted high-cost (top quartile) and lower cost beneficiaries using a risk-adjustment model. For each group, total annual standardized costs of care were regressed on beneficiary, usual source of care physician, practice, and market characteristics.Principal findingsAmong high-cost beneficiaries, health was the predominant predictor of costs, with most physician and practice and many market factors (including provider supply) insignificant or weakly related to cost. Beneficiaries whose usual physician was a medical specialist or reported inadequate office visit time, medical specialist supply, provider for-profit status, care fragmentation, and Medicare fees were associated with higher costs.ConclusionsHealth reform policies currently envisioned to improve care and lower costs may have small effects on high-cost patients who consume most resources. Instead, developing interventions tailored to improve care and lowering cost for specific types of complex and costly patients may hold greater potential for "bending the cost curve."
| S-EPMC3165175 | biostudies-literature
Project description:BackgroundAlthough the Medicare Part D coverage gap phase-out should reduce cost-related nonadherence (CRN) among seniors with diabetes, preferential generic prescribing may have already decreased CRN, while smaller numbers of patients using more costly branded oral anti-diabetic (OAD) medications remain vulnerable to CRN.ObjectiveTo estimate the effects of cost sharing in the Part D standard (non-LIS) benefit on adherence to different OAD classes, comparing two classes dominated by inexpensive generic medications and two by more costly branded medications.Design and patientsRetrospective cohort study using dispensed prescription data for elderly non-LIS (N=81,047) and LIS (low-income subsidy) (N=150,359) beneficiaries using same class OAD(s) in 2008 and 2009. Logistic regression modeled non-LIS likelihood; LIS and non-LIS patients matched using propensity outcome (N=38,054). Logistic regression, controlling for demographic and health status characteristics, modeled effects of non-LIS coverage on 2009 OAD class adherence.Main measuresMain outcome measures were within-class OAD coverage year adherence, with patients considered adherent when days supplied to calendar days ratio at least 0.8.Key resultsNon-LIS patients had 0.52 and 0.57 times the odds of branded-only DPP-4 Inhibitor (N=1,812; 95 % CI: 0.43, 0.63; P<0.001) and Thiazolidinedione (TZD) (N=6,290; 95 % CI: 0.52, 0.63; P<0.001) adherence. Most patients (N=32,510; 82 %) used OADs in primarily generic classes, where we found no significant (Biguanides; N=21,377) or small differences (Sulfonylureas/Glinides [N=19,240; OR: 0.91; 95 % CI: 0.86, 0.97; P=0.002]) in adherence odds. Crude adherence rates were sub-optimal when CRN was not a factor (Non-LIS/LIS: Biguanides: 65 %/65 %; Sulfonylureas/Glinides: 66 %/68 %; LIS: DPP-4 Inhibitors: 66 %; TZDs: 67 %).ConclusionsGap elimination would not affect generic, but should reduce branded OAD CRN. Branded copayments may continue to lead to CRN. Policy initiatives and benefit changes targeting both cost deterrents for patients with more complex disease and non-cost generic OAD underuse are recommended.
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Project description:Recent economic and health policy changes may have affected the ability of chronically ill patients to afford their medications. We assessed changes in cost-related nonadherence to medication (CRN) before and after the implementation of Medicare Part D in 2006.We used data from the National Health Interview Survey, an annual, population-based survey of community-dwelling, noninstitutionalized US adults, to estimate CRN in 8,673 stroke survivors aged 45 years or older, representing 4.8 million survivors, for the years 1999 to 2010. The main outcome measure was CRN, defined as self-reported inability to afford prescribed medication within the past 12 months.During the period 1999 to 2010, 11.4% of stroke survivors, approximately 543,000 individuals, reported CRN. From 1999 to 2010, CRN more than doubled among stroke survivors aged 45 to 64 years (from 12.7 to 26.5%; ptrend = 0.01). CRN remained stable among those aged 65 years or older (from 3.8 to 7.0%; ptrend = 0.21). From 1999-2005 to 2006-2010, CRN among uninsured stroke survivors aged 45 to 64 years increased from 43.1 to 57.1% (p = 0.03). Among stroke survivors aged 65 years or older with Medicare coverage, CRN was higher among Medicare Part D participants than those without the drug benefit (7.9 vs 4.8%; p = 0.02). After adjustment for sociodemographic and clinical factors, CRN was similar among Medicare Part D enrollees and nonenrollees.From 1999 to 2010, CRN increased significantly among stroke survivors younger than 65 years, particularly among those without health insurance. There was no evidence that Medicare Part D decreased CRN among stroke survivors with Medicare.
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Project description:IntroductionHospitalization increases the risk of a subsequent diagnosis of dementia. We aimed to identify diagnoses or events during a hospitalization requiring critical care that are associated with a subsequent dementia diagnosis in the elderly.MethodsA cohort study of a random 5% sample of Medicare beneficiaries who received intensive care in 2005 and survived to hospital discharge, with three years of follow-up (through 2008) was conducted using Medicare claims files. We defined dementia using the International Classification of Diseases, 9th edition, clinical modification (ICD-9-CM) codes and excluded patients with any prior diagnosis of dementia or cognitive impairment in the year prior to admission. We used an extended Cox model to examine the association between diagnoses and events associated with the critical illness and a subsequent diagnosis of dementia, adjusting for known risk factors for dementia.ResultsOver the three years of follow-up, dementia was newly diagnosed in 4,519 (17.8%) of 25,368 patients who received intensive care and survived to hospital discharge. After accounting for known risk factors, having an infection (adjusted hazard ratio (AHR) = 1.25; 95% CI, 1.17 to 1.35), or a diagnosis of severe sepsis (AHR = 1.40; 95% CI, 1.28 to 1.53), acute neurologic dysfunction (AHR = 2.06; 95% CI, 1.72 to 2.46), and acute dialysis (AHR = 1.70; 95% CI, 1.30 to 2.23) were all independently associated with a subsequent diagnosis of dementia. No other measured ICU factors, such as need for mechanical ventilation, were independently associated.ConclusionsAmong ICU events, infection or severe sepsis, neurologic dysfunction, and acute dialysis were independently associated with a subsequent diagnosis of dementia. Patient prognostication, as well as future research into post-ICU cognitive decline, should focus on these higher-risk subgroups.
| S-EPMC3672622 | biostudies-literature
Project description:ObjectiveTo identify patient social risk factors associated with Continuity of Care (COC) index.Data sources/study settingMedicare Current Beneficiary Survey (MCBS), the Dartmouth Institute, and Area Resource File for 2006-2013.Study designWe use regression methods to assess the effect of patient social risk factors on COC after adjusting for medical complexity. In secondary analyses, we assess the effect of social risk factors on annual utilization of physicians and specialists for evaluation and management (E&M).Data collection/extraction methodsWe retrospectively identified 59 499 patient years for Medicare beneficiaries with one year of enrollment and three or more E&M visits.Principal findingsAfter adjustment for medical complexity, individual-level social risk factors such as lack of education, low income, and living alone are all associated with better patient COC (P < .05). Similarly, area-level social risk factors such as living in areas that are nonurban or high poverty, as well as in areas with low specialist or high primary care physician supply, are all associated with better patient COC (P < .05). We found the opposite pattern of associations between these same risk factors and annual patient utilization of physicians and specialists (P < .05).ConclusionsMedicare patients with multiple social risk factors have consistently better COC; these same social risk factors are associated with reduced patient-realized access to specialist physician care.
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Project description:Background: Incident cancer diagnosis may increase the risk of coronary artery disease (CAD)-related hospitalizations, especially in older individuals. Adherence to statins and/or angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs)/?-blockers reduces CAD-related hospitalizations. This study examined the relationship between medication adherence and CAD-related hospitalizations immediately following cancer diagnosis. Patients and Methods: A retrospective observational longitudinal study was conducted using SEER-Medicare data. Elderly Medicare fee-for-service beneficiaries with preexisting CAD and incident breast, colorectal, or prostate cancer (N=12,096) were observed for 12 months before and after cancer diagnosis. Hospitalizations measured every 120 days were categorized into CAD-related hospitalization, other hospitalization, and no hospitalization. Medication adherence was categorized into 5 mutually exclusive groups: adherent to both statins and ACEIs/ARBs/?-blockers (reference group), not adherent to both statins and ACEIs/ARBs/?-blockers, adherent to either statins or ACEIs/ARBs/?-blockers, use of one medication class and adherent to that class, and use of one medication class and not adherent to that class. The relationship between medication adherence and hospitalization was analyzed using repeated measures multinomial logistic regressions. Inverse probability treatment weights were used to control for observed group differences among medication adherence categories. Results: Adherence to both statins and ACEIs/ARBs/?-blockers was estimated at 31.2% during the 120-day period immediately following cancer diagnosis; 13.7% were not adherent to both medication classes during the same period, and 27.4% had CAD-related hospitalizations immediately after cancer diagnosis, which declined to 10.6% during the last 4 months of the postdiagnosis period. In the adjusted analyses, those not adherent to both statins and ACEIs/ARBs/?-blockers were more likely to have CAD-related hospitalization compared with those adherent to both medication classes (adjusted odds ratio, 1.82; 95% CI, 1.72-1.92; P<.0001). Conclusions: Given the complexity of interaction between CAD and cancer, it is important to routinely monitor medication adherence in general clinical practice and to provide linkages to support services that can increase medication adherence.
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