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Medication Cost Factors in Prescription Abandonment

By HealthLeaders Media Staff  
   November 23, 2010

Abandoned prescriptions constitute a small but significant component of nonadherence, according to a paper published in the Nov. 16 issue of the Annals of Internal Medicine.

Research by Harvard, Brigham and Women's Hospital, and CVS Caremark researchers found a direct correlation between the amount of a patient's out-of-pocket co-pay and the likelihood of prescription abandonment: Patients having a co-pay of $50 are almost four times more likely to abandon a prescription at a pharmacy than those paying $10. The study also found that e-prescriptions are 65% more likely to be left at a retail pharmacy by patients than are hand-written ones.

William H. Shrank, MD, of Brigham and Women's Hospital, and colleagues, identified prescriptions bottled at a national pharmacy chain and linked them to claims data from a national pharmacy benefits manager to determine how often prescribed medications were not picked up at the pharmacy. They looked at more than10.3 million prescriptions.

In what the researchers believe to be the first study to comprehensively evaluate abandoned prescriptions, they concluded 3.27% of pharmacy-bottled prescriptions went unfilled, and more than half the time the patient did not fill an alternate prescription for the same medication at any pharmacy.

Among the findings:

  • Cost is the strongest predictor of abandonment. The data shows a 1.4% prescription abandonment rate for patients with co-pays of $10 or less, a 3.4% rate for patients with co-pays between $30 and $40, and a 4.7% rate for patients with co-pays of $50.
  • Patients with first-fill prescriptions are three times more likely to abandon prescriptions than those obtaining refills.
  • Younger patients are more likely than older ones to abandon medications.
  • Opiates, anti-platelets, and statins were the least likely to be abandoned; insulin and proton pump inhibitors were more likely to be.

"This represents a relatively... small component of overall medication nonadherence" the paper states, but it notes that "every essential prescription abandoned could represent an important clinical concern" if the patient isn't appropriately medicated.

The researchers also note that physicians need to be more aware of their patients' co-pays and discuss the cost with them before the patient heads to the drug store. That exchange, they say, "may reduce abandonment rates." But they also point out that physicians are often unaware of cost issues.

Allison Rosen, a fellow at University of Michigan's Center for Value Based Insurance Design and associate professor at the University of Massachusetts Medical School, agrees with the researchers: Cost is often not at the forefront of the physician's mind; There are too many competing clinical demands, she tells HealthLeaders Media. "It's just a given," she says, that most physicians don't discuss costs. But she sees that changing?largely because cost issues are so prominent in the headlines.

The paper's authors suggest that use of EHRs may facilitate such discussions.

They also point out that benefit designs that reduce cost-sharing for the most effective medications (i.e., value-based insurance design) could reduce abandonment rates. Rosen, an advocated of VBID, concurs. The goal, she explains, is to make the most important drugs affordable?to remove barriers to high-value therapies. (The flip side, she notes, is to increase barriers to therapies of low value.)

The complexity of the medication can play a role in whether it is abandoned: "Our findings highlight the effects of increasing the complexity of a patient's medication regimen and the importance of simplifying therapy when possible," the researchers note.

It's not a lack of options; it's that patients often don't know all their options. There are, says Rosen, a plethora of "common sense" approaches to address this. For example, she says, "poly pills" can increase adherence and reduce costs by delivering multiple therapies in one dose.

An accompanying editorial praised the researchers for identifying problems and pointing the way to solutions. "Shrank and colleagues elegantly linked pharmacy and pharmacy benefit manager data to shed light on an important component of medication nonadherence, failure to collect the drug. Although this study suggests that prescription abandonment is a small component of nonadherence, it identifies several modifiable factors associated with abandonment and points the way toward solutions."

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