Marion, a 74-year-old retired science teacher, is articulate and immaculately dressed at each visit. Despite being well-informed about managing her diabetes and hypertension, she never seems to have both under control at the same time. She is prescribed three medications to control her diabetes, two for hypertension, one for osteoporosis, and eye drops for glaucoma. Her physician considers her to be “noncompliant”; however, you suspect that something else may be to blame.

Until recently Ralph was a “model patient.” His visits were timely, his lab values within normal ranges, and his depression controlled by medication. Everything seemed to change when he retired early after a back injury. He stopped taking his medicines, missed appointments, and refused to have blood drawn for lab work. To top it off, his check for the last office visit was returned for insufficient funds.

Might these two patients share a problem — the inability to afford their medications? Would you be comfortable asking financially sensitive questions to identify barriers to their health care? Could you help them get assistance? If not, you need to learn how you can step up to the plate.

Money troubles

Lack of finances is a barrier to prescription medication adherence more often than you’d think. A recent survey revealed that about 25% of adults just above the poverty level were unable to afford at least one prescription. It’s no surprise that 34% of patients in this study were uninsured. However, 27% of the study patients who had Medicaid or other state funding could not fill prescriptions. A more shocking finding was that 10.2% of those surveyed with employee-sponsored insurance coverage still were unable to fill their prescriptions.¹

People with disabilities also are severely affected. In one national survey, 1.3 million adults with disabilities did not take their medications as prescribed because of financial constraints. Sadly, half of those who were unable to afford their medicine also reported adverse effects as a result <www.medicare.gov/pdp-basic-information.asp>.²

Having a preferred provider organization plan or Medicare doesn’t automatically translate into the ability to afford medications. The new Medicare Part D drug program represents the first federally funded assistance to Medicare participants covering the cost of prescription drugs, but it may represent a financial hardship for many patients because of monthly premiums and out-of-pocket expenses that can amount to as much as $6,000 annually before a catastrophic coverage level provides relief. It is estimated that one in four Part D participants will spend more for their drugs under the plan.³

Previously, Medicare participants purchased supplemental (Medigap) policies to help offset the cost of uncovered medication expenses. Some Medicare recipients who didn’t sign up for a Medigap policy during an open enrollment period, around their 65th birthday, risked rejection later based on their health and were left without prescription help. Those who opt for traditional Medicare coverage with a supplemental policy that does not include prescription drug coverage, will be penilized for every month they delay enrolling in a Medicare Part D program because the monthly Part D premiums they will pay when they do join will rise.⁴

The Part D plans are confusing at best,to understand, even for the most educated individual, and the government has essentially removed the safety net of free prescriptions from drug manufacturers from those eligible for the Part D plan. Most manufacturers will no longer provide free medications to those eligible for Part D, as the government has viewed this practice as an effort by the drug companies to keep individuals using their product rather than switching to a generic or a competitors’ drug.⁴

In one study of 10,220 PPO participants and 14,635 Medicare participants, all 65 or older, patients reported skipping or not filling their prescriptions at all even if samples were given initially. Some who filled their prescriptions were unable to continue to take their medications as prescribed. In this study, at least 14% of the patients with Medicare and 7% of PPO participants reported taking less medication than prescribed to save money.⁵

A troubling finding is that more than 60% of the patients who need medications the most, such as those with two or more chronic conditions, are least likely to be able to afford them.¹ Research reveals worse outcomes for patients with chronic conditions, such as COPD and diabetes, whose lower income levels contribute to their inability to afford prescription medications.^6,7

To fill or not to fill?

Health care providers must not jump to the conclusion that patients who don’t fill prescriptions are nonadherent. It’s important to understand the financial constraints that may make prescription drugs unaffordable. Ever-rising out-of-pocket responsibilities for medication expenses often force patients to decide between medicine and food.

Unfortunately, drugs often are prescribed without consideration of patients’ ability to pay. Even when a conscientious prescribing professional inquires about financial status, many patients are embarrassed to disclose financial concerns.⁸

And here’s another rub: Drug company marketing to prescribing professionals has been a factor in the use of more expensive, newer medications. Direct-to-consumer marketing — via print, television, and radio media campaigns — also has created greater demand for the “newest and best” (and often most expensive) drugs to be prescribed. Some patients may be unwilling to give less-expensive prescription or over-the-counter medications a chance because they have been influenced by advertising.⁹

Financial triage

It is important to gain an overall perspective of how prescription medication expenses affect patients’ budgets. Nurses need to develop quick screening strategies to gather sensitive financial information to use in directing patients to sources of assistance. This process of gathering information on the ability to afford medications is called financial triage. It is not complicated, and often patients can qualify for reduced-cost or even free medications by completing a few simple forms.⁸

Patients with whom you have an established relationship may be alarmed when the topic of finances is first brought up. While some may view your new line of questioning as caring, others may see you as intrusive. Some may be concerned about being labeled “noncompliant” or worse, suspected of being “destitute.”⁸ To make the process of financial triage smoother, consider the following:

Politeness: Convey a sense of respect and concern. Communicate at eye level and in an unhurried fashion. Allow patients time to share their circumstances that contribute to their inability to afford medications. Your caring attitude will enhance the willingness of patients to open up.

Privacy: Remember that patients may be reluctant to discuss finances. Openly acknowledge this concern and assure patients that information will be kept confidential. Choose a quiet area for questioning and completing paperwork.

Persistence: Screen everybody frequently; patients’ circumstances may change. Patients once able to afford their medicine may have lost a job or insurance coverage. When you develop a screening pattern, it becomes easier to communicate important information to the prescribing professional. If you can elicit information about patients’ ability to afford medications, you will be making a great contribution to the overall plan of care.

Precautions: Screen and assist patients as much as possible, but be wary about inaccurate or incomplete information that might be given to obtain assistance. Underreporting income or providing falsified documentation may result in criminal prosecution.

Directness: Asking about money can be difficult. Patients who will readily share information about sexual practices, drug abuse, and mental health issues may be less open about their finances. They also may be particularly reluctant to reveal unreported income for fear of a reduction in Social Security or public assistance. Fortunately, you don’t need to “know all” to direct them to assistance.⁸

So what’s the quickest and most effective method of “triaging” your patient’s ability to afford medications? The answer is direct questioning. Looks can be deceiving; not all patients who can’t pay for medicine will appear impoverished. In fact, many will appear quite the opposite. Many patients (especially retirees) “dress up” to see their health care providers. Maintaining dignity is very important.⁸

On the flip side, don’t assume that insured patients can afford medications any more than the uninsured. Copayments have skyrocketed, and medications that are not covered on plan formularies (selected medication lists) can result in patients paying full price. But here’s a tip: Formularies often have several “tiers,” with medicines that are less costly, and often older, on the lower tiers. Even if a medication is covered on a formulary, patients may exceed monthly or quarterly “caps” and have to pay out-of-pocket for anything above their limited amount. Remember that prescription coverage varies by plan.⁸

Upon questioning, Marion reveals that she cannot afford all of her medications each month. She “rotates” which four of her seven prescribed medications she will fill each month.

Ralph is reluctant to discuss his finances but discloses that his injury and early retirement also signaled the end of his employer-sponsored health care plan. He has Medicare and a Medigap policy but can’t afford the yearly deductible and copayments for his medications. He has scarcely enough money to pay his household expenses and is using a credit card to purchase food. What can you do next?

Both Marion and Ralph may qualify for pharmaceutical assistance. That assistance can take the form of a discount or “flat fee” card to use at a store pharmacy or medications being directly mailed to patients or their health care provider.

Help for the asking

First, assess whether patients may qualify for federal and state-funded health care assistance, such as Medicare or Medicaid, and direct them appropriately. Patients with Medicare should be directed to the Medicare website, www.medicare.gov, or information line, (800) 633-4227, to learn about the Part D drug program.

For those who are not eligible for the Part D drug program, many drug companies offer assistance programs that can offset or eliminate the out-of-pocket expenses for medicine. Maintaining an “assistance list” can be helpful. See the online version of this CE for a table describing pharmaceutical companies’ assistance programs.

Cautiously capitalizing on pharmacy competition also may help some patients. Often, coupons for gift cards and discounts are advertised in the newspaper and usually require the patient to transfer a prescription or bring in a new prescription to be filled. While this may be appropriate for patients taking established medications such as insulin, filling newer prescriptions at different pharmacies may raise the risk of drug interactions or duplication, especially when patients are taking numerous drugs.

For diabetic patients, glucose-testing supplies are expensive. For many, this can be an entirely out-of-pocket expense. Patients with Medicare can receive supplies, but they now are expected to cover a yearly copayment of $100. Some private insurance companies may cover the expense of testing supplies only if the patient is taking insulin. Lacking adequate funds for supplies, patients may alter their testing schedule, testing less often to conserve supplies. When they test less often and fear hypoglycemia, patients may overcompensate and experience less-strict blood sugar control. While there are many testing systems, patients often will overlook a less expensive store-brand system because their provider has recommended a brand-name one. Switching to a store-brand system can be economical for many patients.

Savings-smart choices

Patients may be unaware of money-saving options built into their insurance plan, such as mail-order services for three-month medication supplies at substantial savings. This option may not always be appropriate, especially when the medicine being prescribed has the potential for addiction or poses an overdose risk. This service is typically available only when a dosage has been stabilized and a patient has had no adverse reactions for a period of time.⁸

Patients should be encouraged to become consumer savvy about medication selection. Often, an older, less expensive medication works just as well as a higher-priced medication that the patient can’t afford. Encourage patients to inquire about less expensive alternatives, which may include OTC drugs. Medication choices are greatly affected by insurance coverage. After all, providers have revealed that their prescribing habits are heavily influenced by prescription coverage constraints.¹⁰

Words of caution

Drug prices in Canada are approximately 33% lower and in other foreign countries between 23% and 28% lower than in the United States.¹¹ Patients may be “crossing the border” for their medicine either by traveling to Mexico or Canada or by using mail-order or Internet pharmacies, but the financial incentive is tempered with safety concerns over quality,⁸ and direct contact with a pharmacist and tracking of medication information are unavailable.

To help patients, some prescribing professionals may order a quantity or strength that is different from what the patient is actually taking. Consider a patient taking 40 mg of atorvastatin (Lipitor). The 40 mg and 80 mg tablets cost the same or nearly the same. If the patient must pay cash for the prescription, a money-saving option may be to prescribe the 80 mg tablets to be taken as a half dose daily, stretching 30 pills over 60 days. This can be an option unless the patient has difficulty seeing or scoring pills. Before going this route, remember that there is potential for confusion. Patients must be clearly instructed and their pill bottles carefully examined for proper labeling. Encouraging patients to request large-print labels when their prescriptions are filled also may be helpful.

While samples may help many patients, they often entice prescribers to start patients on the more expensive drugs as first-line interventions. Samples are meant for short-term trials, not long-term assistance. Patients should not be maintained on samples, but should be directed to assistance programs.

Sharing the responsibility

If you doubt the difference that pharmaceutical assistance programs can make for patients, consider the findings from one study of uninsured cardiac patients. After assistance was received, adherence increased from 48% to 72%, and patients were one-third less likely to be hospitalized. Patients with multiple diagnoses fared even better — their blood pressure readings and low-density lipoprotein cholesterol levels improved, and patients taking warfarin (Coumadin) had improved international normalized ratio readings.¹²

Nurses are responsible for a tremendous amount of the assessment and care planning for patients. Why not try to enhance medication adherence by including a “financial triage” as a routine part of your history taking and assessment process?

Ralph and Marion were both accepted for assistance. While there was an initial investment of time and effort, the payoff was a reduction in risk factors for both patients. Ralph is functioning better after resuming his antidepressant. Marion has better blood glucose control and has met her blood pressure goal at the same time.

Nurses who use financial triage have an overwhelming sense of satisfaction. Isn’t it time you stepped up to the plate?