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Health Tracking

TRENDS

Do Seniors Get The Medicines Prescribed For Them? Evidence From The 1996–1999 Medicare Current Beneficiary Survey

Abstract

 
Using the 1996–1999 Medicare Current Beneficiary Survey, we examine trends in nonacquisition of prescribed medicines among seniors. Each year less than 3 percent of seniors reported not getting the medicines that were prescribed for them, most often for economic reasons, but they also noted reasons relating to their preferences about using medicines. The presence or absence of drug coverage and chronic disease did not appreciably change this percentage, which suggests that a Medicare drug benefit may not greatly increase seniors’ acquisition of their prescribed medicines.

Previous studies. Only a few studies have examined behavior related to whether people have not gotten their prescribed medi cines and the relationship of cost and coverage to such behavior. Using a mailed survey of seniors in eight states, Dana Safran and colleagues found that 14 percent of respondents at least once decided not to fill a prescription because it was too expensive.¹ The rate of nonacquisition was considerably higher for people without drug coverage. Two other recent studies assessed whether respondents did not get needed medicines; one of them specifically targeted affordability.² Interestingly, in these studies the overall rates of nonacquisition were similar (12 or 13 percent), but the rate was lower (8 percent) among elderly respondents in the study that focused on affordability. A study of seniors age seventy-three and older who regularly use prescription medications reported that 4.7 percent noted taking less medication than was prescribed because of cost, potentially including not getting prescribed medicines.³ Another study found that 1.5 percent of seniors with disabilities did not use medicines as prescribed all the time, including not getting a medicine when first prescribed or not refilling a prescription.⁴ In the study of seniors with disabilities, the rate of not using medicines as prescribed decreased as age increased.

These inconsistent findings suggest that further study of this issue is warranted. Consequently, we examine this aspect of access using the Medicare Current Beneficiary Survey (MCBS). We focus on nonacquisition instances where people do not acquire medicines that were prescribed for them.

Data And Methods

Top Data And Methods Study Findings Discussion And Policy... NOTES

 
Since its inception, the MCBS has been used to highlight prescription drug use and cost, plus sources of coverage for prescription drugs, among Medicare beneficiaries.⁵ In 1996 a section on access to prescribed medicines was added to the Access to Care component.

This component is a nationally representative, cross-sectional survey of Medicare beneficiaries conducted in the fall of each year. The survey, conducted by the Centers for Medicare and Medicaid Services (CMS), began in 1991, but our analysis includes only four years of survey data, 1996–1999, because the MCBS did not include questions on access to prescribed medicines before 1996.

Only respondents who were interviewed in the community setting were asked about their access to prescribed medicines. We further limit our analysis to seniors in the continental United States, Alaska, and Hawaii who were enrolled in Medicare for the entire year (Exhibit 1). The resulting sample represents noninstitutionalized, "always-enrolled" elderly Medicare beneficiaries. Additional respondents were removed because of missing values.

Study Findings

Top Data And Methods Study Findings Discussion And Policy... NOTES

 
Trends in and reasons for nonacquisition. In each year during 1996–1999 less than 3 percent of respondents reported that they did not get the medicines that were prescribed for them. The percentage of nonacquisition varied by less than 0.8 percent across the years (Exhibit 2).⁶ The most common reason reported for nonacquisition concerns cost.

Some seniors reported not acquiring prescribed medicines for reasons related to health and risk preferences (for example, "didn’t need medicine" and "was afraid of medicine reactions"). The second most common reason reported was a dislike of taking medicines. These responses may imply the absence of a shared decision-making process whereby the physician’s decision to write a prescription is not in concordance with the patient’s motivations and actions to get the prescribed medicine. Overall, nonacquisition because of discordance is rare among seniors, less than 0.7 percent. Respondents also rarely reported not getting prescribed medicines because of other barriers, such as "no time to have prescription dispensed" or "no pharmacy convenient."

Trends in nonacquisition by coverage status. Between those with and without drug coverage, the percentage of seniors reporting nonacquisition of medicines differs little (Exhibit 3).⁷ Less than 3.5 percent of both groups reported that they did not acquire a prescribed medicine. This reveals that most seniors get prescription orders filled whether or not they have drug coverage. However, the findings do not necessarily suggest that seniors get the same medicines or renew their prescriptions with the same frequency.

View larger version (18K): [in this window] [in a new window]   EXHIBIT 3 Trends In Nonacquisition Of Prescription Medicines, By Drug Coverage, 1996–1999

Trends in nonacquisition by respondent characteristics. By stratifying the sample by respondent characteristics and year, we examine the robustness of the results. Across any singular characteristic and in any given year, less than 4.7 percent of seniors reported not acquiring a prescribed medicine (Exhibit 4). Although all percentages were low, the rate of nonacquisition decreases with age and, inconsistently, with increasing income. People with worse health status or medical conditions tend to report more nonacquisition, but this association may be misleading.

To correct the estimation, we would need to control for the number of prescription orders.⁹ Although the MCBS Cost and Use component includes data on acquisition of prescription medicines, it does not include the number of prescription orders. Future researchers may wish to track prescription orders prospectively and estimate the differential dispensing rates by respondents’ characteristics.

Some proponents of expanding Medicare to include drug coverage suggest that certain subpopulations are particularly at risk, such as uninsured, poor seniors with health problems. We examined the rate of nonacquisition among seniors without drug coverage (including Medicaid drug coverage) who earn less than $10,000 per year and have at least one chronic condition. This population at risk represents 6–8 percent of seniors over the study period, and of these seniors, less than 4.2 percent reported not getting their prescribed medicines (Exhibit 4). This suggests that even seniors at risk get the medicines that were prescribed for them, not unlike the overall elderly Medicare population.

Discussion And Policy Implications

Top Data And Methods Study Findings Discussion And Policy... NOTES

 
For 1996 through 1999 we repeatedly found that less than 3 percent of seniors reported not getting the medicines that were prescribed for them in the survey year. Our results reveal lower rates of nonacquisition than other recent studies do (Exhibit 5). A potentially important factor in the differing results is the wording of the survey questions.¹⁰

It is important to highlight that our results represent the rate of nonacquisition in four one-year time periods assessed with the same question. The rate of nonacquisition did not differ much across time, which lends support to the conclusion that the rate of nonacquisition by seniors is low (less than 3 percent). However, the rate could have increased since the years of our study (perhaps closer to the rates found in other studies). As Medicare reform progresses, future research could track the rate of nonacquisition using MCBS data to identify policy-induced changes in access to prescribed medicines.

Furthermore, we found that the percentage of respondents who reported nonacquisition does not differ between those with and without drug coverage, although the reasons may differ. These results reflect a general availability of prescribed medicines among seniors and suggest that few seniors are unable or unwilling to acquire prescribed medicines, raising questions about the role of expanding drug coverage among seniors.

Possible effects of drug benefit programs. Federal initiatives to incorporate a drug benefit into Medicare or state-level assistance programs for seniors most vulnerable to economic barriers will decrease the financial burden of prescription medicines for some patients, but their effect on the acquisition of medicines already prescribed is less clear. Our results suggest that economic barriers have little influence over the acquisition of prescribed medicines among seniors; most get the medicines prescribed for them. Thus, a relevant question is whether such programs will improve seniors’ quality of life by reducing the financial burden of prescription drugs. Will subsidizing vulnerable populations’ drug expenditures allow seniors to purchase goods and services they would have forgone because of the need for costly drug therapies?

Additional questions arise about how these programs might influence other aspects of access. Will reducing economic barriers to medicines result in increased physician visits, hence increased use of medicines? Will an increase in use be limited to those seniors most in need of drug therapy? Research has shown that drug coverage is correlated with use among seniors, especially among those with chronic conditions.¹² Will reducing economic barriers to medicines influence physicians’ prescribing patterns, resulting in therapies including newer, and possibly more effective, medicines? Research has shown that the presence of drug coverage is associated with the use of more brand-name and newer drug products.¹³ Evaluations of drug assistance programs could consider changes in access to health care services as quality indicators.

Need for a more patient-centered approach. Although the most common reasons for nonacquisition of prescribed medicines were related to economic barriers, some respondents attributed their nonacquisition to health and risk preferences. These results suggest that the expansion of shared decision making and a more patient-centered approach to prescribing could improve agreement between prescriber and patient initiatives and could increase both the acquisition and adherence aspects of access to medicines.

Do seniors get the medicines prescribed for them? The evidence from our analysis is that most seniors, more than 97 percent, do—a result that may not change appreciably with Medicare expansion. Nevertheless, this says little about the appropriateness of prescribing behavior or whether seniors follow their therapeutic regimens well. Furthermore, the evidence does not suggest that seniors’ burden and access to prescription drugs is optimal.

The expansion of Medicare to include a drug benefit likely would reduce the financial burden of prescription drugs, promote quality of care by lessening the role of cost in physicians’ prescribing behavior, and possibly reduce the use of informal mechanisms of distribution (such as drug samples, trips across international borders, and subsidies from charitable organizations and manufacturers).

Editor's Notes

 
Benjamin Craig is a doctoral candidate in the Department of Population Health Sciences, University of Wisconsin-Madison. David Kreling is the Hammel/Sanders Professor of Pharmacy Administration, and David Mott is an associate professor, at the university’s School of Pharmacy and the Sonderegger Research Center.

This study was supported in part by the Sonderegger Research Center and by a T32 institutional training grant, HS00083, from the Agency for Healthcare Research and Quality to the University of Wisconsin Program in Population Health.

NOTES

Top Data And Methods Study Findings Discussion And Policy... NOTES

 

1. D. Safran et al., "Prescription Drug Coverage and Seniors: How Well Are States Closing the Gap?" 31 July 2002, www.healthaffairs.org/WebExclusives/Safran_Web_Excl_073102 (13 February 2003).
2. National Public Radio/Kaiser Family Foundation/Kennedy School of Government, "National Survey on Health Care, Chartpack," June 2002, www.kff.org/content/2002/3238/NPR_Chart_Pack_FINAL2.pdf (14 February 2003); and P.J. Cunningham, "Affording Prescription Drugs: Not Just a Problem for the Elderly," Research Report no. 5, April 2002, www.hschange.org/CONTENT/430/430.pdf (14 February 2003).
3. M. Steinman et al., "Self-Restriction of Medications Due to Cost in Seniors without Prescription Drug Coverage," Journal of General Internal Medicine 16, no. 12 (2001): 793–799.[Medline]
4. J. Kennedy and C. Erb, "Prescription Noncompliance Due to Cost among Adults with Disabilities in the United States," American Journal of Public Health 92, no. 7 (2002): 1120–1124.[Abstract/Free Full Text]
5. See, for example, J.A. Poisal and L. Murray, "Growing Differences between Medicare Beneficiaries with and without Drug Coverage," Health Affairs (Mar/Apr 2001): 74–85; B. Stuart, D. Shea, and B. Briesacher, "Dynamics in Drug Coverage of Medicare Beneficiaries: Finders, Losers, Switchers," Health Affairs (Mar/Apr 2001): 86–99; and M.A. Laschober et al., "Trends in Medicare Supplemental Insurance and Prescription Drug Coverage, 1996–1999," 27 February 2002, www.healthaffairs.org/WebExclusives/Laschober_Web_Excl_022702.htm (14 February 2003).
6. From a policy perspective, the estimated values are not appreciably different across years. Therefore, we do not report tests of statistical significance. Furthermore, sampling weights included with the MCBS were employed in the calculation of all estimates.
7. We applied a hierarchical protocol to assign a point-in-time measure of drug coverage. In the first step, those entitled to Medicaid were set aside. Second, we removed those who reported having drug coverage through a Medicare or private health maintenance organization (HMO). Third, we removed those with drug coverage through employment or retirement. Those with other forms of private drug coverage were place in the Medigap category. The MCBS does not capture drug benefits from other public sources, such as Veterans Affairs or military retirees. To accommodate for this absence, those with non-Medicaid public supplemental coverage were placed in the other public category, if they had not been assigned in a previous step. The remaining respondents make up the "no drug coverage" group. Bruce Stuart and colleagues reported that nearly 17 percent of beneficiaries had a gap in their drug coverage in 1995, which suggests that respondents may have changed coverage over the recall period. Stuart et al., "Dynamics in Drug Coverage of Medicare Beneficiaries." The variability potentially dilutes the implication of a point-in-time measure of drug coverage.
8. For example, frequent fliers are more likely to experience delays in airports simply because they fly more. There is little evidence that airlines target delays toward frequent fliers, although it feels that way at times.
9. Analogously, one can imagine two studies, each asking whether respondents had difficulty getting an appointment to see a physician. One study asks participants to respond based on past experience, while the second asks respondents to try to make an appointment with their physician and respond accordingly. Respondents with less experience with physician services, such as the healthy, are less likely to report difficulty based on past experience. Thus, the first study, by construction, is likely to find a stronger positive correlation between health and access barriers compared to the second, in which experience is controlled.
10. Some questions have longer lengths of recall, include other aspects of access ("taking," "use," "needed," "decide"), and include the acquisition of family members’ medicines. With respect to these attributes, the question in the MCBS is less general, and the differences in questions may have led to the higher estimates found in the previous literature. On the other hand, some studies specified a particular barrier to access, including only nonacquisition because of economic factors. In this regard, the question in the MCBS is more general, because it allows for the presence of multiple reasons. The comparison between results is further challenged by differences in sample sizes, sample representation, data collection methods, and response rates.
11. Safran and colleagues examined data collected from eight states using a mailed survey with a 55 percent response rate, and we examine data collected from all states using in-person interviews with a 94 percent response rate. Safran et al., "Prescription Drug Coverage and Seniors."
12. See, for example, J. Blustein, "Drug Coverage and Drug Purchases by Medicare Beneficiaries with Hypertension," Health Affairs (Mar/Apr 2000): 219–230.
13. See D. Mott and R. Cline, "Exploring Generic Drug Use Behavior: The Role of Prescribers and Pharmacists in the Opportunity for Generic Drug Use and Generic Substitution," Medical Care 40, no. 8 (2002): 662–674[Medline]; D. Mott and E. Rothermich, "Age of Dispensed Drug Products: The Role of Insurance Type, Physician Characteristics, and Physician Practice Systems," Journal of Research in Pharmaceutical Economics 9, no. 3 (1998): 5–19; and D. Mott and D. Kreling, "The Association of Insurance Type with Costs of Prescribed Drugs," Inquiry 3, no. 1 (1998): 23–25.

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