It wasn’t so much the side effects — nausea and belly pain that had once kept me from enjoying my aunt’s home cooking. I didn’t fill my prescription for the malaria prophylactic Malarone before a family trip to India because the $50 co-pay seemed outlandishly expensive to a medical-student-in-debt. Years later, I find that my patients skip crucial medications to treat diabetes and depression because of the reality or even just the fear of insurmountable co-pays.
A 2012 survey of more than 1200 American adults by the Kaiser Family Foundation suggests that my patients and I aren’t alone. Twenty four percent of respondents reported that they or their family members had neglected to fill a prescription because of cost in the previous twelve months. Sixteen percent admitted to cutting pills in half or skipping doses to extend a medication.
Save for the opulent few, we all factor cost into our daily decisions and health care is no exception. This principle is the basis for not-so-new efforts by policymakers to give patients a larger stake in rising health care costs. If patients share a larger portion of their costs through mechanisms like coverage limits and higher deductibles, they might make more responsible use of these resources, the thinking goes.
And we have growing evidence that we respond to these pressures: There’s the classic 1970’s-80’s RAND health insurance experiment showing that when subjects paid a greater share of their health care costs, they reduced how much health care they used. A study published in the journal Health Affairs corroborated these results. Researchers compared a large company that had adopted consumer-directed health plans (or CDHPs, in which employees use savings accounts to pay for much of their health needs) with another that hadn’t. After four years, the employees who had switched to CDHPs had, on average, made 0.26 fewer doctor’s office visits and filled 0.85 fewer prescriptions each year than their counterparts.
So we self-ration, but that doesn’t mean we make the right decisions. Some discretionary non-use may be appropriate — say, saving Viagra for special occasions. But just as often, we don’t choose wisely. The RAND study linked increased cost-sharing to decreased use of both necessary and unnecessary health care, particularly among low income populations. Medical complications from patients not taking prescribed medications leads to $105 billion in avoidable costs each year, according to recent estimates from the IMS Institute for Healthcare Informatics (If I had come down with malaria on that trip to India, I’d be part of the statistic).
Cost-sharing isn’t an inherently bad idea, but it requires some work to be effective. Patients need to price-shop and to be honest with their doctors about what they are and aren’t taking, and why. Doctors need to be creative about prescribing medications that both patients and their pocketbooks can stomach (generic rather than name-brand statins, for example), to not make perfect the enemy of good enough.
Technology can facilitate these efforts: When I prescribe medications electronically, each option is coded with dollar signs and coded symbols — preferred, not covered, low or high cost — to guide me. Though cost is only a small part of the decision to take a medication, it’s one that both patients and doctors must acknowledge and address openly.
Ishani Ganguli is a journalist and an internal medicine-primary care resident who blogs at The Boston Globe’s Short White Coat, where this article originally appeared.
