Many patients don't tell doctors they won't use prescribed medications

September 13, 2004

CHICAGO - About one-third of chronically ill adults who underuse medications because of the costs associated with buying the drugs, never tell their health care practitioners, according to an article in the September 13 issue of The Archives of Internal Medicine, one of the JAMA/Archives journals.

Patients concerned with out-of-pocket medication costs often limit their prescription drug use, according to background information in the article. Because chronically ill patients often take multiple medications, they are especially vulnerable to the strain from drug costs, the article states. The underuse of essential medications, including cholesterol-lowering medications, heart medications, asthma medications and antipsychotics, has been associated with increased emergency department visits, nursing home admissions, acute psychiatric hospitalizations, and a decrease in self-reported health status, according to the article.

John D. Piette, Ph.D., from the University of Michigan, Ann Arbor, and colleagues surveyed 660 chronically ill adults (average age, 62.6 years) nationwide who had reported underusing medication the year before due to cost. Of those surveyed, 16 percent were nonwhite, 64 percent had at most a high school education, and 30 percent had an annual household income of $20,000 or less.

Of those surveyed, two thirds never told a clinician (doctor or nurse) in advance that they intended to underuse their medication due to cost, and 35 percent of respondents never discussed the subject at all. Of respondents who did not tell a clinician, 66 percent reported that they had not been asked about their ability to pay for prescriptions. Seventy two percent of patients who talked with their clinicians about medication costs found the conversations to be helpful. However, 31 percent said their medications were never changed to a generic or less expensive replacement. Also, only 30 percent of patients were informed of programs that help pay drug costs, and fewer people were told where to purchase less expensive medication (28 percent).

"This study suggests that most patients who fail to alert clinicians about their medication cost problems are not asked about their ability to pay for their medication, and many perceive that clinicians are unwilling or unable to help them with this problem," the authors write.

The researchers conclude: "As drug costs continue to escalate and the number of adults with chronic illnesses grows, it will be increasingly important for health care providers to take an active role in discussing patients' medication cost problems and appropriate strategies for addressing them."

(Arch Intern Med. 2004;164:1749-1755. Available post-embargo at Editor's Note: This study was supported by grants from the Department of Veterans Affairs, Washington, DC, and the Agency for Healthcare Research and Quality, Rockville, Md.

Editorial: The Status of Doctor-Patient Communication About Health Care Costs

In an accompanying editorial, Alex D. Federman, M.D., M.P.H., of Mount Sinai School of Medicine, New York, states that "when doctors don't ask and patients don't tell, opportunities to help are missed and patients remain at risk for underusing medications and services."

"The combination of greater cost sharing and higher prices for medical care will increasingly drive patients to forgo medications and other services," Dr. Federman writes. "As the burdens of health care costs increase, physicians have a greater responsibility to direct patients to sources of assistance with health care costs when help is needed, and to select affordable therapies whenever possible."

"Because cost remains a significant barrier to care for many adults, such as the uninsured and the low-income elderly population, major policy initiatives are needed to improve access to care for these vulnerable populations. Meanwhile, physicians should work to facilitate patients' access to care using available resources. At a minimum, physicians can ask patients about problems they might have paying for health care," writes Dr. Federman.

He concludes: "Ultimately, it is the responsibility of the physician to create an atmosphere in which patients can freely discuss matters that affect their health and health care, no matter what the cause."

(Arch Intern Med. 2004;164:1723-1724. Available post-embargo at

For more information, contact JAMA/Archives Media Relations at 312-464/JAMA (5262) or e-mail

To contact John D. Piette, Ph.D., call Kara Gavin at 734-764-2220.

To contact editorialist Alex D. Federman, M.D., M.P.H., call Debra Kaplan at 212-659-9045.

The JAMA Network Journals

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