Objective: To compare rates of cost-related medication underuse and other problems due to medication costs among Department of Veterans Affairs (VA) patients with rates among patients with Medicaid, private health insurance, Medicare, and no insurance coverage.
Study Design: Nationwide survey.
Methods: A total of 4055 chronically ill patients completed an online questionnaire regarding cost-related adherence problems for medications used to treat 16 chronic illnesses. Respondents also reported whether they cut back on necessities due to medication costs, increased their debt burden to pay for prescriptions, and worried about how they would pay for their medications.
Results: Rates of cost-related medication underuse were lower among VA patients (12%) than among patients with Medicaid (25%; P =.0004), Medicare (22%; P =.001), or no insurance (35%; P < .0001). In multivariate analyses, patients with Medicare or no insurance coverage were more likely than VA patients to forego medication at least once per month due to cost (adjusted odds ratios of 3.4 and 3.9; both P ≤ .001). Patients with Medicare or no insurance coverage also were more likely than VA patients to forego basic needs to pay medication costs, borrow money to pay for their treatments, and worry frequently about how they would pay for their medication.
Conclusion: The VA's prescription benefits may prevent problems due to medication costs. Studies assessing the impact of VA prescription coverage on health outcomes and service use will be needed to evaluate the cost-effectiveness of VA drug benefit policies.
(Am J Manag Care. 2004;10(part 2):861-868)
Managed care plans and their patients are struggling
with the burden of skyrocketing prescription
drug costs. Patients with chronic illnesses
often have inadequate prescription coverage,1-3 and
many cut back on medication use due to cost pressures.2,4-10
Because medication underuse can lead to
increased morbidity, mortality, and preventable acute-care
use,10-12 managed care organizations are striving to
develop drug coverage programs that are financially
viable while ensuring that plan members can afford the
treatments they need.
Department of Veterans Affairs (VA) medical centers
offer more comprehensive medication coverage than
almost any other payer in the United States. Drugs on
the VA formulary are 100% covered for patients with
low incomes or service-connected disabilities, and other
VA patients pay a $7 copayment for a 30-day prescription.
VA patients have no cap on the total cost of their
covered drugs, and most patients who incur $840 or
more in medication costs during a given year have all
subsequent copayments waived. Between 1995 and
2001, the number of patients receiving VA outpatient
care increased from 2.8 million to 4.1 million, with
many of these new patients entering the system to
access prescription drug coverage.13-15 In the context of
the current debate over prescription drug costs, the
VA's drug coverage policy and its impact on patients'
use of prescribed medications provide an important
model for inquiry.
In a prior study,12 we compared rates of cost-related
medication underuse among diabetes patients in 3 VA
facilities to rates among patients with private insurance,
Medicare, Medicaid, and no health insurance treated in
a county and a university health system. We found that
VA patients were less likely than patients with any other
type of coverage to report medication underuse due to
cost. We also found that patients reporting cost-related
adherence problems had poorer glycemic control, more
symptoms, and worse physical and mental health functioning.
These findings suggest that the VA's comprehensive
drug benefits may contribute to the better
treatment outcomes among chronically ill VA patients
compared with Medicare patients.16,17 In our prior
study,12 however, all patients were drawn from 5 healthcare
systems, 4 or which were located in Northern
California. Thus, it remains unclear whether the findings
reflect nationwide patterns of adherence among VA
and non-VA patients with chronic illnesses.
The problems chronically ill patients face due to
medication costs extend beyond their treatment adherence.
For example, one recent study found that 21% of
Medicare beneficiaries spent less on basic needs to
cover the cost of their prescription drugs.4 However, we
know little about the extent to which the VA's prescription
drug coverage may buffer chronically ill patients
from these other consequences of out-of-pocket treatment
Accordingly, we surveyed a nationwide panel of
chronically ill older adults about their problems due to
out-of-pocket medication costs. We found that rates of
cost-related medication underuse were high among
individuals with a variety of chronic health problems.9
We also found that more than 22% of patients reported
cutting back on spending for basic needs in response to
medication cost pressures, and that 16% reported
increasing their debt burden to pay medication costs.18
In the current study, we compared rates of cost-related
medication underuse as well as other burdens from
medication cost pressures among survey respondents
using VA care with rates among patients with other
forms of health insurance coverage.
The study was based on surveys completed during
November and December 2002 by a nationwide panel of
adults living in the United States. Details about the
panel's sampling approach and recruitment process are
available elsewhere.19-21 In brief, panel members were
recruited using random digit dialing; the sampling frame
consisted of the entire US population with an assigned
telephone number. Potential panel members were
offered WebTV and free Internet access in exchange for
completing Web-based surveys several times per month.
At the time of this study, the panel included over 40 000
We used sociodemographic and health status information
about panel members to identify all 5644 individuals
aged 50 years and older who reported taking
prescription medication for diabetes, depression, heart
problems, hypertension, or high cholesterol. The
sociodemographic characteristics of these respondents
were similar to those of Americans aged 50 years and
older, as reported in 2000 Census data. For example,
the survey and Census populations were similar with
regard to the representation of African Americans (8%
vs 10%), women (50% vs 54%), married individuals (70%
vs 65%), and individuals with household incomes of
$20 000 or less (17% vs 23%). Institutional review
boards approved the study protocol.
Survey Description and Variable Creation
Respondents were asked about their use and cost-related
underuse of prescription medication for each of
16 chronic health problems: arthritis; asthma; chronic
back pain or sciatica; diabetes; high cholesterol; chronic
obstructive pulmonary disease ("chronic bronchitis,
emphysema, or chronic obstructive pulmonary disease");
depression; heartburn, acid reflux, or irritable
bowel syndrome; atherosclerosis ("blocked arteries in
the heart, angina, or chest pain from heart disease");
heart failure; high blood pressure or hypertension;
myocardial infarction ("heart attack"); migraine
headache; osteoporosis; stomach or duodenal ulcers;
and stroke. On a condition-by-condition basis, participants
were asked: "In the past 12 months, have you
ever taken less of this medication than prescribed by
your doctor because of the cost?" For the current analyses,
respondents were coded as having cost-related
adherence problems if they reported any medication
underuse due to cost for 1 or more of their medications
in the prior year.
Respondents reporting cost-related underuse were
asked how often they engaged in each of the following
behaviors because of the medication cost: taking fewer
pills or a smaller dose, not filling a prescription at all,
putting off or postponing getting a prescription filled,
using herbal medicine or vitamins when feeling sick
rather than taking their prescription medication, or taking
the medication less frequently than recommended
to "stretch out" the time before getting a refill.
Participants were coded as foregoing medication at least
monthly if they reported any of these behaviors "at least
once per month" due to the cost.
Respondents also were asked about 4 other types of
problems associated with out-of-pocket medication
costs: spending less on basic needs such as food or heat
to pay medication costs, borrowing money from family
or friends to pay medication costs, increasing credit
card debt to pay for medications, and worrying about
how to pay for medications at least once per month. See
the footnotes to Tables 2, 3, and 4 for the wording of
For the current study, respondents were grouped
into mutually exclusive categories using a hierarchy
based on their primary source of medical insurance.
Patients were assigned to the insurance category that
we expected would be associated with the most generous
form of prescription drug coverage. Specifically, we
identified the following patient groups: VA patients,
Medicaid patients who did not use the VA, privately
insured patients (without VA use or Medicaid),
Medicare patients with no other form of health insurance,
and uninsured patients. These categories identify
subgroups of patients of particular interest to policymakers
(eg, patients with Medicare coverage only) and
recognize that individuals often are unable to identify in
detail the provisions of their
prescription drug coverage.22,23
The sociodemographic variables
we examined as possible predictors
of problems due to out-of-pocket
included respondents' race, age,
sex, educational attainment,
and annual household income.
We also examined indices of
patients' medication cost pressures,
including their total number
of prescription medications,
total monthly out-of-pocket
medication costs, and number
of chronic health problems.