TABLE 3
Which medication categories were most affected when patients had a problem filling a prescription?
| Medication category | Frequency of occurrence |
|---|---|
| Cardiac/HTN/lipids | 23 |
| Neurologic/psychiatric | 23 |
| Metabolic/endocrine | 16 |
| Gastrointestinal | 15 |
| Pain | 13 |
| Respiratory | 11 |
| Other | 9 |
| Dermatologic | 7 |
| Total | 117* |
| HTN, hypertension. *Total exceeds 100 because some of the 100 patients had problems with medications in more than one category. | |
Discussion
Nearly one quarter of patients in our sample (23%) experienced problems caused by insurance constraints while they attempted to follow the treatment regimens prescribed by their physicians. Although the most commonly reported insurance-related problems (waiting for pharmacist authorization, making extra phone calls to the physician’s office) could be perceived as minor inconveniences, serious consequences were also common. Our study showed that patients who rely solely on Medicaid or Medicare bore the greatest burden of insurance-related obstacles when filling prescriptions, although others were also affected.
Consistent with prior research in Medicare and Medicaid populations, our study found that medication access restrictions can negatively affect patient adherence.13,16,17 Our study showed that 41% of patients who encountered a problem experienced a medically meaningful adverse outcome; 19% reported they received no medication for their condition. Similarly, a study of Medicare beneficiaries who had failed to fill or refill a prescription found that 20% cited lack of insurance coverage for the medication as a reason for not filling the prescription.17
In our study, 23% of patients reported missing doses of their medication due to insurance-related difficulties, and 8% reported a worsening of their medical condition. The increased costs associated with poor chronic care management are well documented.18 Less well described is the potential net savings produced when insurance formularies are adjusted to expand coverage and lower patient costs for prescription treatments for chronic conditions. In an analysis of cost data from the Pitney-Bowes Corporation, Mahoney12 revealed a significant net savings in health care costs and lost productivity when treatments for chronic conditions were moved to the lowest tier of the formulary, thereby making them available to health plan participants at the lowest cost.
We could not link patient reports of treatment disruptions empirically to medical outcomes or increased costs, due to the constraints of our research question and study design. However, it is reasonable to suggest that longer-term insurance costs for these patients could, in fact, negate any short-term cost savings generated from formulary restrictions. In particular, the 5% of our patient sample who reported using the ED as a consequence of an insurance-related disruption of their prescribed treatment likely added significant unnecessary cost to their treatment. This effect has been seen in other studies.19,20 In our study, cardiac/hypertension/lipid medications and medications for neurologic or psychiatric conditions were the most likely to be problematic. In these categories, competition of branded products may contribute to more frequent formulary changes. Furthermore, increases in morbidity and mortality associated with inadequate treatment of the conditions represented in these 2 categories of medications represent a significant burden to the US health system, including insurers, employers, and individuals.21-23
Although patients were less likely to report being upset with their physician than their insurance company or pharmacist, physicians bore a considerable burden for resolving a number of prevalent patient issues. Most of these problems required extra phone calls to the practice, additional medication authorization, or extra office visits. Physicians and their support staff may serve as buffers between patients and the insurance formulary rules, but at significant cost in their time and effort.
Electronic prescribing systems with real-time pharmacy benefit verification may provide additional efficiencies and help physicians and patients avoid some of the problems cited by our respondents. Providers with such systems receive immediate notification of formulary status, including tier and co-pay levels, which can aid in shared decision-making at the point of prescribing. Physicians without access to e-prescribing may want to use newer formulary search engines that can check formulary status of medications across multiple insurance plans. However, these electronic tools often fail to account for variations in formularies within the same insurance plan for different employers based on their benefit structure. Still, when a medication is not on formulary or a co-payment is required, the physician may be forced to play the role of apologist for the constraints imposed by the insurance formulary.
In cases where formularies restrict the patient’s potential access to a preferred treatment plan, the burden of prior authorizations continues to be borne by physicians. Coverage limitations lead to financial and medical consequences that must be managed in partnership with the patient. A system should be put in place by insurance companies that facilitates out-of-formulary authorizations to prevent lapses in patient care or deleterious changes in medical management.