Tough economic choices force patients to reconsider chronic disease care

Hard economic choices mean that many patients with chronic diseases, such as diabetes, are considering alternatives that may be risky to their health — skipping medications, splitting pills, ignoring refills and postponing office visits.

Endocrine Today interviewed several health care providers about how they and their patients are coping with chronic disease management in the current economic environment.

“I have previously experienced downturns in the economy, but nothing like this,” John A. Seibel, MD, director of the New Mexico Endocrine Center in Albuquerque, N.M., said in an interview.

“This is especially serious for patients with diabetes because they tend to be on multiple medications, and many have an average monthly medication bill close to $500,” he said. “Some patients have told me that they will run out of their medications in the next month or so and will not be able to refill their prescriptions.”

A recent Harris Interactive/HealthDay poll found that 56% of adults aged 45 to 65 are “very–to–extremely” worried about having to pay more for their health care or health insurance. Survey results also revealed that 28% of participants had a medical problem but did not visit a doctor; 22% did not fill a prescription.

John A. Seibel, MD, said that patients “have told me that they will run out of their medications in the next month.” Photo by: Bryan’s Photography

With more than 600,000 U.S. adults losing their jobs each month, Seibel said he has at least two patients per day who tell him that they or their spouse have lost their job.

“There are so many layoffs and economic issues that health care takes a back seat,” Donna Rice, RN, CDE, president of the Diabetes Health and Wellness Institute, Baylor Health Care System, told Endocrine Today. “In fact, a patient just emailed me and asked if I could help them save their home.”

Cutting back on medications, visits

According to the American Diabetes Association, the estimated cost for diabetes was $174 billion in 2007, and the estimated medical cost was $116 billion. The ADA also estimated that the monthly cost to treat diabetes ranges from $350 to $900 for patients who do not have insurance, and emergency care and short-term hospitalization can cost $10,000 or more.

“Without insurance — or even with it — patients may need to cut back on some of their medications,” Seibel said. “For some, this will mean sacrificing good control of their illnesses.”

One method of “cutting back” has included switching to generic medications. Although the most prudent route may be to switch to as many generic medications as possible, this can sometimes mean less control of disease.

“Patients are more likely to bounce around by using generics with medications that have a narrow therapeutic range, such as thyroid replacement therapy. Some have switched from brand name statins that give better control to generics that require much larger doses to come close to good control. Some patients with diabetes have had to stop analogue insulin and switch to older insulin, again possibly sacrificing good control,” Seibel said.

Richard Dolinar

In some cases, patients have stopped taking medications altogether “just to get by”.

“Ironically, at times, it seems as though my patients are demanding a cheaper disease,” said Richard Dolinar, MD, an Endocrine Today Editorial Board member.

“One thing to keep at the forefront is that the actual cost of skimping on medications may not be evident right away, but down the road this is setting patients up for the complications of diabetes,” said Dolinar, senior fellow in health care policy at Heartland Institute in Chicago and clinical endocrinologist in private practice in Phoenix. “Patients get a false sense of economizing, but they will actually lose dollars down the road.”

Some patients take other extreme measures to deal with their health care needs. Seibel said a patient ended up visiting the emergency department because he ran out of insulin and could not pay for it. In May of this year, a man attempted to rob a convenience store in Fort Smith, Ark., because he needed the money for insulin; the store clerk gave the robber $40 from his own wallet, according to news reports.

“We are seeing more ‘no shows’ in the office and cancellations because they cannot afford the office co-pay,” Seibel said. “In talking to other physicians, they are all seeing the same things.”

Rice added, “Diabetes educators have noticed a decline in patient visits, especially in states where the economic decline is in crisis, such as Michigan. Although office visits with the physician may be decreased, patients can still keep up with their physician via email or phone.”

Donna Rice

One way to combat this problem is evaluate whether office visits can be scheduled less frequently; for example, one visit every four months instead of every three months, or one every six months instead of every four months.

UCLA cardiologists have also noticed the effect of the economy on patients with heart disease, as increased stress, poor eating and forgoing activities such as going to the gym when money is scarce can take a toll on the heart. They suggested not cutting back on health care because efforts to reduce costs may worsen a patient’s health “down the road.” Studies show that patients who stop their cardiovascular medications are at much higher risk for myocardial infarction, stroke, heart failure and reduced survival compared with patients who adhere to their medical regimen.

“We’ve seen an increase in patients complaining about heart palpitations, anxiety and stress over the past months,” Karol Watson, MD, associate professor of cardiology at the David Geffen School of Medicine at UCLA, said in a press release in January. “Much of heart disease can be prevented, that’s why it is so important to follow a healthy lifestyle and to control CV risk factors.”

A sedentary lifestyle and poor diet have been associated with an increased risk for chronic diseases such as diabetes, stroke or MI. According to a recent study published in the Journal of the American Medical Association, “Obesity-attributable costs account for 5% to 7% of annual health care expenditures — currently amounting to more than $100 billion per year.”

Counseling patients

Patients should continue regular contact with their health care provider and check into alternatives, Dolinar suggested.

“Some illnesses such as diabetes and hypertension can be helped to some extent by environmental factors,” Seibel said. “Patients need to become more active and start physical activity and nutritional programs to help control their illness; this could result in cutting down the amount of medications they use.”

Experts recommend continued regular exercise. For those who cannot afford a gym membership, inexpensive options include walking in the neighborhood or swimming at the local pool. The most current recommendations by the U.S. Department of Health and Human Services suggest 30 to 60 minutes of daily exercise.

Twila Brase

Twila Brase, RN, public health nurse and president of the Citizen’s Council on Healthcare, said uninsured patients with chronic diseases seem “more in tune with taking care of themselves, outside the doctor’s office as well as in the doctor’s office.”

“They pay cash, they negotiate for cheaper prices, they ask questions about how much everything will cost and then make the decision with their doctor as to exactly what they are willing to pay,” Brase said.

Rice said providers need to do “whatever it will take.” She suggested contact with diabetes educators via phone or email because it is free, joining support groups for guidance, going to free or “ability–to–pay clinics,” utilizing blood pressure screenings at local libraries and emailing blood glucose levels to providers in lieu of an office visit.

Pharmaceutical companies are now assisting individuals with programs that offer free or low-cost medications for a set period of time. PhRMA offers a number of programs through the Partnership for Prescription Assistance (pparx.org); AstraZeneca has the AZ&Me Prescription Savings Program (astrazeneca-us.com); and Eli Lilly has the Lilly Cares and Lilly Answers programs (lilly.com).

In May, Pfizer launched MAINTAIN (Medicines Assistance for Those who Are in Need) to help eligible unemployed Americans and their families who have lost their health insurance maintain access to their Pfizer medicines for free for up to one year (pfizer.com).

However, with all programs, patients must meet certain qualifications to participate. Some people may make too much money to qualify for help but do not have enough funds to afford the medications on their own.

“There are programs out there that the pharmaceutical industry runs that will be of some help to many, but they cannot help all,” Seibel said.

“We need to know what the resources are and how to direct people,” Rice said. “Right now, the population that is in the most trouble is aged younger than 65.”

Experts offer several recommendations for hard-pressed patients and providers, such as exploring all options for covering the cost of diabetes supplies and pumps. Other suggestions include:

• Consider generic and/or combination drugs for patients on more than one medication.
• Check with the local and state government for medication and diabetes supplies prescription assistance.
• Buy test strips and syringes in bulk to save money.
• Look for generic brand meters and supplies.
• Research ordering supplies though the mail — many insurance plans will charge a lower co-pay.
• Compare the cost of other insulin delivery systems, like insulin pens vs. vials.
• Participate in research trials as source of health care.

“Patients and physicians need to look for these resources and be savvy,” Rice said. “We need to be prepared for the patient who cannot pay, and I think everyone needs to do a certain amount of charity work.” – by Jennifer Southall

How can providers help hard-pressed patients?

For more information:

• Dietary Guidelines for Americans 2005. www.health.gov/dietaryguidelines/dga2005/document/html/chapter4.htm. Accessed Aug 5, 2009.
• Harris Interactive HealthDay Poll: www.harrisinteractive.com/news/pubs/harris_healthday_poll_2009_03_09.pdf. Accessed Aug 5, 2009.
• Ludwig DS. JAMA. 2009;301:533-535.