Is self-rationing of medications a good or a bad thing?

In America, the conventional wisdom is that we don’t ration health care. But we do, and there’s no better example than patients rationing themselves when it comes to the medicines they take.

Recently, a young twenty-something I know had a nagging cough—seasonal allergies, her doctor said and prescribed a generic medicine for asthma and allergies. She did not fill the prescription—the $160 price tag was too steep. Although she had health insurance from her employer, she had declined drug coverage because it was expensive and being young and healthy, she figured she could swing the bill for an occasional antibiotic.

At my local pharmacy, I have observed other patients walking away empty-handed after they learn the price of their medicines. When one woman was told the price for a skin ointment that was more than $600, she left the package on the counter and walked away. When the pharmacist tells customers they must now pay hundreds of dollars in coinsurance for a refill because their benefits have changed, they walk away too.

People are shocked to learn at the counter that their insurance company (or their employer who actually chooses the coverage) has switched from a plan with modest copayments—a set amount for prescriptions—to coinsurance, a percentage of the bill that is almost always more costly to the patient. All this is a form of health care self-rationing, and although it has always gone on to some extent, it is now showing up in Americans’ consumption of prescription drugs.

Last year, spending on prescription drugs fell for the first time in 58 years, according to IMS Institute for Health care Informatics. Not only has total spending on prescriptions dropped, but per capita spending has gone down too, from $931 to $898. Perhaps those declines suggest that the American love affair with prescription medicines – at least expensive ones – is fading.

Even though people are using more lower-cost generic drugs, that doesn’t mean generics always fit the pocketbook. The twenty-something who needed the seasonal allergy medication found that even the generic drug her doctor prescribed did not fit hers.

Affordability is a big problem that goes hand-in-hand with higher cost-sharing and out-of-pocket costs that even people with insurance are being asked to pay. As deductibles rise and the more expensive coinsurance is substituted for the cheaper copayments, there will be more self-rationing.

There may be clinical reasons for self-rationing as well. We know that patient compliance with prescription regimens is also a big problem, but when so many drugs now come with severe side effects, it’s understandable why some people self-ration and don’t take their meds. The treatment may be worse than the disease.

The of doctor prescribing patterns by ProPublica, the online investigative news organization, makes a case for clinical self-rationing. ProPublica found that doctors and other health care professionals were prescribing “large quantities of drugs that are potentially harmful, disorienting or addictive.”

Using Medicare data, ProPublica reporters discovered, for example, a Miami psychiatrist who gave hundreds of dementia patients an antipsychotic drug even though it carried the government’s most serious “black box” warning that the drug increases the risk of death. The reporters also found that in 2010, health care professionals wrote more than 500,000 prescriptions for the muscle relaxant carisoprodol, also known as Soma, even though it was pulled from the European market in 2007. The drug is also on the list of medications seniors should avoid, as published by the American Geriatrics Society. ProPublica found too that Medicare is not doing such a hot job of monitoring questionable medications.

So ProPublica has provided consumers with a tool for checking up on their doctors and asking some sharp questions about why they are asked to take certain drugs. That should be standard operating procedure for an engaged patient.

And that leads to the question: Is self-rationing of medications a good or a bad thing?  If your doctor prescribes some drug that Europeans have banned from the market, or one that carries a black box warning (which I have had doctors tell me to ignore), then self-rationing might be a good step along with finding a new doctor.

On the other hand, the twenty-something’s cough continued to worsen. Finally, she broke down and paid the asking price for the drug. Relief was on the way within a couple of hours. In medicine, very little is black or white — even rationing.

Trudy Lieberman is a journalist and an adjunct associate professor of public health, Hunter College. She blogs regularly on the Prepared Patient Forum.

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  • HJ

    Someone who becomes educated on the safety and efficacy of a medication isn’t self-rationing…it’s more like self-treatment.

  • Guest

    “Although she had health insurance from her employer, she had declined
    drug coverage because it was expensive and being young and healthy, she
    figured she could swing the bill for an occasional antibiotic.”

    So she took a gamble. She got to keep X number of dollars in her pocket, just as the person who decides not to pay for flood insurance for their home does.

    But of course anyone who decides not to buy insurance can hardly complain when something they WOULD have been insured for, if they had PAID for it, happens, and they have to pay out of pocket.

    A lot of people decide they want their money to spend now, instead of having to pay boring old insurance policies. They made a choice, it’s not a good look for them to grumble about the consequences.

    • SBornfeld

      How do you know there is grumbling involved? Or that this patient goes to fancy restaurants? Or…can afford the medication or the insurance?
      I find among my patients (those that receive health insurance as an employment benefit) have any idea about the cost of medical insurance.
      As a health care professional who recently downgraded my family’s health insurance because it was getting to the point of being very difficult, I can attest that millions of people are faced with difficult choices every day.
      And many of my patients are forced to do without.

      • http://journaltowellness.com Kathleen (Kathie) Clohessy

        Thank you for saying what I was just about to say. I am a disabled woman who weaned herself off of a number of beneficial but very expensive drugs because the price, even for generics, was simply too high. I was not choosing between a cell phone and my medicine. I was choosing between medicine and FOOD! I have no car, no cable, and no disposable income. Those entitled idiots who think that people are rationing their drugs because they want to spend the money on a new smart phone or a big screen TV are the same ones who propagate the myth of welfare recipients living in the lap of luxury on the government’s dime. Neither illusion could be further from the truth.

  • Guest

    If people start deciding whether or not to follow their doctor’s advice, due to prescription costs, this country is headed in a dangerous direction.
    I bet you that young who passed on her drug plan has no problem whatsoever paying her $70-a-month cell-phone plan. Many Americans have very little financial discipline and do not value healthcare; how many people do you know drop their medical insurance because they can’t afford it, yet they pay for expensive car loans, have fancy TVs, and eat out often? I have health problems, so my insurance is my number-one financial priority next to my mortgage, but many Americans are in denial that they will one day (or at any moment in their lives) require very expensive medical care.
    At the same time, doctors need to be on top of their game at all times–prescribing only safe and necessary medications, tests, and procedures–and patients need to do what they are told, because the doctor is the health expert.
    We need a Medicare-for-all plan in this country, or we are doomed.

  • sparklingsoul

    If people start deciding whether or not to follow their doctor’s advice, due to prescription costs, this country is headed in a dangerous direction.

    I bet you that young woman who passed on her drug plan has no problem whatsoever paying her $70-a-month cell-phone plan. Many Americans have very little financial discipline and do not value healthcare; how many people do you know drop their medical insurance because they can’t afford it, yet they pay for expensive car loans, have fancy TVs, and eat out often? I have health problems, so my insurance is my number-one financial priority next to my mortgage, but many Americans are in denial that they will one day (or at any moment in their lives) require very expensive medical care.

    At the same time, doctors need to be on top of their game at all times–prescribing only safe and necessary medications, tests, and procedures–and patients need to do what they are told, because the doctor is the health expert.

    We need a Medicare-for-all plan in this country, or we are doomed.

  • http://journaltowellness.com Kathleen (Kathie) Clohessy

    I wish people really understood the depth of the ignorance of some of the physicians they believe are gods. Doctors make mistakes–lots of them–as at least part of the content of this article clearly shows.. They are also so busy that they believe they hype from the drug reps rather than reading and investigating the risks, benefits and alternatives themselves.

    On the other hahd, a patient who thinks that her doctor is giving her unsound advice or unnecessary medicine should not just ignore what the doctor says. She should question him and get a second opinion before deciding for herself what to do. After all, you go to your doctor because you ostensibly trust him or her..Blindly ignoring what he says is kind of shooting yourself in the foot.

  • http://www.dpsinfo.com LaurieMann

    Sometimes, doctors don’t prescribe medications in a reasonable way. I have allergies and asthma, but, for the last 5 years, they’ve been very mild. As a result, I haven’t taken anything like Albuterol or Claritin in years. This spring, my allergies roared back to life and I developed bronchitis. I asked for Albuterol (which they prescribed), but didn’t get much relief. I went in for a check, asked for Advair (which they prescribed and which helped quite a lot). They also prescribed Singulair and gave me a 90 day dose, which cost over $500 (luckily, only $40 as we have insurance). But, it was clear within a few days that I had every adverse reaction you could have to Singulair – headache, stomache, worse insomnia. Why didn’t they just give me a sample or a month’s dose? After a few days, I stopped taking Singulair and felt much better, but didn’t like that my insurance company paid $500 on a drug that didn’t work for me.

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