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Research

The effect of cost on adherence to prescription medications in Canada

Michael R. Law, Lucy Cheng, Irfan A. Dhalla, Deborah Heard and Steven G. Morgan
CMAJ February 21, 2012 184 (3) 297-302; DOI: https://doi.org/10.1503/cmaj.111270
Michael R. Law
Centre for Health Services and Policy Research (Law, Cheng, Heard, Morgan), School of Population and Public Health, University of British Columbia, Vancouver, BC; the Department of Medicine (Dhalla), University of Toronto, Toronto, Ont.; the Li Ka Shing Knowledge Institute (Dhalla), St. Michael’s Hospital, Toronto, Ont.; and the Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.
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  • For correspondence: mlaw@chspr.ubc.ca
Lucy Cheng
Centre for Health Services and Policy Research (Law, Cheng, Heard, Morgan), School of Population and Public Health, University of British Columbia, Vancouver, BC; the Department of Medicine (Dhalla), University of Toronto, Toronto, Ont.; the Li Ka Shing Knowledge Institute (Dhalla), St. Michael’s Hospital, Toronto, Ont.; and the Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.
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Irfan A. Dhalla
Centre for Health Services and Policy Research (Law, Cheng, Heard, Morgan), School of Population and Public Health, University of British Columbia, Vancouver, BC; the Department of Medicine (Dhalla), University of Toronto, Toronto, Ont.; the Li Ka Shing Knowledge Institute (Dhalla), St. Michael’s Hospital, Toronto, Ont.; and the Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.
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Deborah Heard
Centre for Health Services and Policy Research (Law, Cheng, Heard, Morgan), School of Population and Public Health, University of British Columbia, Vancouver, BC; the Department of Medicine (Dhalla), University of Toronto, Toronto, Ont.; the Li Ka Shing Knowledge Institute (Dhalla), St. Michael’s Hospital, Toronto, Ont.; and the Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.
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Steven G. Morgan
Centre for Health Services and Policy Research (Law, Cheng, Heard, Morgan), School of Population and Public Health, University of British Columbia, Vancouver, BC; the Department of Medicine (Dhalla), University of Toronto, Toronto, Ont.; the Li Ka Shing Knowledge Institute (Dhalla), St. Michael’s Hospital, Toronto, Ont.; and the Institute for Clinical Evaluative Sciences (Dhalla), Toronto, Ont.
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  • RE: Compliance (Blister/Bubble) packs – Be aware of the hidden cost
    Malvinder S. Parmar
    Posted on: 30 July 2019
  • Leadership on prescription drugs needed
    Edward Xie
    Posted on: 19 March 2012
  • Posted on: (30 July 2019)
    Page navigation anchor for RE: Compliance (Blister/Bubble) packs – Be aware of the hidden cost
    RE: Compliance (Blister/Bubble) packs – Be aware of the hidden cost
    • Malvinder S. Parmar, Consultant Physician, Northern Ontario School of Medicine

    I agree with Law et al(1) that cost of therapy is an important factor that may result in sub-optimal adherence to medical therapy. In addition, barriers to adherence are numerous including the treatment of asymptomatic conditions or risk factors, complex medical regimens, side effects, drug-drug interactions, poor understanding of the individual patient. To improve adherence to therapy, various modalities have been used in clinical practice including compliance packaging (also known as blister packs), that have their benefits(2) and limitations (Table). However, the major limitation being the increased cost of therapy, as the blister packs are often filled by the pharmacies at 2 to 4 week intervals (than every 90-days or every 3-months, when medications are prescribed in the containers), and each time the new blister pack is given to the patient, is considered as a refill and full dispensing fee is charged either to the patient or to the insurer. The dispensing cost associated with re-filling the blister packs is a major cost factor than the cost of the actual medication, especially for common conditions where the agents often are generic. For example, the cost of a single 90-day prescription of metformin is $21.48 ($10.99 for the cost of drug + $10.49 the dispensing fee), and if the same medication is filled monthly, the cost is over 2-times at $44.01 ($4.10 x3 = $12.54 for cost of the drug + $31.47 (3 times the dispensing fee of $10.49 each)), and if the same prescriptio...

    Show More

    I agree with Law et al(1) that cost of therapy is an important factor that may result in sub-optimal adherence to medical therapy. In addition, barriers to adherence are numerous including the treatment of asymptomatic conditions or risk factors, complex medical regimens, side effects, drug-drug interactions, poor understanding of the individual patient. To improve adherence to therapy, various modalities have been used in clinical practice including compliance packaging (also known as blister packs), that have their benefits(2) and limitations (Table). However, the major limitation being the increased cost of therapy, as the blister packs are often filled by the pharmacies at 2 to 4 week intervals (than every 90-days or every 3-months, when medications are prescribed in the containers), and each time the new blister pack is given to the patient, is considered as a refill and full dispensing fee is charged either to the patient or to the insurer. The dispensing cost associated with re-filling the blister packs is a major cost factor than the cost of the actual medication, especially for common conditions where the agents often are generic. For example, the cost of a single 90-day prescription of metformin is $21.48 ($10.99 for the cost of drug + $10.49 the dispensing fee), and if the same medication is filled monthly, the cost is over 2-times at $44.01 ($4.10 x3 = $12.54 for cost of the drug + $31.47 (3 times the dispensing fee of $10.49 each)), and if the same prescription is filled every 14 days, then the cost is 3.5 times higher at $75.72 ($12.78 for the cost of drug and $62.94 (6 times the dispensing fee of $10.49 each), with still short of 6-days supply. This cost of dispensing fee exponentiates as the number of therapeutic agents increase.

    Physicians should consider the not only the actual cost of the medication(s) but also the dispensing fees charged to the patient when writing prescriptions and patients who are stable on therapy should be given at least 3-month supply to curtail the dispensing costs, especially when patients are on multiple agents. The Pharmacies should supply the prescribed duration of therapy, whether the medications are dispensed in bottles or in compliance packages, and must follow The Ontario Drug Interchangeability and Dispending Fee Act that states, “The medications used in the compliance aid are to be dispensed for the entire prescribed quantity, unless otherwise indicated by the patient or prescriber(3).” The pharmacists should be transparent with the patients of the indirect increased cumulative cost of the prescription, when the duration of refills is shortened.

    Table: Advantages and disadvantages of compliance (blister or bubble) packing of medication(s)

    Pros

    • Improves adherence – improved outcomes

    • Improves integrity of medications by improving shelf life and barrier against tempering

    • May Prevent overdosing (accidental or intentional) – by weekly supplies

    Cons:

    • Higher Cost – 2 to 4 times prescription charges

    • Difficult to Stagger medications

    • Interaction with other agents – L-thyroxine and iron

    • If there are changes – need to go back to pharmacy

    • Time consuming

    • PRN or as required medications are not suitable for such devices

    • Storage temperature for different agents might be different

    • May not be ‘child resistant’

    Malvinder S. Parmar, MB, MS, FRCPC

    References:

    1. Law MR, Cheng L, Dhalla IA, Heard D, Morgan SG. The effect of cost on adherence to prescription medications in Canada. CMAJ. Feb 21 2012;184(3):297-302.
    2. Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. JAMA. Dec 6 2006;296(21):2563-2571.
    3. Drug Interchangeability and Dispensing Fee Act, R.S.O. 1990, c. P.23 Section 9.1. https://www.ontario.ca/laws/statute/90p23#BK9 (accessed 22 July 2019).

    Show Less
    Competing Interests: None declared.
  • Posted on: (19 March 2012)
    Page navigation anchor for Leadership on prescription drugs needed
    Leadership on prescription drugs needed
    • Edward Xie, Family - Emergency Medicine fellow
    The article by Michael Law et al. raises issues germane to both clinical practice and public policy. After hospitals, drugs comprise our second greatest national health expenditure.1 It is unsurprising that low income and chronically ill Canadians struggle to maintain medication adherence.

    The high cost of medications for people with chronic disease may also have effects beyond nonadherence. Patients have told me about sacrif...

    Show More
    The article by Michael Law et al. raises issues germane to both clinical practice and public policy. After hospitals, drugs comprise our second greatest national health expenditure.1 It is unsurprising that low income and chronically ill Canadians struggle to maintain medication adherence.

    The high cost of medications for people with chronic disease may also have effects beyond nonadherence. Patients have told me about sacrifices such as limiting dental care, child care, or even food to afford their prescriptions. The relative benefits of each prescription should be weighed against these concealed repercussions. Screening for cost-related nonadherence at the time of prescription may be a way to reduce this.

    Encouragingly, drug cost awareness is increasing amongst clinicians. Some hospitals I have worked at now cite antibiotic costs on microbiology reports. Printed resources such as Rx Files and the Medication Use Management Services books are available for office practice.2,3 Additionally, drug price guides can be added to electronic medical record systems.

    Of critical importance, as the authors allude to, public policy can and should also play a role in reigning in nonadherence and prescription drug expenditure. A vast gap exists in the Canada Health Act leaving drug coverage fragmented amongst the provinces and territories.4 Unifying this "patchwork" could be a cheaper and healthier option. After the example of other developed nations, it is time we seriously explore a national prescription drug strategy.5

    References

    1. Canadian Institute for Health Information. Drug expenditure in Canada, 1985 to 2010. Ottawa (ON): The Institute; 2010.p>

    2. Rx Files. Available: www.rxfiles.ca (accessed 2012 03 12).

    3. Medication Use Management Services. Available: http://mumshealth.com (accessed 2012 03 12).

    4. Demers V, Melo M, Jackevicius C et al. Comparison of provincial prescription drug plans and the impact on patients' annual drug expenditures. CMAJ February 12, 2008 vol. 178 no. 4 405-409

    5. Thomson S, Mossialos E. Primary Care and Prescription Drugs: Coverage, Cost-Sharing, and Financial Protection in Six European Countries. Commonwealth Fund 2010; 1384: 82.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
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Canadian Medical Association Journal: 184 (3)
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Vol. 184, Issue 3
21 Feb 2012
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The effect of cost on adherence to prescription medications in Canada
Michael R. Law, Lucy Cheng, Irfan A. Dhalla, Deborah Heard, Steven G. Morgan
CMAJ Feb 2012, 184 (3) 297-302; DOI: 10.1503/cmaj.111270

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The effect of cost on adherence to prescription medications in Canada
Michael R. Law, Lucy Cheng, Irfan A. Dhalla, Deborah Heard, Steven G. Morgan
CMAJ Feb 2012, 184 (3) 297-302; DOI: 10.1503/cmaj.111270
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