Background: Up to 45% of Americans do not fill prescriptions because of cost. Medication non-adherence annually leads to $100-$300B in excess morbidity and mortality. To better inform medication cost effects on a potentially vulnerable patient population, our primary aim was to measure annual patient out-of-pocket outpatient medication cost for patients without prescription drug insurance coverage after discharging from the hospital for new prescriptions. Secondary measures included medication primary adherence (filling prescription within 30 days of discharge date), 30-day readmission rates, and subgroup analysis.
Methods: We prospectively enrolled unique adult, non-pregnant, non-incarcerated patients discharging from an inpatient general medicine team to home; receiving a new electronic prescription for one or more chronic (anticipated to be taken ≥1 year) standing tablet-or-capsule-delivered medication(s) at time of discharge; and paying full-cash price out-of-pocket for outpatient medications (e.g., uninsured or Medicare A/B without Part D coverage). Patients received usual cares during their inpatient stay and after discharge. The primary outcome was determined through information request from dispensing pharmacy, the “National Averaged Drug Acquisition Cost” (NADAC) database, and/or a retail pharmacy cash price database (GoodRx). The secondary outcomes of medication primary adherence and 30-day readmission rate were determined through communication with dispending pharmacy and manual chart review, respectively.The study was approved by the Institutional Review Board.
Results: Of 145 enrolled patients, 72 were screen failures. The 73 accrued patients were prescribed 130 qualifying medications. We obtained 64 pharmacy responses. Regarding the primary outcome, the average annual cost from pharmacy-provided data (35/73 patients) was $522.77 (MIN-MAX [IQR]: $0-$5,819.93 [$378.63]. Of note, nearly all pharmacy responses only included pricing data if prescriptions were filled. Using NADAC (wholesale) data (72/73,) the average was $1,004.02 ((MIN-MAX [IQR]: $4.75-$25,711.39 [$136.59]). Using GoodRx for fill-pharmacy data (26/73), the average was $2,788.75 (MIN-MAX [IQR]: $40.51-$16,631.83 [$2,184.06]). Using GoodRx for a national retail pharmacy for comparison (70/73), the average was $3,242.33 (MIN-MAX [IQR]: $83.43-$43,145.03 [$2185.44].Primary adherence was 46.9-49.7% (not including partial fills-including partial fills); 30-day readmission rate was 27.4%.
Conclusions: For patients paying full price for outpatient medications, after general medicine hospitalization, new chronic medications prescribed at discharge carry a significant cost (likely averaging ~$2,000-$3,000 annually) which may lead to reduced primary medication adherence. This study population’s primary medication adherence is low at 47-50% as compared to >72% in a large outpatient study, especially considering one would expect post-discharge adherence to be higher than an outpatient setting. Finally, the 30-day readmission rate of 27.4% for this population is more that 60% higher than national and our institutional averages of approximately 17%, suggesting significant deleterious downstream effects for the patients and healthcare system. Thus, hospitalist attention to medication cost, adherence, and readmission risk in this patient population is of particular importance to improve patient care.