Just because it's low cost doesn't mean it's accessible.

Prescription medications are widely used among older adults in the United States,1 and play an important role in reducing the morbidity and mortality associated with many chronic diseases that are increasingly common among an aging population. Despite this, medications are still underused by many patients,2 and there are noteworthy disparities in medication use between racial minorities and their counterparts.3 During the past decade, several steps have been taken by policy-makers, payers and other stakeholders in an attempt to improve the affordability of prescription medications. One important step was the passage of the Medicare Part D program in January 2006, which marked the greatest change to Medicare since its inception. Part D has been associated with increased medication use and reduced out-of-pocket costs.4 Although its impact on overall quality of care is more difficult to discern, cost-related underuse persists in some patients, particularly racial minorities and those with multiple comorbid conditions.5 In addition, Part D’s price tag may seem large relative to the modest increase in medication use associated with its implementation—a discordance due to the fact that both wealthy and poor individuals generally had secure medication access even prior to its implementation.6 Another important step in improving the affordability of prescription drugs has been the advent of $4 generic programs (“low-cost generic programs”). These programs offer generics for many, but not all (e.g. simvastatin (Zocor) is not eligible) commonly used non-patented prescription medications for a fraction of the cost of their branded counterparts. For example, patients can get a prescription for a 30-day supply of lisinopril (Zestril) filled for $4, or a 90-day supply for $10. The popularity of these programs may be in part due to the increasing availability of many previously patented, “blockbuster” medications now available as generics. During the past five years, the overall fraction of medicines dispensed as generics has increased from 63 % in 2006 to nearly 80 % in 2011,7 a remarkable shift in the market that continues to be fueled by additional patent expirations, including the recent expiry of atorvastin (Lipitor) and clopidogrel (Plavix) patents. Although these changes in the marketplace are welcome news, one often overlooked irony is that many older adults encounter barriers in accessing prescription medications beyond their costs.3 These range from individual-level factors such as patients’ beliefs8 to the accessibility of pharmacies and pharmacy services, as studied by Zhang et al. in this issue of JGIM.9 . There are more than thirty-nine thousand community pharmacies scattered throughout the U.S. that offer a number of programs and services, including low-cost programs, which facilitate the provision of prescription medications to the community. Zhang et al. are among the first to evaluate the accessibility and utilization of these “low-cost generic programs” among older adults with Medicare Part D. The authors combined 2007 Medicare Parts A, B, and D with U.S. census 2000 data and information about pharmacy locations to characterize the use of these low-cost programs. The authors concluded that many Medicare patients were not using these programs to fill their generic prescriptions. Use was more common among Medicare patients living in poor neighborhoods and slightly less common among racial minorities and among those with a greater driving distance to a participating pharmacy. Zhang et al.’s report provides important insights, and as with many investigations, also raises many questions. One key implication from this study is that the geographic inaccessibility of pharmacies may be a barrier to the use of pharmacy-based initiatives, such as the low-cost generic programs. Although the authors’ use of driving distance was understandable given the data they had available, the absence of information about individuals’ travel time is noteworthy, given that this may be a more helpful measure in older adults.10 Travel time may also be particularly important in understanding the geographic accessibility of pharmacies for African Americans, since they are more likely to live in low-income urban neighborhoods, where transportation barriers may be particularly pronounced and are not captured in measures of driving distance alone. The time it takes to travel to a pharmacy may be longer for African Americans and may contribute to the marginal racial disparities observed in this study. The authors’ findings also beg further exploration of other mechanisms accounting for the low rates of utilization of these pharmacy programs. Little is known about how pharmacies and pharmacy services vary across different communities and as a function of community socioeconomic development and racial and ethnic diversity, although there is some evidence that there may be significantly fewer pharmacies, and pharmacy services (e.g. retail clinics) in low-income communities.11 Incorporation of area-level measures of socio-economic status (SES) into analyses such as the ones reported might provide additional insights into the basis for the utilization patterns observed. These measures reflect residential characteristics and better indicate the availability, and not affordability, of health care resources, including pharmacies, in the neighborhood. Such investigations might borrow from considerable investments made to examine the phenomenon of “food deserts” and how access to high quality and nutritious food may vary systematically across neighborhoods and communities, based on their socioeconomic development. A lot has changed in the health care sector, including pharmacy, since 2007, the year of data that was analyzed in this report.7 Alongside expanding insurance coverage, the number of pharmacies in the community are growing and are increasingly offering programs and interventions, aside from low-cost generics, to improve adherence.12 In addition, eight out of ten retail pharmacies have currently adopted programs similar to the $4 generic program first launched by Walmart in 2006, and this study only focused on two pharmacies (including Walmart) that account for a small share of the pharmacy market. Furthermore, publically-insured patients, including those with Medicare Part D coverage, are not eligible to participate in several of these more recent low-cost pharmacy programs, which may contribute to the surprisingly low uptake of these offerings.13 Indeed, even the capture of the use of low-cost generic programs for research purposes is fraught with challenges.14 It is particularly difficult to assess the role of these programs in improving access to prescription medicines among uninsured or cash-paying patients who are more likely to experience cost barriers, but are also more likely to be excluded from pharmacy claims data. In 2000, John Eisenberg and Elaine Power published a seminal manuscript challenging conventional wisdom about access to health care, emphasizing the multiple sequential steps necessary for the delivery of high quality truly accessible care.15 Zhang et al.’s report contributes to a growing literature examining medication access. The paper serves as an important reminder that just because a medication is low-cost doesn’t mean that it is accessible.