Navigating medication, food, transportation and mental health barriers to care
Many patients with diabetes experience significant barriers to receiving the care they need to control their disease. Health care providers are usually well versed in choosing appropriate regimens for patients with diabetes; however, they often struggle when dealing with social and economic barriers to care. The resources for these barriers are less straightforward and often harder to identify. Regardless of their insurance status, patients may be faced with barriers to accessing their medications. Additionally, patients with diabetes may also have difficulty accessing sources of food and transportation to appointments and/or struggle with mental health. All of these barriers to care can influence a patient’s ability to reach optimal diabetes care goals.
Access to medication
Recent data from the 2017-2018 National Health Interview Survey, a nationally representative household survey of the U.S. population, identified that 13.2% of adults with diabetes prescribed medication in the previous 12 months did not take the medication as prescribed in order to reduce prescription drug costs. Of this same population, 24.4% reported asking their health care provider for a lower-cost medication to help lower their prescription drug costs. Certain populations are more affected than others, which include those under the age of 65 years and the uninsured. However, a portion of all subpopulations, regardless of age and insurance status, reported not taking medication as prescribed and asking for lower-cost medication to reduce medication costs.1
Difficulty accessing medication is not limited to those without insurance. Individuals with insurance face many obstacles to obtaining medications they need for optimal blood glucose targets. Barriers to accessing medications include high co-pays for medications, needing to reach deductibles, falling in the Medicare coverage gap (“donut hole”), having a lapse in insurance coverage, not having insurance to cover prescriptions, or having to use more expensive brand-name medications. Patients who have unexpected out-of-pocket expenses that affect their monthly budget, such as an emergency department visit or a car repair, may also struggle to find the money needed to purchase needed medications. A general lack of cost transparency exists in health care, making it difficult for patients to know what their medication costs will be and plan around that.
For a health care provider, it is important to take time with each patient to identify any trouble with medication access. Patients may be hesitant to admit non-adherence or having trouble with affording medications. Taking the time to address cost using a non-judgmental approach will potentially help the patient be more comfortable sharing this barrier. Additionally, asking specific questions may help you better understand how the cost of medications affects your patient. Example questions to ask include:
- Where do you obtain your prescriptions?
- Do you have insurance that covers your prescriptions?
- How much is your co-pay for this medication (or these medications)?
- I recognize that medications can get expensive. Are you able to afford all of them each month?
Some patients may prioritize their medications despite the fact that costs may be high. This could, in turn, affect other parts of their life, such as the ability to afford food to maintain a healthy dietary pattern, transportation, and even basic needs such as utilities.
Patient assistance programs are sponsored by and available from most pharmaceutical manufacturers. The intent of these programs is to provide free or discounted medications to those who cannot afford them. Each company establishes rules and guidelines, which means there may be variability between programs on which medications are available, income qualifications, and paperwork requirements. All programs require paperwork to be submitted from both the patient and the prescribing health care provider. There are some helpful websites that compile databases of these programs to promote ease in identifying programs and their requirements. Examples include:2-4
- NeedyMeds: www.needymeds.org
- RxAssist Patient Assistance Program Center: www.rxassist.org
- Medicine Assistance Tool: www.medicineassistancetool.org
In some cases, pharmaceutical companies also provide co-pay cards to decrease the co-pay of a medication or provide a free initial prescription to try out the medication. These cards may be provided to health care offices or available online, where patients can sign up and print off a card to take to the pharmacy. Co-pay cards usually exclude people with government insurance (including plans associated with military and veterans as well as Medicare), and the fine print is important to read to look for the maximum amount the card will cover, the expiration date, and the number of times the patient is allowed to use the card.
Encouraging patients to assess insurance options available to them is also an important part of helping patients decrease the costs of their medications. Patients may be able to access their formularies to find a preferred medication with a lower co-pay or identify if a 90-day supply of the medication is available at a reduced co-pay. Patients with Medicare may benefit from an alternative Part D prescription insurance if an alternative plan provides better coverage for their medications. Medicare Part D plan enrollment, which usually occurs between October and December of each year, is the time to make changes.5 Additionally, for those with Medicare who may be enduring financial hardship, they may qualify for Low-Income Subsidy, also known as “Extra Help.” Low-Income Subsidy lowers the cost of Medicare prescription drug coverage by eliminating the deductible and reducing prescription co-pays.6 For patients who have no insurance, encourage them to look into options through the health insurance marketplace to determine if there is a good insurance option or if they qualify for Medicaid in their state.7
Access to food
Individuals who live in poverty have reduced access to healthy food.8 Many, even some above the federal poverty line ($16,910/year for a family of two),9 face food insecurity. Food insecurity is defined as “limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.”9 Helping patients have access to healthier foods on a consistent basis is necessary in managing diabetes.10 A provider can help by linking patients to resources on both a federal and community level.
Supplemental Nutrition Assistance Program (SNAP)
SNAP is commonly referred to as “food stamps.” Many people are eligible to receive them; however, they may not be aware of this. Eligibility is determined by each state based on income and number of residents in a home, but the federal guideline includes any person (or household) that is 130% or more below the federal poverty line.11 SNAP benefits are meant to help purchase healthy food for a patient and their family to alleviate financial hardship. To apply for SNAP, a patient can go to: https://www.benefits.gov/benefit/361
Food banks and alternatives
Many with food insecurity access local sources in addition to, or in substitute of, federal benefits. In this case, alternatives would include things such as soup kitchens, church resources and obtaining food independently (hunting, fishing, gardening, etc.).12 Food banks usually offer a range of food, including canned goods, seasonal fruit and vegetables, and meat, when available. Some of these organizations are open to the public (with certain documentation), but some require referral from a health care provider or social worker. Access local food banks at www.feedingamerica.org/find-your-local-foodbank.
Access to transportation
People living in poverty are the most vulnerable to geographical barriers in accessing health care. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use.13 The vast majority of states provide transportation for patients who have Medicaid.14 Medicaid transportation services can be accessed through your state social services agency. Transportation services for Medicare vary by state based on how state-specific businesses access the federal funding. More information on accessing transportation services for a patient can be obtained by contacting a transportation service (e.g., the American Red Cross Wheels Program) that is local to you or the patient’s particular insurance provider.
Access to mental health treatment
Regardless of insurance status, individuals living with diabetes are at an increased risk for depression, anxiety and eating disorder diagnoses, and only about one-third of patients with these coexisting conditions receive a diagnosis and treatment.15 Health care providers can help address this issue by assessment and referral during routine appointments. Not addressing mental health issues is often negative in two ways. A patient lacking access to appropriate mental health treatment is often a detriment because not only does their mental health suffer, but also their physical health often worsens as well.16 The Patient Health Questionnaire 9 (PHQ-9), the Generalized Anxiety Disorder 7 (GAD-7) and the Diabetes Distress Scale (DDS17) are all widely used in assessing symptoms of depression and anxiety.17-19
The PHQ-9 is an evidence-based tool that is shown to accurately diagnose Major Depressive Disorder (MDD) in over 90% of patients. It is free to the public and commonly integrated into primary care or specialized practices.17
The GAD-7 is an economical and efficient way to detect GAD as well as other anxiety disorders. This assessment can be used in helping a patient access mental health care.18
The DDS17 is a widely used scale that specifically assesses a patient’s level of diabetes distress. It is theory-driven and looks at several different components of diabetes management (medical appointments, diet and regimen).19
Maintaining awareness of patient barriers to diabetes care can be a vital part of helping them succeed with diabetes health goals. Understanding and connecting patients to the resources available can help empower your patients to best self-manage diabetes.
Access additional resources and practical information to enhance the care and treatment of your diabetes patients.
About our experts
Kristina Naseman, PharmD, MPH, MLDE, BCACP, CDCES, Pharmacist Program Coordinator, Diabetes Stewardship, Barnstable Brown Diabetes Center & Maternal-Fetal Medicine, University of Kentucky HealthCare, Lexington, KY