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Low Levels of Awareness of Pharmaceutical Cost-Assistance Programs Among Inner-City Seniors
To the Editor: Although Medicare Part D has improved access to prescription medications, drug costs remain a problem for many older adults.1 The Medicare low-income subsidy program (Extra Help) and state-sponsored pharmaceutical assistance programs can help seniors mitigate this problem by providing cost-sharing or Part D premium assistance, yet they are underenrolled by as much as 50%,2-3 possibly due to lack of awareness. We assessed a diverse sample of inner-city seniors for rates of awareness of New York State's Elderly Pharmaceutical Insurance Coverage (EPIC), established in 1987, and Extra Help, established in 2006.
Methods
We recruited independently living adults aged 60 years or older by convenience sampling from 20 senior centers and residential complexes in New York, New York, between June and September 2007. Sites were selected from zip code areas with median annual household incomes below $50 000. Men were oversampled and interviews were conducted in English and Spanish. Race and ethnicity were determined by participants' responses to multiple-choice questions and were included because race and Hispanic ethnicity are associated with participation in insurance assistance programs.4 Unadjusted associations of awareness of EPIC and Extra Help with socioeconomic and health-related variables were determined using  2 test and Wilcoxon rank-sum test. Testing was 2-sided, and significance level was set at P < .05. Analyses were conducted with SAS 9.1 (SAS Institute Inc, Cary, North Carolina). Written informed consent was obtained from all participants and the study was approved by the Mount Sinai School of Medicine institutional review board.
Results
We interviewed 451 adults (Table). The mean (SD) age was 73.8 (8.6) years and the sample was balanced among black, white, and Latino individuals. Income was 200% of poverty level ($1350/month) or lower in 184 participants (42%); 153 (34%) had 4 or more chronic illnesses. Avoiding medication use because of cost was reported by 81 individuals (18%). Based on age, income, and assets criteria, an estimated 323 (72%) were eligible for EPIC and 211 (47%) were eligible for Extra Help.
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Table. Characteristics of Study Participants by Awareness of Assistance Programsa
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Overall, 302 individuals (67%; 95% confidence interval [CI], 62%-71%) were aware of EPIC, although only 91 (20%; 95% CI, 17%-24%) were aware of Extra Help (Table). Similar rates of program awareness were observed among those who qualified for EPIC (224; 69%; 95% CI, 64%-74%) or Extra Help (48;23%; 95% CI, 17%-28%). Among those with cost-related medication avoidance, there was awareness of EPIC in 55 (68%; 95% CI, 57%-79%) and of Extra Help in 19 (23%; 95% CI, 15%-34%).
Awareness of EPIC was less likely among nonwhite study participants as well as among those with lower education levels (Table). For Extra Help, program awareness was not significantly associated with socioeconomic status, health status, or health care use, including insurance type, general health, and medication spending.
Comment
In this study population, many low-income, vulnerable seniors were not aware of these state- and federal-supported pharmacy assistance programs. Furthermore, those who might benefit from the programs, such as individuals with cost-related medication avoidance, were not more likely to be aware of them than others. These observations may partly explain underuse of these safety net programs.
The state EPIC program has been in existence much longer than the federal Extra Help program, which may explain its wider recognition. However, there were multiple differences between those who were aware and unaware of EPIC, especially for variables representing vulnerability, whereas no such differences were observed for Extra Help.
The study generalizability is limited by its administration in a single metropolitan area. Bias might have been introduced through convenience sampling, although our program eligibility estimates are similar to those obtained from population-based estimates.5-6 There were no data on actual program enrollment. Nevertheless, these results suggest that seniors may benefit from greater efforts to increase awareness of state and federal pharmaceutical assistance programs and thereby expand their access to medications.
Author Contributions: Dr Federman had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Federman, Safran, Siu, Halm.
Acquisition of the data: Federman.
Analysis and interpretation of the data: Federman, Keyhani, Siu, Halm.
Drafting of the manuscript: Federman.
Critical revision of the manuscript for important intellectual content: Federman, Safran, Keyhani, Siu, Halm.
Statistical analysis: Federman, Keyhani, Halm.
Obtained funding: Federman.
Administrative, technical, or material support: Federman, Safran, Halm.
Study supervision: Safran, Siu, Halm.
Financial Disclosures: None reported.
Funding/Support: This study was supported by a Paul B. Beeson Career Development Award in Aging from the National Institute on Aging (Dr Federman, 1K23AG028955-01). Dr Federman receives additional support from the Robert Wood Johnson Generalist Physician Faculty Scholars Program. Dr Siu is supported by a Mid-career Investigator Award in Patient-oriented Research from the National Institute on Aging. Additional support was provided by the VA Health Services Research and Development Service to the Bronx VAMC Program of Research on Serious Physical and Mental Illness and the Mount Sinai School of Medicine Alzheimer's Disease Research Center (NIH AG0051318).
Role of the Sponsor: The National Institute on Aging had no role in the design or conduct of the study; in the collection, management, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript.
Additional Contributions: Paul Hebert, PhD (Health Services Research and Development, Veterans Administration Puget Sound Health Care System), provided technical assistance with statistical procedures, and Diego Chiluisa, BA (Division of General Internal Medicine, Mount Sinai School of Medicine), assisted with manuscript preparation. Neither individual received compensation for his role in the study.
Alex D. Federman, MD, MPH
alex.federman{at}mssm.edu
Division of General Internal Medicine
Mount Sinai School of Medicine
New York, New York
Dana Gelb Safran, ScD
The Health Institute
Institute for Clinical Research and Health Policy Studies
Tufts-New England Medical Center
Boston, Massachusetts
Salomeh Keyhani, MD, MPH
Department of Health Policy
Albert L. Siu, MD, MSPH
Brookdale Department of Geriatrics and Adult Development
Ethan A. Halm, MD, MPH
Division of General Internal Medicine
Mount Sinai School of Medicine
1. Neuman P, Strollo MK, Guterman S; et al. Medicare prescription drug benefit progress report: findings from a 2006 national survey of seniors. Health Aff (Millwood). 2007;26(5):w630-w643.
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2. Low-income assistance under the Medicare Drug benefit. Kaiser Family Foundation. http://www.kff.org/medicare/upload/7327_03.pdf. Accessed July 14, 2007.3. State pharmaceutical "wrap around" programs in 2006-08: helping to make Medicare Part D easier and more affordable. National Conference of State Legislatures. http://www.ncsl.org/programs/health/SPAPCoordination.htm. Accessed January 12, 2006.4. Federman AD, Vladeck BC, Siu AL. Avoidance of health care services because of cost: impact of the Medicare Savings Program. Health Aff (Millwood). 2005;24(1):263-270.
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5. Strengthening New York's EPIC program: options for improving drug coverage for Medicare beneficiaries: September 2003. Commonwealth Fund. http://www.cmwf.org/usr_doc/560_Davis_NY_EPIC_program.pdf. Accessed August 25, 2008.6. Doors to Extra Help: boosting enrollment in the Medicare Part D low-income subsidy. AARP. http://assets.aarp.org/rgcenter/health/2007_15_medicare.pdf. Accessed February 7, 2008.
Letters Section Editor: Robert M.Golub, MD, Senior Editor.
JAMA. 2008;300(12):1412-1414.
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