by Tracy Staton

Meghan Gerety, M.D.

America's seniors often avoid taking the drugs that are prescribed for them, either because they can't afford it or they don't feel they need to, according to a detailed analysis of the feedback gathered by Medicare. And those seniors who do take drugs as their doctor suggests often take a complex variety of pharmaceuticals that are often prescribed by more than one doctor and are frequently filled in different pharmacies.

The researchers paint a complex picture of seniors who often appear deeply confused by the drugs that they're on, the potential for harmful interactions as well as anxiety over who picks up the tab. And the three groups that conducted the analysis - the Kaiser Family Foundation, the Commonwealth Fund and Tufts-New England Medical Center - say that the data also presents some clear challenges to Medicare as it rolls out a new prescription benefit plan in January.

Altogether, four out of 10 seniors said that they failed to fill a prescription either because they couldn't afford it, didn't think they needed it or simply didn't want to. At the same time, almost half of the 89 percent of seniors who said that they had filled a prescription said they paid for five or more drugs. More than half of seniors taking drugs said they received a prescription from more than one doctor and a third used more than one pharmacy. And of those elderly Americans with three or more chronic illnesses, nearly 75 percent took five or more drugs while more than half had failed to fill all their prescriptions.

The dizzying set of responses prompted healthcare experts to call for better coordination and a much sharper focus on the possible fallout.

"With two out of five seniors not taking medicines as prescribed, there is a real opportunity to improve patient care both by urging doctors and patients to talk more about these issues and by developing systems to monitor quality and safety," said Commonwealth Fund President Karen Davis, Ph.D. "These steps are an important complement to the new Medicare prescription drug coverage."

"The substantial variations in drug coverage across states documented in this survey suggest that targeted outreach efforts have the best chance of reaching seniors," said Kaiser Family Foundation President Drew E. Altman, Ph.D.

And as the number of drugs available for treating an ailment rise, the need for better communication rises right along with it.

"What has changed in the last decade is that we simply have many more highly effective drugs," says Meghan Gerety, M.D., the chairman of the board of the American Geriatric Society and a practicing geriatrician in San Antonio. "Ten years ago someone being treated for diabetes had a very limited range of choices. Now they have two or three drugs for diabetes. That's true for most of the chronic illnesses."

In one study she cited, people with four or more chronic conditions see an average of 8.1 different doctors per year and have up to 19 or 20 physician visits a year. People with five or more chronic conditions are seen by 13.8 unique physicians and have up to 37 doctor visits.

"We in the American Geriatric Society believe that this is fragmented care," says Dr. Gerety. "It increases the chance of doctor errors. Furthermore, there's good evidence that patients seeing that large number of physicians indeed get conflicting advice, conflicting diagnoses" and conflicting advice on drug interactions and the diagnostic tests they need.

At the time the Medicare survey was done in 2003, the prospect of a national drug benefit for seniors was still far off. And about one in four seniors had no coverage for drugs. As income fell, the chances of a lack of coverage - and failure to fill a prescription - rose. And in Ohio, Louisiana, Texas, and Washington, 40 percent of seniors had no drug support. Overall, close to one in three seniors had an employer-sponsored health plan that helped cover the cost of drugs.

Seniors without coverage were more likely to look to either Canada or Mexico for their drugs, but only one in 20 had ever filled a prescription outside U.S. borders. For seniors without coverage, the figure rose to 11 percent.

All that will change dramatically at the beginning of 2006, when a new federal Medicare drug benefit takes effect. At that point, Medicare will begin providing significant new drug subsidies to seniors, raising the likelihood that compliance may improve but the numbers of drugs seniors take will rise. And as the baby boom generation reaches retirement age, the number of seniors on medication is projected to soar.

That has some physicians alarmed by the already dire shortage of geriatricians, doctors trained to take care of the elderly. In a study that came out in May, the American Geriatric Society noted that there is also little in the way of geriatrics research underway in the United States. Only 62 physician-fellows were in their second or subsequent years of geriatric research in 2003. And unless more doctors commit to specializing in caring for older Americans, the Society adds, by 2030 there will be only one geriatrician for every 7,665 older adults.

And that could spell real trouble.

"We coordinate care with other professions and across community-based settings to ensure that patients' needs, as well as those of patients' caregivers, are met," explains David B. Reuben, M.D., president of the society. "Geriatricians take care of people, not just their diseases."