Millions of Americans struggle every day to pay for their prescription medicines, often cutting back on how often they buy or take some of their drugs to save money. But a new study suggests that many of the sickest patients don’t tell their doctors what they’re doing—even though skimping on certain drugs could harm their health and their physicians could help them.

The study’s authors, from U-M, the Veterans Affairs Health Services Research Program and Stanford University, say their findings reinforce how critical it is for doctors and nurses to take the initiative in asking patients if they’re having trouble paying for their drugs and educating them about which ones are most necessary to protect their health. The researchers found that most patients who spoke up got help through free samples, generic drugs or information about assistance programs.

The study, published in the Sept. 13 issue of the Archives of Internal Medicine, found that two-thirds of 660 chronically ill patients who had cut back on their prescription drugs because of trouble paying for them didn’t tell their doctors before they did it. And even after they had started skimping, 35 percent never told their doctors.

All of the patients surveyed had at least one serious medical problem, such as high cholesterol, high blood pressure, diabetes, heart disease, lung disease, osteoporosis or ulcers. And the vast majority of patients were on three or more prescription drugs when they started skipping doses or refills to save money.

“These chronically ill adults are the patients who most need their medications. Yet their doctors don’t know that they aren’t taking them because of cost pressures,” says lead author John Piette, a career scientist at the VA Ann Arbor Healthcare System and associate professor of internal medicine at the Medical School. “As drug costs and the number of chronically ill Americans both continue to rise, it’s essential that health care providers proactively discuss costs and adherence with their patients.”

Patients who didn’t bring up the uncomfortable issue of cost weren’t likely to get asked, either, the study shows. Two-thirds of those who had never talked with their doctors about their prescription cost problems said no one on their medical team had inquired if they were having any trouble paying for their drugs. More than half of these patients thought their doctors and nurses would not be able to help, and nearly half were embarrassed to raise the issue or didn’t think it was important.

Piette notes that this means health care providers should ask even their better-off patients if they’re having trouble paying for their medicines or cutting back due to cost. “This issue is important for all patients, especially those with conditions that can be controlled through regular use of medications,” Piette says.

Piette and his colleague Dr. Michele Heisler, also of the VA Ann Arbor Healthcare System and U-M, recently published findings from another study that showed long-term poor health consequences among people who had reported cutting back on their medications due to cost. That study was the first to demonstrate such an effect by following the same population over time.

In the new study, the 65 percent of patients who did raise the issue of medication costs with their health care providers got help—free samples, a less-expensive medication or advice about which medications they definitely should not skip. However, less than a third of patients received other forms of assistance, such as information about less-expensive sources for medicines or programs that could help them afford their drugs.

The study was funded by the Agency for Healthcare Research and Quality, and by the Department of Veterans Affairs. In addition to Piette and Heisler, the study was co-authored by Todd H. Wagner of the VA Health Economics Resource Center and Stanford University.