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April 19, 2017

5 ways to improve medication adherence—health care's $289 billion problem

Daily Briefing

Read Advisory Board's take on improving medication adherence.

Research shows that poor medication adherence leads to preventable deaths and costs the U.S. health care system billions of dollars annually.

However, experts say addressing the issue can be complicated because there are various reasons why patients might not take medications as prescribed.

Research shows many US residents do not take medications as prescribed

According to a research review published in Annals of Internal Medicine, "Studies have consistently shown that 20 percent to 30 percent of medication prescriptions are never filled, and that approximately 50 percent of medications for chronic disease are not taken as prescribed." For instance, the review found that individuals who take prescription drugs generally only take about 50 percent of the prescribed doses.

Further, the review found that poor medication adherence causes approximately 125,000 deaths each year, as well as at least 10 percent of hospitalizations that occur in a given year. Overall, the review estimated that poor medication adherence costs the U.S. health care system between $100 billion and $289 billion annually.

Bruce Bender, co-director of National Jewish Health's Center for Health Promotion, explained, "When people don't take the medications prescribed for them, ED visits and hospitalizations increase and more people die."

Experts say a lack of medication adherence also can explain why some prescription drugs appear to work better in studies than they do among the general population, and why patients experience relapses or die when they have been prescribed medication that should control their conditions, New York TImes' "Well" reports. Simply put, former Surgeon General Everett Koop said, "Drugs don't work in patients who don't take them."

Addressing medication adherence is complicated, experts say

However, while several experts acknowledge that medication nonadherence is a significant problem, they also say addressing the issue is difficult because there are numerous reasons why patients choose to alter or stop taking medications as prescribed.

How SSM Health's 'pharmacy concierge' program helps patients afford medications

For instance, Bender said some parents will discontinue certain treatments for their children "because they just don't like the idea of keeping kids on medication indefinitely." But doing so could exacerbate underlying issues that could lead to complications later, Bender said.

In another example, Lisa Rosenbaum, a cardiologist at Brigham and Women's Hospital, said patients being treated for heart attacks told her they stopped taking their medications because they are "old-fashioned" and "don't take medicine for nothing," as she heard from one patient.

Bender highlighted a similar trend, saying some patients will "do a test, stopping their medications for a few weeks and if they don't feel any different, they stay off of them." However, he explained, "Although the consequences of ignoring medication may not show up right away, it can result in serious long-term harm."

Rosenbaum also said patients might stop taking medications because the drugs "remind people that they're sick" or patients think the drugs are "unnatural." Rosenbaum said, "There's a societal push to do things naturally," adding that society's "emphasis on diet and exercise convinces some people they don't have to take medications."

Further, Bender said some patients stop taking medications or reduce their dosages because of costs. "When the [copayment] for a drug hits $50 or more, adherence really drops," he said (Brody, "Well," New York Times, 4/17; Murphy, Becker's Infection Control & Clinical Quality, 4/17).

Advisory Board's take

Lindsay Conway, Pharmacy Executive Forum

Patient non-adherence to medication regimens is a major problem that will only grow as drug prices rise and regimens become more complex. But there's not a one-size-fits-all solution to the issue. To improve outcomes and lower costs, health systems should consider these five root causes of non-adherence—and best practices to address them:

1. Patients can't afford their medication. Multiple studies have found that adherence declines with rising medication costs. That's why progressive health systems dedicate staff time to determining whether patients can afford their out-of-pocket costs and to securing financial assistance for patients who need help.

2. Patients don't understand how and when to take their medication. Patients who are taking many medications often benefit from meeting with a pharmacist to learn more about their regimen. To provide this support, many health systems are embedding clinical pharmacists into ambulatory care sites to work with their most complex patients. Pharmacists can provide basic medication education and counseling, help troubleshoot problems, substitute medications, adjust patients' dosage, and manage side effects. They can also help create pill calendars and set up apps that remind patients when and how to take their medications.

3. Patients don't know where to turn for help if they experience side effects. Patients may assume that any uncomfortable side effects are inevitable and decide to stop taking their medications. This is a particular concern for cancer patients taking oral oncolytics. To address the problem, many cancer centers are ramping up their phone triage and symptom management systems to ensure that patients get the care they need in a timely manner.

4. It's not easy for patients to refill their medication. Patients with chronic conditions routinely have to make multiple phone calls to their doctors' offices, navigate complex phone trees, and wait on hold in order to renew their prescriptions. At the same time, refill requests place an extra burden on already-busy physician office staff. In response, progressive health systems are establishing centralized refill hotlines manned by pharmacy staff.

5. It's inconvenient for patients to pick up their medication. We're all more likely to follow through on things that are easy to do. For that reason, many health systems have invested in bedside delivery programs so that discharged patients leave the hospital with their medications in hand. Others have co-located retail pharmacies with their outpatient clinics and built mail-order pharmacies to manage refills.

To learn more about designing and implementing a bedside medication delivery program, join me for an upcoming webconference that is open to all Advisory Board members.

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