No Silver Bullet for Medication Adherence

Cost and forgetfulness play a large role in non-adherence, but even when medications are supplied at no cost, adherence hovers around only 50%. Forging personal connections with pharmacy staff can help, one insurer says.

A "spoonful of sugar helps the medicine go down," Mary Poppins, the quintessentially perky nanny,explains in song and dance to her young charges.

If only it were that simple to get patient to follow prescription orders.

A report card [PDF] released last week by the National Community Pharmacists Association places medication adherence for individuals with chronic conditions at the C+ level, with one in seven receiving a failing report card grade.

Skipping medicine doses and failing to get prescription refills are among the patient behaviors that threaten patient health, especially among individuals with chronic conditions. The NCPA report estimates that medication non-adherence adds about $290 billion to healthcare costs each year.

There is no shortage of interest among industry stakeholders in resolving this issue, especially as the delivery of healthcare services becomes more interdependent and accountability for patient outcomes extends all along the care continuum. A breakdown anywhere along that path can take money out of everyone's pocket.

Unfortunately, there is no one-size-fits-all solution to medication non-adherence. That's mostly because there's "not just one thing that keeps a group of patients or even one patient from taking their medications as prescribed," says Edmund Pazella, MD, national medical director for pharmacy policy and strategy for the Hartford, CT-based insurer, Aetna.

While cost or forgetfulness often play a role in non-adherence, Pazella clicks off a laundry list of additional reasons, including drug side effects, patient concerns about the number of pills they take, and worries about drug interactions.

"It's a multifactorial problem that results in less than optimal outcomes for our members. We're very concerned about it," he says.

What's particularly frustrating, says Pazella, is that some of the areas where patients are most at risk, such as the advancement of cardiac disease, cardiovascular risk factors, hypertension, and high cholesterol, are each treated primarily with medications. Yet adherence is low.

In considering the barriers to taking medications as prescribed, Pazella and his team looked at the effect of different settings on adherence, as well as why certain members are more at-risk for poor adherence than other members.

From there, it's a matter of "identifying a variety of solutions to the problem to find the combination of solutions that work best."

That is a tall order.

A few years ago the New England Journal of Medicine published a study about Aetna's efforts to improve medication adherence following a heart attack. Aetna provided the medications at no cost rather than requiring a copayment. Pazella says the results were promising. The patients taking their medications as prescribed had better outcomes, their costs were lower, and they didn't return to the hospital.

Still, giving the medications away only moved the adherence needle from 42% to 49%.
"These patients had had a heart attack and even with giving them the meds for free we still couldn't get adherence to more than 50%," says Pazella.

Combining free medications with counseling by a pharmacist has helped move the needle a bit further. Pazella notes that pharmacists are on the front line of patient engagement and in the perfect position to help with adherence in terms of explaining the purpose of medications, how to take them, and the importance of staying on them.

According to the NCPA report card, a personal connection with a pharmacist or pharmacy staff is a leading indicator of medication adherence "They can answer patient questions about drug safety, interactions between multiple medications, and anything that might prevent a patient from taking their medications on a regular basis," notes Pazella.

Aetna also stresses medication adherence in a follow-up program for patients who have been prescribed an anti-depressant. A study from CVS Caremark released last week identifies patients with depression as having the lowest medication adherence rates [PDF].

Aetna's case management program for patients with chronic diseases also includes an adherence component where the nurses administer a short questionnaire to identify patients who may need additional attention to help them with adherence. That connection is very important.

"Generally we don't see compliance for adherence for any chronic disease where there is no intervention for more than 60% of the time after the first year," says Pazella.

While the program results are encouraging, Pazella admits that improvement in adherence is often gradual. "We see a 10% improvement here, a 3% improvement there, and a 5% improvement somewhere else. But, it does begin to add up."