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.