Healthcare Technology Featured Article

December 19, 2017

Following What the Doctor Ordered: Addressing Medication Noncompliance

All prescriptions instruct patients to take a medication as directed, yet millions of Americans fail to follow through. About half of the 3.2 billion annual prescriptions dispensed in the United States are not taken as prescribed, and that number is even lower for patients with chronic conditions. The toll on patients and the health care system is staggering. According to recent estimates, medication nonadherence causes some 125,000 deaths, untold disabilities, as well as 10% to 20% of hospitalizations and nursing home admissions each year. This adds up to between $100 billion and $289 billion annually. To be sure, medication noncompliance is a long-standing issue. Now we have reached an inflection point where technology, new care models, value-based purchasing and concerns about the costs of chronic illness are converging to meaningfully address the problem.

Drivers for change. Several drivers are motivating stakeholders to address medication adherence at this time. They include:

  • Costs of noncompliance for chronic illness. As mentioned previously, the overall costs of non-adherence are significant. They also are significant for individual chronic diseases, which are on the rise. Take costs associated with diabetes, which is one of the most common chronic conditions. According to ExpressScripts, diabetics who were noncompliant with their oral diabetes drugs had 1.3 times higher medical costs and 4% higher total health care expenditures compared with those who were adherent. Put another way, annual spending on compliant diabetics was at least $500 less than for nonadherent patients, which extrapolates to an estimated $210 million in savings for 2016. This kind of savings potential grabs the attention of policy makers, payers and providers.
  • New care models. Medical care is moving toward a patient-centered, team approach, which includes nurses, care managers, pharmacists and other clinicians. These teams engage patients in their care and offer guidance and support as patients move along the care continuum. The team approach can help patients understand their disease and importance of taking their medications as directed, thus motivating them to be compliant and stay on therapy. Pharmacists’ roles are expanding to include patient counseling with the objective of improving medication compliance. Increasing efforts to pay pharmacists for such services can ultimately have a positive impact on adherence.
  • Value-based contracting. Value-based contracting is becoming more common. These arrangements reimburse providers for lower costs, better outcomes and fewer hospitalizations.  As a result, medication adherence is becoming both a quality and outcomes measure in accountable care and performance-based contracting, including the Medicare star ratings program. Moreover, the potential savings resulting from improved medication compliance can incent physicians participating in value-based and pay-for-performance arrangements to take a more active role in identifying and addressing adherence.
  • Technology. Technology is now available to better share patient information and help identify and monitor noncompliant patients. For example, formulary and benefit information at the point of electronic prescribing (ePrescribing) can help physicians prescribe affordable medications covered by the patient’s health plan. Prescription price is important because a significant number of prescriptions are not picked up once patients learn how much they will cost, or patients will halve or skip doses to save money. The RxFill function can indicate whether a patient filled or refilled a given medication, which could indicate compliance. Reports can be run on electronic health records (EHRs) to identify potentially noncompliant patients. In addition, there is a wide range of wearable, mobile and other devices to help patients improve medication adherence. Examples include smart pill bottles, mobile applications (such as text messages and pill alarms) and ingestible pill sensors.

Moving forward. There are many innovative opportunities to address medication adherence in a meaningful way. For example:

  • Going beyond reminders. Forgetfulness is a major contributor to nonadherence. Oral and written medication reminders can help, as well as wearable and mobile reminders and those using other technologies. However, there is growing evidence that reminders are not enough and patient engagement is vital. A recent study shows that use of a high-touch pharmacy patient engagement system made patients 2.57 times more likely to remain adherent with their medications. Promising results also were seen in two pilots at Duke University of a patient-facing application that engages patients about medication adherence through the use of questionnaires and availability of educational resources.
  • Addressing cost of prescriptions. The cost of prescriptions is a major cause of medication noncompliance. According to a survey by CVS Caremark, 62% of retail pharmacists believe the high cost of drugs is the biggest reason why patients are noncompliant. Even raising copay amounts can unintentionally reduce medication adherence. Innovative pilots can be developed to create new medication payment structures (including free medications and patient assistance programs) that could improve compliance. The emergence of the Real-Time Benefit Inquiry could be helpful in addressing adherence by providing even more accurate information at the point of prescribing addressing which particular medications for a patient’s condition would be a good fit with insurance coverage and the ability to pay out-of-pocket costs.
  • Analyzing data. Data analytics can be used to identify compliance issues and develop smart interventions. EHR data, supplemented by lifestyle and sociodemographic information, can be captured and analyzed to predict compliance problems. Integrating pharmacy claims data into the mix also can provide valuable insights. Population health vendors already are making investments in assessing medication adherence and risk factors in their core risk analytics applications (such as risk stratification dashboards) for providers’ care teams.
  • Educating patients and providers. Lack of health literacy is another cause of medication noncompliance. As a result, patients need to be educated about their disease, the benefits of the medicine being prescribed and instructions for properly taking it. This feeds into improved compliance. Similarly, providers need to be educated about the impacts of noncompliance and how EHRs and other technologies can help identify patients at risk as well as those who have become noncompliant.
  • Leveraging innovative partnerships. Health care organizations are developing numerous strategies and tools to help patients adhere with their medication regimens. An example is the eHealth Initiative’s Electronic Medication Adherence Collaborative, which is aimed at helping to identify how information technology and data analytics can be used to improve medication adherence. It will include a consumer-oriented approach to understand the behavioral and economic factors that influence patient behaviors and preferences.
  • Mining the research. There is a growing amount of literature concerning medication adherence, yet, to our knowledge, no meta-analysis has been done. Such analyses could better inform policies and practices, as well as help connect researchers to policy makers.

Together, these approaches can meaningfully improve medication adherence.

Edited by Mandi Nowitz
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