Medication Adherence innovative strategies
November 19, 2019
Medication adherence has an enormous impact on improving quality and length of life and health outcomes and can be instrumental in lowering overall healthcare costs. Despite the known health and economic benefits associated with adhering to a treatment plan, medication nonadherence remains a problem and a significant contributor to avoidable healthcare costs in the United States.
Medication nonadherence contributes approximately $100 to $300 billion in unnecessary healthcare costs annually and can account for 50% of treatment failures and 125,000 preventable deaths each year.2 Understanding the factors that lead to nonadherence combined with innovative strategies to address these factors and engaging patients with education about their treatment plan are critical elements for success. While there is no fail-safe solution to improve adherence, experts agree a collaborative approach tailored to address a patient’s specific adherence challenges will equip patients with the understanding and tools they need to foster ownership, responsibility, and empowerment of their medication regime.
A recent study of Medicare Advantage beneficiaries reported that 19% of respondents said that they forget to take prescribed medications; of those, 24% said they forget at least once per week.3
Barriers to medication adherence
There are five factors or dimensions as defined by the World Health Organization that lead to a patient not following a recommended treatment plan.
Social and economic factors such as poverty or financial stress, transportation challenges, cultural beliefs, medication costs, and inadequate insurance are significant drivers of medication nonadherence.
Patient-related factors like forgetfulness, physical impairments, beliefs about medication, and low health literacy also impact the ability to optimize medication therapy. Lack of knowledge about the disease and the reasons the medications are needed, lack of motivation, and substance abuse also are associated with poor medication adherence.
A study by Health Policy Institute notes that prescription drug use increases with age. For example, 75% of those aged 50 to 64 use prescription drugs, compared to 91% of those aged 80 and older. The average number of prescriptions filled also increases with age. An average of 13 prescriptions are filled for those aged 50 to 64, increasing to 22 for those aged 80 and older.4
Therapy-related factors like complex therapy regime, taking different medications at different times of day, frequent changes in medication regime or long duration of treatment and side effects of medications are also major barriers to adherence.
Condition-related factors can be strong determinants to adherence and are related to the level of disability (physical, psychological, social and vocational), rate of progression and severity of disease.
Healthcare team and system-related factors like overworked healthcare workers, lack of training on chronic diseases, poor communication between the physician and patient regarding the benefits of the medication, instructions for use and medication side effects can adversely affect medication adherence. Conversely, developing strong provider/patient communication is an important step in obtaining optimal medication adherence.
Six in 10 adults in the United States have a chronic condition; four in 10 have two.6 Add to that research that shows that within six months of being prescribed medications for chronic diseases, the majority of patients reported taking less medication than prescribed or stopping altogether, and it is easy to see the damage done with the confluence.7
. . . the rise of new technologies gives the industry a potentially powerful way to improve medication adherence. Providers and pharmacists can now watch patients from afar and intervene when they aren’t following directions.8
The rise of new technologies gives the industry powerful new ways to improve medication adherence.
Pharmacy incentive programs, such as Walgreens’ Balance Rewards for Healthy Choices, which provide a set of web, app and text-based programs designed to improve medication adherence, promote engagement and encourage immunizations.
In-home telemonitoring that utilizes remote patient monitoring programs to monitor medication adherence in high-risk patients.
Innovative medication packaging as offered by PillPack, designed to help patients manage multiple medications through convenient packaging, modern technology and personalized service.
In-home dispensing devices that create reminders and pre-packaged, unit-dose medications in conjunction with a clinician portal and caregiver app to enable providers to quickly flag non-adherent patients and connect them to a healthcare professional, as needed.
Mobile apps that periodically remind patients to take their medications, connect patients and pharmacists for collaborative care and initiate notifications to a patient’s family and friends if the person has not taken prescribed medications.
“Smart Bottle Caps” that fit standard drugstore containers. The lids register when they’re removed and log each event in an app to provide real-time oversight by specialty pharmacists and care coordinators, who can contact the patient if there’s a problem.
“Smart Pills” such as those under the AbilifyMyCite label that incorporate sensors that track ingestion and send a signal to a wearable patch. The data transfers to a cloud-based health record to track adherence, with patients deciding who receives their information.
Real-time benefit checking at the point of care, which allows providers to look at the cost of the proposed medication and alternatives in conjunction with an individual’s payer coverage and deductible status. This allows the patient and provider to have an immediate conversation as to whether the medication cost is reasonable or if a lower-cost alternative is available.
Interactive “gamification” solutions that tap into the psychological aspects of game mechanics to create high-value interactions with patients by rewarding patients for engaging in health activities.
All this said, there are still some fundamental adjustments that can have impact. For instance, according to data from Kaiser Permanente, a switch to home delivery can significantly improve adherence over drugs that must be picked up personally.9
Performance under the STARS
The Centers for Medicare and Medicaid Services put medication adherence front and center with their “Five-Star Quality Ratings System,” or STARS, created to measure the experiences Medicare Advantage beneficiaries have with their health plans and healthcare systems. Once reported, this data is intended to enable beneficiaries to choose high-quality organizations, thereby improving the quality of care and coverage.
Under this pay-for-performance system, three medication adherence measures – cholesterol, diabetes and hypertension – are triple-weighted and figure into several Part D measures and Part C disease management measures. The financial implications of the ratings are significant, as 4- and 5-star plans receive bonuses and rebates, and rewards also accrue to hospitals that meet the threshold. In addition, high ratings can mean greater market share for both payers and providers. Payers seeming to underperform in this system can expect punitive action, including fines and potential removal of contract.10 Hospitals, too, can face penalties.
Strategies for improving medication adherence
Financially responsible for the medical costs of their populations and focused on costly downstream consequences of non adherence, health plans are looking at a variety of strategies to cure their part of the problem.
Examples include Humana, which urges pharmacists to consult with beneficiaries face-to-face or over the phone regarding drug adherence and safety. It also has initiated RxMentor, a medication therapy management (MTM) initiative that keeps a central list of a patient’s drugs and provides advice about them. Cigna offers MTM services through its CoachRx program, which provides guidance for beneficiaries at high risk for non adherence and their physicians. United Healthcare, for its part, provides its participating providers with various tips and suggestions on how to improve adherence literacy of their patients.11
Addressing affordability, some payers have implemented subsidies and reduced co-pays as a method to improve adherence, with some looking at the idea of value-based insurance, which would bring select drug co-pay costs down to zero or nearly zero for patients covered.12
Cost issues have driven payers to also look at risk-sharing contracts with pharmaceutical manufacturers, linking coverage and payments to outcomes, factoring in potential reductions in the downstream costs that adherence can produce. It also has been found that interventions, including team-based or coordinated care, increase adherence rates. In one study, patients assigned to team-based care were significantly more adherent, with patients reporting that the approach improved their comfort in asking clarifying questions, raising concerns about their medication regimen and collaborating in developing their treatment plan.13
All these efforts will be supported and propelled by health information technology, the foundation for patient-facing interaction, monitoring, interpolation of analytics, assessment of risk and all other pieces of this multi-faceted puzzle.
The impact of pharmacy on medication adherence
Pharmacists are an integral part of the healthcare team and are among the most trusted and accessible healthcare professionals. Standing at the intersection of prescribers, payers and patients, they are poised to be both hubs and catalysts. Often, the pharmacist is the last healthcare professional that patients see before taking their medications, and this interaction can impact their perception of the therapy. At this juncture, pharmacists can influence and manage patient expectations, while getting an undistorted picture of the patient’s condition, including dexterity, vision and cognition, that could factor into use and misuse.14
As healthcare moves to value-based payments, pharmacy will continue to change, especially in areas such as Medication Therapy Management (MTM). Pharmacists also have a crucial role in planning and leading medication safety programs and improvement initiatives within healthcare organizations – no small task given the increasing complexity of medication therapy. And more changes are to come, according to the Pharmacy Quality Alliance, which reported that the prioritizing of value-based care principles and patient engagement outcomes will heighten the integration of the pharmacist as a key healthcare team member – noting that pharmacy care is already set up to deliver by measuring patient outcomes, making patient satisfaction a priority and driving medication adherence.15
Medication Adherence: The Elephant in the Room, US Pharmacist, January 19, 2018, https://www.uspharmacist.com/article/medication-adherence-the-elephant-in-the-room(opens in new tab/window)
With Drug Adherence Given Triple Weight Among Star Ratings Measures, 19 Percent of Medicare Advantage Beneficiaries Forget to Take Medications. HealthMine News Release, January 27, 2019, https://healthmine.com/blog/iu 2press/with-drug-adherence-given-triple-weight-among-star-ratings-measures-19-percent-of-medicare-advantage-beneficiaries-forget-to-take-medications-healthmine/(opens in new tab/window)
Prescription Drugs: A vital component of health care, Health Policy Institute, April 30, 2014, hpi.georgetown.edu/rxdrugs/(opens in new tab/window)
Nearly 7 in 10 Americans Take Prescription Drugs, Mayo Clinic, Olmsted Medical Center Find, June 19, 2013, https://newsnetwork.mayoclinic.org/discussion/nearly-7-in-10-americans-take-prescription-drugs-mayo-clinic-olmsted-medical-center-find/(opens in new tab/window)
Chronic Diseases in America, National Center for Chronic Disease Prevention and Health Promotion, last reviewed April 15, 2019, https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm(opens in new tab/window)
Why You Need to Take Your Medications as Prescribed or Instructed, U.S. Food & Drug Administration, February 16, 2016, https://www.fda.gov/drugs/special-features/why-you-need-take-your-medications-prescribed-or-instructed(opens in new tab/window)
Building trust through technology for medication adherence, Modern Healthcare, May 26, 2018,https://www.modernhealthcare.com/article/20180526/TRANSFORMATION01/180529960/building-trust-through-technology-for-medication-adherence(opens in new tab/window)
Home-Delivery Meds May Be Solution to Medication Non-Adherence, Health IT Analytics, February 26, 2016, https://healthitanalytics.com/news/home-delivery-meds-may-be-solution-to-medication-non-adherence(opens in new tab/window)
Rewards and incentives: Best practices to help improve star ratings, Rise Institute, April 15, 2019, https://www.risehealth.org/insights-articles/medicare-market/rewards-and-incentives-best-practices-to-help-improve-star-ratings/(opens in new tab/window)
Payer Strategies for Improving Member Medication Adherence Rates, VALUE-BASED CARE NEWS, November 10, 2017, https://healthpayerintelligence.com/news/payer-strategies-for-improving-member-medication-adherence-rates(opens in new tab/window)
The Effects of Value-Based Insurance on Medication Adherence, University of the Sciences, November 5, 2018, https://www.usciences.edu/blog/noteworthy/posts/the-effects-of-value-based-insurance-on-medication-adherence.html(opens in new tab/window)
CDC Grand Rounds: Medication Adherence for Chronic Disease Management — Innovations and Opportunities, Morbidity and Mortality Weekly Report, National Institutes of Health, November 17, 2017, https://www.ncbi.nlm.nih.gov/pubmed/29381269(opens in new tab/window)
How Pharmacists Can Drive Patient Engagement, Value-Based Care, Patient Engagement HIT, March 28, 2019, https://patientengagementhit.com/news/how-pharmacists-can-drive-patient-engagement-value-based-care(opens in new tab/window)
The role of pharmacists in a changing health care environment, CVS Health, January 26, 2017, https://cvshealth.com/thought-leadership/the-role-of--pharmacists-in-a-changing-health-care-environment(opens in new tab/window)