Designing for High Medication Adherence

As the healthcare industry continues its quest to lower costs and improve patient outcomes, many have focused on the problem of medication adherence.

As estimated in a 2012 Annals of Internal Medicine review, when patients can’t-or won’t-take medications as prescribed, the numbers add up. Those numbers include the number of deaths (approximately 125,000 in the United States alone), the number of hospitalizations (a 10% increase in hospitalizations), and the number of extra costs incurred to a healthcare system already stretched perilously thin (approximately $100 to $298 billion each year).

Jennie Byrne, MD, a psychiatrist with Community Care North Carolina, an organization contracted by North Carolina Medicaid to improve care and reduce costs, said there are many reasons why a patient may not be following a prescribed medication regimen. The American Medical Association lists fear, costs, and misunderstandings about the nature of the medication at the top of the list. Byrne says none of these items surprise her, but she would also add that the stigma associated with medications, particularly psychiatric medications, can also play a role in a patient foregoing prescribed treatments.

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“Patients tell me they feel like they are being judged when they go to the pharmacy-or that their friends and family are not supportive of the medications they are taking,” she says. “We know that patients do better when they are taking their medication as prescribed. We also know that it costs the healthcare industry a lot less when they do. So if people can work together to come up with ways to encourage compliance, it’s a good thing.”

But Byrne said that it will take all healthcare players coming to the table to find effective ways to encourage medication adherence in order to curb costs and improve patient outcomes. Yet, many pharmacy benefit designs may actually inadvertently interfere with that goal.

In the recent Managed Healthcare Executive’s Managed Care Pharmacy Survey, specialty pharmacy stakeholders, including providers, consultants, health plans, and pharmacy benefit managers (PBMs), were asked to note what they believed was the most effective strategy to increase patient engagement and adherence to key maintenance therapies, more than one third of the survey respondents suggested newer benefit designs that reward patients for high-level engagement/adherence were key.

Read the full survey results here

That strategy was followed by advancement in digital tools and other technologies to support patient adherence/engagement (30.5%) and greater outreach, education, and counseling by pharmacy benefit managers (PBMs)/managed care organizations (MCOs) (14%).

Byrne was surprised that some sort of cost discounts weren’t on the list. She also would have liked to have seen streamlining prior authorization processes and reimbursement for care management highlighted as well.

“Cost plays a role, no doubt. But sometimes it’s less about the cost itself and more about the lack of transparency around the cost and prior authorization,” she explains. “When I am prescribing a new medicine for a patient, I, as the doctor, am trying to figure out how much it might cost the patient so I can talk to the patient about it. But, more and more, I can’t figure out whether a drug will be a typical copay or cost a lot more. It’s also harder for me to determine whether which medicines may require prior authorization.”

That means patients go to the pharmacy to pick up their medication and are too often blindsided by the price tag or told they need to get back in touch with their physician to get prior authorization. Byrne says it can leave a bad taste in patients’ mouths-and result in them not even bothering to pick up prescribed medications.

“It’s kind of a vicious cycle. The benefit plans are trying to make things cheaper by limiting the prescriptions available but they are just creating more burden on practices and patients,” she says. “Some of this will be remedied as we move toward value-based contracting but greater transparency about these things now could go a long way.”

As for reward programs and new monitoring technologies, Byrne is circumspect. She says such strategies could work but, without payer organizations offering reimbursement for care management to help support patients, a points system or new app will just be another thing patients have to keep track of.

“I think if health plans would pay practices to do care management and give them the guidelines they think would work best for medication adherence, it would end up working better than incentivizing the patients directly,” she says.

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Byrne said that there is good research on medication adherence that can offer guidance about strategies that can work-they just have yet to be implemented on a large scale. One of those things is increased outreach, education, and counseling, which 14% of survey respondents did select-but Byrne says that outreach also needs to come from providers and care managers.

“There are a lot of things out there that we’ve seen can and do work so I’m not sure what the obstacles are to implementing them,” she says. “Investing in health behaviors matters. And we see that improving a plan’s network of care managers, social workers, counselors, or peer support options are great tools that are underutilized but have great power to help make a difference when it comes to medication adherence.”

Kayt Sukel is a science and health writer based outside Houston.