Medication non-adherence sends healthcare costs soaring

The math didn’t add up.

Andrew Saxon, MD, a Seattle-based psychiatrist, had written a prescription for one of his patients, a military veteran battling post-traumatic stress disorder (PTSD), to help deal with nightmares. The prescription was meant to cover 90 days of treatment. By the time Saxon met with the patient more than four months later, though, records showed that the veteran had yet to request even one refill.

With a bit of quick mental math as he looked over the patient’s electronic medical records to verify dates, Saxon quickly deduced the patient wasn’t taking his medication at its prescribed frequency.

“The patient really couldn’t give a reason, but globally, he said he just doesn’t like taking pills,” Saxon says. “He wishes he wasn’t taking so many. What we have here is a situation in which the patient has a general aversion to taking medications. While he realizes the medication helps him a bit, his way of coping with that aversion is to just not take it sometimes.”

The tale of Saxon’s patient is not uncommon. Whether it’s a case of aversion or another motivator, more than half of the 187 million Americans who take at least one prescription drug do not take their medications as prescribed, according to a 2005 study published in the New England Journal of Medicine.

Medication adherence—or, more accurately, the lack thereof—is a $337 billion problem in the United States and accounts for roughly 11% of the nation’s overall healthcare spending, per Express Scripts’ 2013 Drug Trend Report.

Reasons behind the trend

The reasons for non-adherence range from honest mistakes to nefarious purposes. Sometimes, it’s a matter of simply forgetting, Saxon says.

“Anyone who has ever taken medication has had the experience of, ‘Did I take my pill?’ ” Saxon says. “Then you’re facing the issue of whether you’re going to double up on the dose by accident or maybe it’s better to skip the dose because you don’t remember if you took it.”

For many patients, though, non-adherence is more of a personal decision.

Amy Gross is the senior director of clinical specialists at Express Scripts and a board-certified psychiatric pharmacist. During her years working in hospitals in Kansas and Colorado, she frequently saw patients, particularly those diagnosed with schizophrenia, repeatedly admitted because they had a lack of insight into their illness and were in denial that they needed medication at all.

“The consequences of a lack of adherence [for patients with schizophrenia] are not as overt as some other conditions,” Gross says. “If you have hypertension and you’re not adherent, the result is a heart attack. You can draw a line from A to B. With schizophrenia, if you have a lack of adherence and you end up in the hospital because you are not taking your medication, you end up with cognitive decline that is permanent. You are resetting the bar lower and lower each time.”

As a caregiver, Gross says her focus became using motivational interviewing techniques to understand why patients felt they didn’t need to take their medications.

“You need to ask open-ended questions and not be confrontational to get at the root of why the person doesn’t want to take their medication,” Gross says. “The focus is to help that person gain insight into their illness. That will also help that person understand the benefits of medication to stay adherent.”

Psychologist Dennis Ortman, PhD, says he has seen plenty of patients who opt for substances over their prescription regimens.

“People want to self-medicate with alcohol and drugs,” Ortman says. “At some point, they have to make a choice: Am I going to self-medicate or do I want to use a prescribed medication? You can’t do both. That’s often a tough one to work through for people with addictions.”

For patients with a costly regimen, there can be a temptation to stop taking the medication, saving some for when they believe they “need” it, Saxon adds. However, for maintenance medications, the patient’s perceived “need” for medication might be a poor indicator of actual clinical need.

In cases of substances with street value, such as Suboxone (buprenorphine with naloxone), some patients forgo their own drug treatment to make fast cash, even though diversion means breaking the law.

Improved communication

Perhaps the biggest issue lies in the communication between the physician and patient. Saxon outlines several instances where a lack of dialogue between the prescriber and the patient can increase the chances for non-adherence:

• Physicians not checking with patients to ensure they are taking their medications. “We believe we’re giving a treatment that the patient is not really receiving,” Saxon says.
• Patients not realizing the problems created by cutting a prescription short. Saxon cites the example of antibiotics, which can relieve symptoms within 24 to 48 hours, but need to be taken for their full defined course for maximum effectiveness.
• Prescribers not communicating the full range of side effects associated with a medication, and how long they last. “Often times, side effects are transient,” he says. “If that’s well communicated and there is some coaching, the patient might continue the medication and work through the period when there are side effects before they dissipate.”

One way to overcome communication challenges with patients is through comprehensive medication management (CMM), an advanced form of medication therapy management (MTM) that focuses on the whole patient with the goal of optimizing outcomes for a particular condition. Further, the California Department of Public Health defines CMM as: “an evidence-based, physician-approved, pharmacist-led preventative clinical service ensuring optimal use of medications that is effective at improving health outcomes for high-risk patients while decreasing healthcare costs.”

A recent research report co-authored by communications firm Health2 Resources and consulting firm Blue Thorn explored CMM as a means to improve outcomes and control spending. The report assessed responses from 935 healthcare professionals who participate in the management and execution of CMM programs. Per the report’s findings, in addition to achieving high satisfaction rates for patients, enlisting the help of clinical pharmacists to provide CMM services has helped clinicians by reducing their workloads and allowing them to address the acute needs of more patients.

In terms of medication adherence, the key to CMM is that it gets patients started on the right foot when a medication is prescribed, says Blue Thorn President Terry McInnis.

“CMM really requires you to make sure first the medication is indicated for the patient, that the medication is the right dosage for the patient, they’re on the right combination of medications and then the medication is safe, not only from a drug interaction standpoint, but also for the patient’s tolerability,” McInnis says.

While CMM programs have proven to be helpful, they are not necessarily available to all patients. For now, the Health2/Blue Thorn report states, successful CMM practices target patients who will gain the most benefit. For CMM practices to advance, the support of physicians, nurses, administrators and C-level executives is needed.

In the meantime, Ortman says working with patients to develop personal accountability is critical. Ortman’s approach is straightforward and tough: “I tell patients they’re responsible, nobody else.” Ultimately, though, they find it empowering, he says.

“I try to help them understand they have a condition that doesn’t define who they are as a person,” Ortman says. “I want to impress on them to take responsibility for their own lives, just like you would if you had any other medical condition. It’s a relief for patients because I respect them as adults. With mental illness, they’ve been treated almost like they’re helpless and they’re victims of their condition. That, to me, is very demeaning.”

He cautions that patients say they can’t do certain things, when the reality is they won’t.

Tom Valentino is Senior Editor for Behavioral Healthcare.