Three reasons for nonadherence

People have a hard time keeping their different medications straight and taking them as directed. This problem is exacerbated when medications are due to be refilled on different dates. For the patient, this means more trips to the pharmacy and doctor, increasing the chance that they will forget to pick up a medication or will deviate from a care plan. This is a serious problem for patients with chronic conditions: According to the CDC, hospital admission rates increase for nonadherent patients with chronic illness by up to 69%. For managed care organizations this has a number of consequences, from diminished treatment effectiveness to adverse health outcomes for their members and increased costs associated with disease progression.

This should come as no surprise to managed care executives. Many managed care organizations are likely to have programs already under way to prevent gaps in medication regimens. Yet, the problem, it would seem, continues to evade an effective solution. The scale of this issue is staggering: Some estimates point to about 125,000 deaths per year in the United States due to medication nonadherence alone. In addition, poor medication adherence is estimated to have a “resultant cost of approximately $100 billion a year.”

A recent study conducted by Humana and the University of Pennsylvania may help to shed light on at least one dimension of this challenge. But first, it’s important to review why so many patients today remain nonadherent.

What causes nonadherence?

There are many, varied reasons why patients might not be taking their medication as prescribed. Here are three reasons for nonadherence:

• Cost barriers. Sometimes, they can’t afford it. According to the CDC, “Some adults offset the cost of prescription drugs by reducing the dosage and frequency of the recommended pharmacotherapy.” These patients take their medication less frequently than recommended in order to make their prescription last longer and save them money.
• Negative beliefs. Others hold negative beliefs about their medication. Negative beliefs could encompass thoughts that the patients’ doctor does not understand them, fear of becoming dependent on the medication, and thinking that their medication is ineffective, or that taking it could disrupt their life. Whether caused by negative beliefs, issues with cost, or simply forgetting to take the medication, nonadherence affects more than just a small group of people-in fact, some research estimates that up to 50% of patients are medication nonadherent. 
• Behavioral economics. While we may be aware of some of the specific reasons why patients are not taking their medication as prescribed, we can take this a level deeper by exploring the field of behavioral economics. This can be described as “A theory stating that there are important psychological and behavioral variables involved in the economic decisions of consumers or countries.” 

Put simply, people often take actions or make decisions that conflict with their long-term interests-for example, skipping a gym session, eating pizza for lunch instead of a salad, texting while driving, or not taking their medication as prescribed. Through behavioral economics, we can consider these psychological and emotional factors and help guide patients to better outcomes. Understanding behavioral economics also helps us create solutions that make it easier for people to take their medication when and how they’re supposed to.  

Next: Medication synchronization

Medication synchronization

This brings us to our study with the University of Pennsylvania. Working together, we evaluated the impact of a pilot refill synchronization program implemented by Humana. We had noticed that while synchronizing medication refills is an increasingly popular strategy to improve medication adherence, little research has been done regarding its effectiveness. A random sample of Medicare Advantage patients receiving mail-order refills for common maintenance medications (antihypertensive, lipid-lowering, or antidiabetic agents) were invited to join the program and followed for twelve months. The study found that synchronizing prescription refills does, in fact, lead to improved adherence for patients taking multiple medications. We demonstrated an absolute increase in the proportion of patients deemed adherent during follow-up of 3 to 10 percentage points for the intervention group, compared to 1 to 5 percentage points for the control group. Patients with poorer baseline adherence showed larger increases in the absolute proportion deemed adherent in intervention (23 to 26 percentage points) compared to a control group (13 to 15 percentage points). In a different, but related study-also conducted with the University of Pennsylvania-we found that synchronized medication schedules were particularly effective for patients filling medications exclusively at retail pharmacies.

Synchronizing medication refills is an increasingly popular and common strategy to improve medication adherence. However, the interesting point to take away from our research is that synchronizing refills could be a particularly promising intervention to improve adherence to maintenance medications (often taken by people with chronic conditions), especially among Medicare patients with low adherence to start with. In addition, the retail setting for pharmacy refills appears to have an effect on medication adherence. Proximity to patients’ homes and convenience could be contributing factors. This should be investigated further as a strategy for improving medication adherence.

Get creative and experiment with your solutions

Medication synchronization is only one approach. Depending on the unique needs of your patient populations, any number of strategies may prove effective in reaching patients in their communities to remind them to take their medications. The key is keeping an open mind. For example, we recently conducted a test in which our members received reminder phone messages from a number of sources (e.g., their pharmacists, their physicians), and a select group received reminder messages from celebrities, including former New Orleans Saints quarterback Bobby Hebert. We found that the combination-calls from the pharmacists and celebrities-had the greatest impact on members.

Medication adherence is a daunting problem, and one that won’t be solved by any one approach. However, by uncovering the root causes of why patients become nonadherent, staying current with evolving strategies such as medication synchronization, and experimenting with emerging approaches, your organization will be better positioned to improve the lives of patients and reduce costs through improved health outcomes.

Clay Rhodes, BCPS, BCGP, PharmD, MBA, is director of pharmacy safety programs at Humana.