At least 70% of adults took some form of medication in the last 30 days. While some might be short-term use for acute conditions, over half of adults have multiple chronic conditions and accompanying medications. When patients don’t take their medications exactly as prescribed, everyone is quick to point to individual factors, with forgetfulness and willful defiance among the top contributors.
However, there are also systemic, socioeconomic and individual factors that contribute to poor medication adherence. What this means is that we as health care providers need to examine both systemic and individual factors in a team-based approach to enable the patient to reach their best health outcomes.
The Costs of Medication Mismanagement
As a patient ages, medication adherence becomes both more critical and more complex. The complexity of medication regimens, the seriousness of adverse effects and the frailty of old age all contribute to a $100 billion to $300 billion annual cost in the United States for hospitalizations due to medication nonadherence. For an individual patient, a hospital stay can be devastating in terms of health and finances. Not only does it increase the patient’s likelihood of being admitted to a nursing home, but it also contributes to the 60% to 65% of individuals with medical debt who file for bankruptcy each year.
Additionally, nonadherence is estimated to cause 125,000 avoidable deaths in the U.S. each year. In comparison, hypertension is the primary cause of just 36,000 deaths yearly. The stark contrast between a month-long global campaign to address hypertension and the complete lack of nonprofit and government support to address medication adherence issues creates an even starker contrast between the mortality statistics.
Between the financial burden and risk of morbidity and mortality, there clearly needs to be better support for seniors to adhere to their medications.
The Adherence Support Gap
Eighteen years have passed since the World Health Organization released a paper deeming that medication nonadherence affects 50% of patients with chronic conditions in the developed world. Unfortunately, there has not yet been a mass organized effort to get nonadherence recognized and treated by national medical plans. There are both insurer and individual patient solutions on the market aimed at increasing adherence, including third-party reminder apps and high-tech medication dispensers. While initial uptake is high for reminders, enthusiasm quickly wears off, leaving the patient back where they started before downloading the app. Additionally, reminders do not necessarily track intentional nonadherence, which means intentional omissions are not addressed in a timely manner. Just as the problem of nonadherence is multifaceted and complex, solutions need to address both individual and systemic challenges.
Comprehensive adherence management is available to select patient populations under certain situations but is certainly not the norm. For example, in a program in British Columbia, Canada, transplant patients receive frequent scheduled check-ins with a multidisciplinary team of physicians, nurses and pharmacists to ensure good adherence to the post-transplant care plan. The one-year rejection rate for transplant patients in British Columbia is less than 10%, compared to the 25% rejection rate reported elsewhere. While other conditions, such as diabetes and congestive heart failure, also demonstrate the need for adherence, there are fewer systemic supports available for these more prevalent conditions.
In part, this is due to the funding model around adherence—or the lack thereof. While Medicare and Medicaid are moving towards value-based reimbursement models, medication adherence is not a mandatory quality indicator. Insurers recognize the importance of taking medications correctly for good outcomes, but their insight is limited to mathematical factors such as refill records and medication possession ratio. In reality, someone needs to be there for the patient to interact with and learn good adherence behaviors. For effective adherence support, the intervention needs to be sustained over a protracted period, beyond the initial period of enthusiasm, to ensure the optimal patient outcomes.
A Multifaceted Care Team Approach
While there have been some moves to improve adherence among certain providers and patient populations, there is still limited support for most seniors. With the plethora of options available, there is opportunity and access to improved medication adherence available for more dedicated families and homecare agencies. However, the question then becomes: Who can assume ownership of this massive health problem?
Addressing the socioeconomic contributors of nonadherence requires input from the prescriber, pharmacy provider and third-party insurance, as well as the patient or their family. There are a lot of stakeholders, making exchanging and tracking information and follow-ups burdensome. There are also power and knowledge inequities for the patients, who are expected to be their own advocates without the full medical or financial knowledge afforded to health care providers and insurers.
To help individual patients address their adherence concerns, those best positioned need to empower the patient to formulate and discuss their challenges with the appropriate provider. While prescribers and pharmacies are suppliers of diagnoses and medication, they can be inaccessible due to the volume of patients they deal with. Insurers have departments dedicated to access, but their processes are not easy to navigate or transparent to patients and their families. Of course, in-home care providers, either employed or family, are best positioned to help patients with adherence challenges, but they also experience gaps in medical knowledge and navigating the insurance system.
Whatever the solution, a sustained team-based approach comes with increased communication, clarity and quality of solutions. By involving prescribers, providers, homecare and insurers, all parties gain the same information and are more able to work on solutions to complex, multifactorial problems. This can start with the patient, but it can also start with homecare providers. Because they are literally in the patient’s home, in-home care is best positioned to answer patient inquiries and encourage them to seek answers from their health care providers.
Medication Adherence Presents an Access & Interprofessional Opportunity
Offering a medication adherence program and helping the patient through documentation and communication with health care providers is an enormous step toward addressing the challenge and finding a solution. While there are occasional adherence programs for a few special patient populations, widespread recognition and reimbursement (via Medicare or private insurers) will go a long way in increasing access and driving down overall health system costs. Medication nonadherence continues to be a widespread epidemic responsible for loss of life and loss of function—and the solution needs to be as complex as the problem.