Tuesday, June 10, 2008

Lack of action on medication adherence

I heard an excellent presentation today by George Paz, Chairman and Chief Executive Officer of Express, Scripts, Inc., a leading company in the pharmacy benefit management field (processing more than a million prescriptions a day). George said I could share some of his numbers with you. They were stunning to me and many others in the meeting we attended. See if you are surprised.

The topic is medication adherence -- what people do with those prescriptions that are written by doctors. I have written about this before, but George makes the case more tangible.

Of all patients who get a prescription, 24% either do not pick it up or don't begin using it.

Among those who begin taking their medication:
- For those with diabetes, the average adherence is 78.9%;
- For those with high blood pressure, the average adherence is 83.7%; and
- For those with high cholesterol, the average adherence is 84.7%.

Looking at it another way:
- For those with diabetes, 4 out of 10 patient comply less than 80% of the time;
- For those with high blood pressure, 3 out of 10 patient comply less than 80% of the time; and
- For those with high cholesterol, 3 out of 10 patient comply less than 80% of the time.

What happens when there is poor adherence? At a subsequent visit, the doctor sees persistent symptoms and assumes that the dosage is not working. The doctor then reissues the same drug at a higher dose and/or adds a second drug!

George estimates that poor adherence to drug regimens in these categories of chronic disease adds $22 to $34 billion in increased costs because the patients' conditions deteriorate to the extent that hospitalization is needed. He did not quantify the cost of drugs that are purchased by the insurance companies and never used by the patient, but that should be added in, too.

In all the debates about cost control and improving quality care, I have heard very little on this topic, particularly from payers. I have heard some suggest that insurers do not have a strong interest in the matter because they perceive that patients will churn out of their membership ranks. If we were cynical, we could say that they don't mind if people don't use as many drugs. They avoid the short-term costs, and the long-term costs are likely to be paid by the next company or by Medicare. Is it fair and accurate to suggest that?


Anonymous said...

While I am inclined share your cynicism I think that the third party payer system assumes a level of client/patient retention that acknowledges some periodic risk shifting. The lack of patient adherence to prescription regimes or any other medical advice for that matter benefits no one and in the end only serves to increase overall health care costs.

Anonymous said...

I don't know if it's fair or accurate to ask the question, but it's reasonable (if cynical) to think it -which plays into my opinion that insurance companies, in their typical manifestation, do not belong in health
care. After all, they are managing their OWN risk, not the patients'. This is any insurance company's right and proper mindset, which is opposed to the welfare of the patient. We need another type of company, similar but not identical to that proposed in Porter's book, which has a lifetime contract with the patient and acts as his/her advocate and assistant with the financial aspects of his care.

As for medication adherence, this is an old problem. I would imagine it's worse now since the doc no longer has the time/inclination to spend time explaining why taking this medication is necessary.


Anonymous said...

This is all quite scary. What I find is the amount of people that do take prescription drugs and are not really aware of what goes into them or to as there actual purpose - but still continue to take to them regardless.

Anonymous said...

As a person with diabetes and a member of a health plan in this state, I don't think it's accurate.

I am in a program where a nurse calls me and makes sure I get my regular check-ups and am taking the medications that my doctor has prescribed. I get reminder calls from my plan when my mail prescriptions are due to be renewed.

If they thought I was just a burden to pass on to the next plan or to Medicare, I don't think that they would do that.

Anonymous said...


I am surprised that those adherence rates are so high! Medication non-adherence is America's biggest drug problem as 1 in 2 patients do not take their medication as prescribed. With the chronic conditions you mention, I have seen reports that cite the adherence rates in the mid 60s.

Perhaps George's numbers were from his members who actually are engaged in their medication regime? Was it self reported?

Working for a vendor of medical adherence technology, I am surprised by the lack of action of some of the stake holders I have spoken with over the last year.

One VP at a PBM said they were not interested in adherence, only in lowering the cost to their clients. One director of a hospital system stated they were in the business of treating people who are sick. Some insurers "get it" - since medication non-adherence costs $300B in unnecessary healthcare costs and lost revenue.

Employers say they are interested in Wellness Programs, however don't address medication non-adherence since (as you mention) they will probably not have to pay in the long run. 23% of employers healthcare budgets are spent on medical non-adherence so you think they would want to lower those numbers!

There was a Medco study a few years back that showed improved adherence rates lowered overall healthcare costs. Yes, prescription costs go up, but wouldn't you rather pay a few hundred dollars a year for medications instead of a few thousand for each hospital visit?

To address your readers comments: doctors spend 2.3 minutes discussing their prescribed medication regime with their patients; 32% of patients do not know what medications they are taking or why when they leave their docs office; medication adherence is a daily problem - refill reminders are nice, but what about the other 30 or 90 days when you have to take the medication everyday?

What is your stance as a CEO of a hospital? Do you want to see the same person come in three times a year due to medication non-adherence, or would you rather treat them once?

Medication non-adherence is wasting vast resources in our healthcare system, and needs to be addressed more proactively.

Nichole said...

AHHHH! Paul, I hate to see you step on this landmine & am surprised no one has commented as of yet. Adherence and compliance are some of the worst terms in the health care industry!

Definitions are as follows:
Adherence- the quality of adhering; steady devotion, support, allegiance, or attachment.
Compliance- 1. the act of conforming, acquiescing, or yielding; 2. a tendency to yield readily to others, esp. in a weak and subservient way.

They imply that what the doctor says, goes, and if the patient doesn't do it, they are somehow not invested in their health. We know this isn't true, but still the terminology persists. I agree that not taking meds, especially for chronic conditions like diabetes, asthma, and heart disease, is a big problem. However it only masks that people don't understand their meds & their importance, can't afford them, and don't feel like they are activated participants in their own health care experience.

Another way to approach this problem is to adjust the locus of control from the hands of the medical system to those of the person visiting the health care system (i.e. the patient) through the use of shared care plans and self management support. The health care system contributes a mere 10% to our overall health (Schroeder SA. Shattuck Lecture. We can do better--improving the health of the American people. N Engl J Med. Sep 20 2007;357(12):1221-1228), yet at times the system acts like it owns the whole pie, instead of just a slice. "Adherence" and "compliance" have got to go.

Anonymous said...

This will sound simplistic, but there's a possible solution in packaging. When I don't adhere or comply, it's usually because I forget or it's too much of a bother (take 1 pill four times a day 1 hour before eating). By noon I don't remember if I took the morning dose or not and I'm guessing that anybody with a health issue feels the same way. I only remember if I box it all in schedule boxes.

Why not start me off that way? What if you gave me a packet similar to birth control packaging? I think it's very effective for birth control use, why not for everything? I might remember to take that antibiotic on schedule for once.

Anonymous said...

@mdspencer: there are a few companies that will package all of your pills for you in shrink wrap with the medications listed, as well as what time to take them. I can't think of the names off hand, but they do help for polypharmacy and multiple dosing. Packaging can play a key role in adherence as well, considering the elderly with poor eyesight can barely read pill bottles.

@nicole w - I agree that compliance is such a negative term, but adherence is inline with a prescribed course of action - you could use concordance - but the NCPIE report of last year asked that all stake holders simplify the language so patients know what their providers or payers are referring to. I agree that cost and education are issues - but as Dr. Showalter says, how do you convince patients that healthy behaviors and doctor recommendations are good for them? What term would you suggest?

Anonymous said...

Considering Express Scripts was fined close to 10 million dollars to over half the states in this country at the end of last month, I offer the following related written words to educate others, so let's see how authentic the moderator in fact is regarding comments of the posts:

The Price of Innovation Combined With Corruption

Recently, you may have heard or read in mass media sources about the issue of pharmacy benefit managers who have clients that are prescribed biologic medications and then are required to pay a great deal of money for such meds due to the placement of these meds on their PBMs. This is due to their status on the PBM, which is known as Tier 4 status, which requires patients to pay higher co-pays for these meds. Tier 4, which also includes lifestyle meds, is determined by the PBM based on variables such as rebates and discounts from the manufacturer, which are intended to be passed on to the PBM clients. However, in some cases, the PBMs fail to do this, and have been penalized for their self-interest above patient interest as required when this activity is discovered. Regardless, because of the tier 4 status of biologics, very sick patients have to pay a great deal of money for these meds. PBMs, by the way, are pharmacy benefit managers that were created apparently to meet the pharmaceutical needs of employees and are a benefit along with their insurance through their employer. Furthermore, what an employee pays for their prescribed meds is determined by their employer, who may or may not have an element of cronyism with a PBM. It is my understanding that PBMs and those that own them are now paying doctors possibly 100 dollar per patient to switch their treatment to a generic equivalent, or to initiate treatment with a generic. Perhaps this is a response from the pharma industry paying remuneration to doctors for so long. Fight corruption with corruption

First of all, and returning to biopharmaceuticals, biologic meds are specialty meds created differently than other typical meds, and therefore are have a unique molecular complexity that are designed for serious illnesses such as anemia or multiple sclerosis. They are created with living material, unlike synthetic molecules typically created to have a new molecular entity. Because of their uniqueness and exclusivity, they are very expensive- costing thousands a month for the payers. In addition, generics are not authorized to be produced as of yet for these types of meds. Their cost of these biological meds is contributed more for the complex process of their creation, as the material costs are typically less expensive than traditional molecular medications.
Biologics began to be used primarily in the 1980s and now presently make over 60 billion a year, with about 20 percent growth in this market annually. With anemia patients, oncology and dialysis clinics are targets for such meds in this category, as anemia is associated with their treatment and conditions for such diseases.

Yet, some claim that biologic meds benefit patients to only a certain degree, as they extend life of such patients, such as those on chemotherapy or dialysis, by only a few months, so the high cost of the meds is questionable and has been analyzed by others, yet no substitutes exist for biologics, so that’s why the producers of these drugs can charge so much for these products. Efficacy of these biologic meds have also been questioned as well in other treatment aspects aside from life extension, such as the money such patients pay because others refuse to obey their commitment to them. Words instead of action.
Then there is the issue of fraud with kickbacks and overuse of some of the biologic meds used to treat anemia in dialysis clinics in particular. On a few occasions, doctors and clinics have been penalized for overusing the meds and for kickbacks in the form of discounts of the manufacturers. Ironically, the dialysis process was never patented, yet the many centers that exist have proven to be very profitable, more for some than others. An example is the situations where dialysis doctors, called nephrologists, have been accused of over-dosing patients with biologic meds to increase their income through their discount arrangement through the manufacturer of such meds, such as those biologics for anemia, and this arrangement is being investigated by regulators and encouraged by the representatives of such meds. Ironically, the process of dialysis was never patented by its creator so there would be greater use for others, and therefore would benefit others. It’s similar to being criminal in a church, in my opinion
Presently, there are many that approach the FDA to aggressively insist that generic biologics be allowed into the market for the benefit of these critically ill patients, and this would be of great benefit for such patients, and this can be done, as far as the generic creation of these meds. And this situation illustrates one of many flaws in the U.S. Health Care System- when the sickest have to complicate their illnesses by possible financial stress, such as the case with biologic meds. Relief is needed, and should be demanded by the public. After all, why be so sick, and then be financially burdened?

“A little learning is a dangerous thing.” ---- Alexander Pope

The more you discover, the more you have to act,
Dan Abshear

Author’s note: What has been annotated is based upon information and belief.

eeka said...

Agreed re: "compliance" and "adherence." In the supported housing program where I used to be an admin, I was part of devising a policy that stated that we never used this language. This language implies that the provider is always right and the client is flawed if s/he chooses to do something other than that provider's recommendations. We did work with all of our clients on informed consent, which included understanding the pros and cons of a particular medication or type of treatment, and making a decision whether to pursue it.

That being said, there are definitely problems in terms of consistent medication use among people who have made an informed choice to take the medication. We know that diabetes and high blood pressure are much more prevalent in populations of folks who take antipsychotic meds, and these folks are more likely to have organizational difficulties that make it hard to take meds consistently. A number of other more typical folks have undiagnosed learning disabilities, and probably aren't getting any sort of support in terms of strategies that could help them take their meds more consistently. Finally, the whole "compliance" mentality leads to, well, reduced, um, compliance. The medical model teaches people that they shouldn't be upfront with providers about their bad habits -- I'm sure you've seen all the studies showing how people report that their lifestyles (diet, exercise, substance use, medication management) are much healthier and more consistent than they really are. Particularly if someone is older or has a disability, they're not going to feel that they can tell their physician that they forget to take their meds, or that they choose not to take them at times that they don't want side effects. I worked with a number of people in supported housing whose physicians dismissed their concerns about sexual side effects, brushing it off as grandiosity -- people with disabilities don't have sex, right?

I've also been concerned with how readily meds are handed out without seeing if they're really needed and providing full education as to their pros and cons. Many of my clients in supported housing were given scripts for blood pressure meds after having one high reading in the doctor's office and no supporting bloodwork. (My blood pressure is quite a ways into the "high" range every time I go into a doctor's office, while it's quite healthy if I take it at work myself while not freaked out about being at the doctor. But they never say anything to me about my blood pressure, because I look active and don't look disheveled.) Some of my clients took their blood pressure meds, others said they didn't have high blood pressure and didn't plan to take it, and others took it and then passed out a few days later from low blood pressure. It isn't just not taking meds that's a problem -- the issue is more dynamic than that.

Anonymous said...

My dad uses a medication adherence program called dosetrak.

Lily said...

Why don’t people take their medications? Because they cost too much! I’ve seen ads on TV for Caduet. It has two ingredients. One is Amlodipine and the other is Atorvastatin. With my RxDrugCard I can get 30 tablets of Amlodipine for $9 and 30 tablets of Simvastatin for $9. I’ll bet they are charging more than $18 for this new drug! Don’t pressure your doctor into giving you something just because it’s new. Do your homework. Find a drug card like I did at www.rxdrugcard.com. I think that RxDrugCard.com is the best drug card available for prescription discounts.