New England Journal of Medicine Article Cites Adherence Support as a Key Priority for Health Care Reform

While gaps in the delivery of evidence-based medical therapies are common, increasing attention is being devoted to what many experts regard as an equally important, yet unrecognized problem: poor medication adherence. A recent article by Harvard’s David Cutler and Wendy Everett titled “Thinking Outside of the Pillbox—Medication Adherence as a Priority for Health Care Reform” notes that as many as half of all patients fail to adhere to prescription medication regimes, leading to more than $100 billion in avoidable hospitalizations and 89,000 premature deaths in the US.

These authors cite out-of-pocket costs for medication as one cause of nonadherence with the 3.8 billion prescriptions written every year in the US. However a recently study found that even among health plans with no member cost sharing for medications, nonadherence rates were 40%. Poor coordination is another factor cited. Better optimization and tailoring of medication regimes at the time medications are prescribed could help. And, for the highest risk patients—those with coexisting conditions taking multiple medications, prescribed by multiple physicians—it is critical that health care providers reconcile the medications that have been prescribed, with the medications that the patient is actually taking. This requires better management and coordination between direct care providers (as well as disease management and case management professionals).

Cutler and Everett emphasize that individual-level factors must also be better addressed to support patient adherence including lifestyle factors, psychological issues, health literacy, support systems, and medication side effects. Research has shown that most patients who are nonadherent make a conscious choice not to take their medications. According to these authors, patients’ “Personal attributes probably have the strongest influence on adherence…engaging and supporting patients in improving their adherence are critical to improving health outcomes.” Consequently, the routine use of formal, evidence-based health coaching approaches that have been demonstrated to improve medication adherence may be among the most effective strategies for improving medication adherence in direct care, disease management and care management programs.

There are a number of best practice models that have been implemented to improve adherence. The article cites integrated adherence support programs at Community Care of North Carolina (CCNC), Geisinger Health System and Group Health Cooperative. Geisinger has achieved 5-7% reductions in monthly costs, CCNC a 5-7% increase in adherence, and Group Health a savings of $476 per patient annually. Each of these organizations leverages information technology and patient-level data. They also provide adherence support through formal care coordination and case management. And, each offer follow-up and patient support by clinicians who are specifically trained to work with patients on adherence issues.

In summary, Cutler and Everett note four lessons learned from adherence support programs:

1) Address financial barriers to medication adherence through reductions in medication copayments and medication adherence incentive programs
2) Make investments in health information technology to document medications and support data sharing
3) Advocate for payment reform that rewards care providers for better patient outcomes and care coordination
4) Support wider adoption of validated screening and assessment tools to identify and target patients who are at highest risk for nonadherence

This information can be invaluable in encouraging adherence at the point of care and in follow-up contacts with patients.

HealthSciences Institute will host a Population Health Improvement Learning Collaborative event on May 7th titled “Adherence is not a Patient Problem: Practical Skills for Better Adherence” with Susan Butterworth, Ph.D, associate professor with Oregon Health & Science University’s Schools of Nursing and Medicine, NIH-funded health coaching authority, and HealthSciences Institute Advisory Board Member.