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Executive Director, CAHC
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This is a serious problem that requires a thoughtful and sustained response by Congress, the Administration and the private sector.
According to the national survey we commissioned, two-thirds of Americans are not adhering to their prescribed medication regimen. This results in higher health care costs and greater prevalence of conditions such as cancer, diabetes, heart disease and hypertension. Unfortunately tens of thousands of Americans die annually due to poor medication adherence and a study published in the New England Journal of Medicine estimates that hospital admissions resulting strictly from poor medication adherence costs the United States $100 billion per year.
Because the reasons patients fail to take their medications are multi-faceted, solutions must also be multi-faceted to have maximum impact. Medication non-adherence occurs too often due to a combination of social, financial, and behavioral factors. While one intervention may increase adherence for some patients, it may be ineffective for others.
What we do know is that there are many demonstrations, pilot program and reams of research that have or are being conducted that shows the payoff for focused strategies can be immense. Broadly, the opportunity is about $300 billion in annual waste. $100 billion might be saved in avoided hospitalizations, fewer ER visits and reduced hospital stays. Research shows outcomes also improve with improved adherence.
As we began our work on this issue with our diverse and growing partners, it became readily apparent that federal and state programs are not focused on improving adherence, despite the clear return on investment. Likewise, the host of pilots and demonstrations lack coordination, and are ad hoc at best.
The partnership is engaged in developing a coordinated, focused and robust response to the medication adherence challenge. Through our consensus process, we have come to agreement on several changes that will reduce non-adherence.
First, we need to break down the data and payment silos between Medicare’s drug benefit and its physician and hospital benefits. Because these programs are siloed, there are few incentives for Part D plans to invest in robust interventions because they don’t share in any savings from keeping people out of hospitals. One change may be to rework the current Medicare Part D medication therapy management benefit to a more comprehensive approach that would share savings across silos.
Second, we must address communication issues. What our poll found was that simple communication between prescribers, patients and pharmacists may overcome many of the adherence barriers. New models of care coordination, such as a pharmacist-engaged medical home, that leverages information technology, can address communications as they arise.
Practical patient barriers also exist, so we should, third, make things as simple and easy for patients as possible. One way that shows promise is by synchronizing medication fills and refills at the pharmacy once a month. This simple change may improve adherence rates. Initial research has found that adherence and persistence is significantly higher with synchronized patients compared to control patients for all chronic medication classes. In fact, patients enrolled in the program had 3.4 to 6.1 times greater odds of adherence compared to patients not enrolled in the program who had a 52% to 73% greater likelihood of becoming non-persistent.
Finally, we need a better picture of adherence rates across federal programs. The Federal Government finances almost half of all health expenses, but we have little information on adherence rates, particularly in Medicare fee-for-service. CMS, AHRQ and other agencies should start tracking how we are doing so we can do better.
Our diverse partnership continues to work on these issues, and we’ve issued a call to all interested stakeholders to join us in our work. In 25 years in Washington, I haven’t encountered another issue that Members of Congress from both parties have responded to in such a positive way.
We need to capitalize on the growing political support and good ideas for addressing medication non-adherence.
Ola Akinboboye, M.D.
President, Association of Black Cardiologists
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Medical non-adherence is not only a threat to the health of Americans, it is a threat to their economic well-being, and scientific evidence has shown that adherence rates vary among different classes, races and ethnicities. As I have previously mentioned, the relationship between a physician and patient is critical to achieving appropriate, high-quality care. While there are many factors that can steer patients away from taking their medications properly, improved access to treatments, combined with improved education for both the patient and their physician, will play an integral role in resolving this dangerous and costly issue among the African American communities we serve.
Studies show that nonwhite patients are 53 percent more likely to be medically non-adherent to statin therapy, used to improve cholesterol levels, compared to white patients. While this number has improved, down from 75 percent before 2008, more than half of nonwhite patients are currently at risk for becoming non-adherent, which can lead to an increase in non-drug medical spending such as emergency room visits, hospital stays and other related costs. Patients with Chronic Heart Failure (CHF), who stick to their medication regimen, save between $3 and $8 in non-drug spending for each additional dollar spent on medicines.
In the African American community, it’s important to look at the socioeconomic status, insurance status, and other relative factors that may lead patients to take their medications improperly or stop taking them all together. Programs such as Medicare Part D and Medicaid play a critical role in providing patients with the quality health care coverage and access to treatments they need. As CHF is a leading reason for hospitalization among seniors, (one-fifth of all admissions), access to appropriate treatment is critical to improving patient health and increasing adherence rates. Removing barriers to access, such as prior authorization and step therapy, will allow physicians and patients to determine the best paths for treatment.
Additionally, our organization is working to educate both patients and physicians to improve overall patient health and reduce associated short- and long-term costs of non-adherence. Physicians who understand the culture of their patients’ community can better individualize treatments, while increasing patient understanding. Patients who take a more engaged role in following their medical regimen, and are comfortable doing so, are more likely to achieve better treatment results.
Increased access to treatments as well as improved education for both patients and their physicians are two examples of how we can work toward increasing medical adherence rates among our African American communities. We will continue to strive to improve patient health and reduce the health and economic burden of cardiovascular disease within these communities.
Executive Director, National Consumers League
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Taking medication correctly may seem like a simple or personal matter, but non-adherence (or not taking medication as directed) is a complicated, complex and all too common problem.
Patients often have understandable reasons for not taking their medicine as directed. They face some very real barriers. The barriers can vary for any patient over time, with the type of medication, and often a patient experiences not just one barrier, but numerous ones.
These barriers include:
The National Consumers League’s campaign to raise awareness of the importance of medication adherence, Script Your Future, is designed to help patients with chronic conditions, such as diabetes, COPD, asthma, high blood pressure, and high cholesterol, overcome these barriers and take their medications as prescribed. This patient-centered campaign is focused on opening the dialogue between health care professionals and patients about the health consequences of non-adherence. The campaign emphasizes that health care professionals need to ask patients the right questions, not simply hand them prescriptions and expect the patient to understand why she is taking them and the consequences of non-adherence. The campaign also recognizes that some patients may be reluctant to ask questions of the nurse, doctor, or pharmacist so these professionals need to learn how to probe about a patient’s medication taking behavior.
As we have worked on this campaign and talked to patients across the country,
NCL has learned that the more patients understand the impact medication has on their health and the consequences of their own poor adherence, the more likely their adherence will improve.
By encouraging patients to talk to their health care professionals (doctors, pharmacist, nurses) about their medications, they can determine their barriers to adherence and work together to overcome them so they can live a longer, healthier life, and be more in control of their future. Whatever their personal goal may be (lowering blood pressure by 20 points or attending a granddaughter’s high school graduation) it can be used as a motivator to manage medications and health.
Script Your Future is working in communities across the country (with targeted outreach efforts in Baltimore, Birmingham, Cincinnati, Providence, Raleigh, and Sacramento) to encourage more conversations about the health consequences of non-adherence and to provide patients and their health care professionals with tools and resources to help improve adherence among patients with chronic conditions. The integrated media campaign includes an interactive Web site (www.scriptyourfuture.org), public service announcements, material dissemination, social media presence, text message medication alert services, health professions student outreach activities and more.
We’re also teaming up with pharmacy and medical schools, and health professional students across the country to ensure that the next generation of health care providers are aware of the challenges of adherence and are personally committed to do their part as professionals to help patients adhere.
Surgeon General Dr. C. Everett Koop once famously said that “drugs don’t work in patients who don’t take them.” Script Your Future is working together with patients to change the paradigm from one of blaming or shaming patients for not taking their medications, to breaking down barriers that keep patients from talking to their doctors, pharmacists and nurses and ensuring that the causes of non-adherence are understood on both sides. That, we believe, will go a long way toward solving the problems related to non-adherence.
Jon Easter, BSPharm, RPh
Senior Director, GSK
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As a pharmacist by training, and someone who has worked in the pharmaceutical industry for more than 20 years, I have spent a considerable amount of time exploring ways to better integrate the pharmacy practice into coordinated care teams with the goals of improving outcomes and lowering costs. Patient adherence to medication is a significant component to achieving these goals and this issue must be addressed consistently from a variety of angles at multiple stages of care.
It is my belief that greater adherence will come from overall improvements to our health care delivery system. One way to do this - coordinating the delivery of health care through a Patient Centered Medical Home (PCMH) model - is gaining popularity among public and private payers as well as policy makers. The medical home model is gaining momentum because of its value proposition for the patient, physician, and payer by improving outcomes while lowering costs. The medical home model is gaining strong political support as well. The 2010 Patient Protection and Affordable Care Act (ACA) contains several provisions relating to the PCMH - most notable is the creation of the Center for Medicare and Medicaid Innovation (CMMI), which is piloting broad payment and delivery system reforms across the country. In addition to the federal activity, most states understand the value of the medical home and several are currently implementing pilot programs.
Unfortunately, of all the coordinated care work that is being done across the country, very few of these initiatives include clinical pharmacists on the care team, and we must change this in order to achieve greater outcomes. Appropriate use of medications is a key element of a coordinated care delivery system, and in my opinion, pharmacists are the best suited to lead the effort to optimize therapy and help patients achieve their clinical goals.
Ultimately, pharmacists must play a more substantive and coordinated role with other health care providers in patient health management. By doing so, we will achieve greater health outcomes, lower overall health care costs, and improve patient adherence to the medications for which we are responsible.
You can read more of Jon Easter’s viewpoints in his recent article, “Medication Management: Integrating the Pharmacist as the Champion,” on PharmacyTimes.com.