Viewpoint: How Nonadherence Is Killing Us—and What Can Be Done

By Robert Nease, Express Scripts Apr 26, 2012

Nonadherence to medications is the costliest health condition afflicting Americans today. In 2011, medication nonadherence—not taking drugs as prescribed by the doctor—cost the U.S. health care system $317.4 billion in treating medical complications that could have been avoided if patients had taken their medication. This amount was higher than the total U.S. medical cost of treating diabetes, congestive heart failure and cancer combined, according to the Express Scripts 2011 Drug Trend Report, published in April 2012.

Much of that cost ended up being absorbed by those paying for the benefit—in many cases, the employers that sponsor group health plans.

Patients who are nonadherent are more likely to suffer from long-term complications and more emergency room visits, unnecessary hospital admissions, additional physician visits and lab tests, and other related expenses than other patients. For HR professionals, that means that health benefits cost far more than they should.

On the other hand, patients who take medications for high blood pressure and high blood cholesterol as prescribed have a 50 percent lower risk of visiting the hospital than demographically similar nonadherent patients. Up to half of cardiovascular hospital admissions might be caused by nonadherence.

According to the 2011 Drug Trend Report, the rates of nonadherence in the U.S. for the most prevalent conditions include:

30 percent among those with high cholesterol.

31 percent among those suffering from high blood pressure or heart disease.

43 percent among diabetes patients.

Specialty Patients

Nonadherence isn’t just a challenge in conditions such as diabetes and heart disease. The cost of nonadherence in specialty patients—those with complex conditions needing specialized care—is even higher. For patients in critical care areas such as oncology, transplant, bleeding disorders and pulmonary hypertension, nonadherence to therapy can lead to expensive and dangerous adverse health effects such as treatment failure, development of complications and even death.

And the costs add up quickly: for example, keeping one transplant patient adherent to anti-rejection therapy can avoid more than $19,000 in unnecessary medical costs per year.

In addition, nonadherent employees are sick more often and take more days off than others, which reduces productivity. This can force employers to reduce benefits.

What’s Driving Nonadherence?

Although concerns over drug effectiveness and cost come quickly to mind, most nonadherence reflects the all too human tendency toward inattention and procrastination. In fact, nearly 70 percent of nonadherence is caused by behavior-related factors, based on findings in the 2011 Drug Trend Report:

Of nonadherent patients, 39 percent just forgot to take their medication.

Failing to renew or refill a prescription accounted for 30 percent of nonadherence.

Looking at Nonadherence Differently

Screening colorectal cancer and hypertension shows us the clear benefits of combining early detection of at-risk patients with effective interventions. These screening tests allow us to identify patients earlier in their course of disease, when intervention is much more likely to be effective. And this raised a question: What if there was a way to screen for nonadherence? One promising area, predictive modeling, allows us to identify—up to one year in advance—those patients at greatest risk for nonadherence. Using health, demographic and other data to estimate how likely a patient is to be adherent, predictive models enable earlier and more targeted interventions by third-party benefit providers in accordance with privacy rules under the Health Insurance Portability and Accountability Act (HIPAA).

These inexpensive interventions can help increase adherence for a large percentage of at-risk people. For instance:

Patients likely to become nonadherent because of behavioral factors such as procrastination and forgetfulness can receive daily alerts, 90-day fills and auto-renewals.

Patients likely to have clinical questions and concerns about their medication can receive a pharmacist consultation.

Patients for whom high cost is the primary concern can be contacted about payment assistance programs, lower-cost medication alternatives and lower-cost pharmacy options such as home delivery.

Screening patients for nonadherence and tailoring interventions for those patients at elevated risk is a promising approach. Reducing nonadherence will save employers and the U.S. health care system billions of dollars in unnecessary health care costs while producing better health outcomes for patients.

Facts About Nonadherence

Curing nonadherence could pay for the health care of 44.8 million Americans.

Most patients think that adherence is important: More than 90 percent agreed that taking medications as prescribed is important for their health, and 81 percent agreed that skipping medication is bad.

Nearly $106 billion of the annual cost of nonadherence occurred in the top three therapy classes: diabetes, high cholesterol and high blood pressure/heart disease.

For many therapy classes, less than 50 percent of patients take their medication as prescribed.

Most patients think that they are more adherent than they are: 85 percent reported taking their medications as prescribed at least 80 percent of the time.

Source: Express Scripts, 2011 Drug Trend Report.

Robert Nease, PhD., is the chief scientist at Express Scripts. He leads the organization’s Research and New Solutions group, and isresponsible for developing innovative programs to tackle today’s health care challenges using current findings from related areas of study. Nease retains adjunct appointments at the Washington University School of Medicine and the School of Public Health at St. Louis University. He also served as an assistant professor of community and family medicine at Dartmouth Medical School.

© 2012 Express Scripts. Reposted with permission. All rights reserved.

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