A perspective on improving adherence in the one third to one half of Americans who don’t take their medication as directed

Learning how to deal with patient non-adherence is one of the most difficult tasks assigned to a medical professional. Dr. Lisa Rosenbaum and Dr. William H. Shrank conveyed their perspectives on the subject in their recent article featured in The New England Journal of Medicine.

The article discusses issues associated with medication adherence and their ideas on how to combat non-adherence. Development in the adherence  industry is critical to addressing the estimated 100 to 290 billion dollar annual cost burdened by the U.S Government. Accountable Care Organizations are also discussed in the article as a way to provide more efficient healthcare methods at lower prices.

“A new patient with an abnormal electrocardiogram comes to your office. He is 53, smokes, and has hypertension and hyperlipidemia. Though he comes for preoperative risk evaluation, he needs more than ‘medical clearance’ — he needs a primary doctor. Given his risk factors and hesitance to change his lifestyle, you recommend aspirin, a statin, and an antihypertensive. When he doesn’t show up for his stress test, you call him, and he says he doesn’t understand what the fuss is all about — he feels fine. ‘Why don’t you wait until something is wrong with me to give me these medications?’ he asks, launching into a litany of justifications for not taking them: cost, nuisance, potential side effects, not wanting to put anything ‘unnatural’ in his body, and lack of perceived benefit. You attempt to educate him about his risk, but he says, ‘No disrespect to you, Doctor, but I’ve just never been a pill person. But,’ he adds, ‘if something were to happen, you would still take care of me, right?’”

“Of course you would. Our willingness to care for patients has never depended on their willingness to do what we say. But an estimated one third to one half of U.S. patients do not adhere to prescribed medication regimens.1 Because nonadherence leads to increased complications and hospitalizations, it costs the United States an estimated $100 billion to $290 billion annually.2 In a health care delivery system where physician payment will increasingly be tied to patient outcomes, nonadherence poses both new challenges and opportunities.”

“Recognizing that such behavior costs money and lives, researchers have begun testing interventions to improve adherence. Although the multifactorial nature of nonadherence means there will never be a one-size-fits-all solution, interventions ranging from education to elimination of selected copayments3 to telephone-based counseling have achieved modest improvements in clinical trials.2 But even if we had more robust interventions, we’d lack simple, cost-effective ways of targeting the right intervention to the right patient.”

“Now, however, there’s a business case for investing in improving adherence. The Affordable Care Act aims to shift reimbursement from fee for service toward rewarding of improved quality, outcomes, and efficiency. Payment and delivery-system models such as patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and bundled payments encourage greater care coordination by holding providers accountable for total costs and outcomes in their patient populations. Rather than maximizing billing for each patient seen, these models promote efforts to improve population health at the lowest possible cost. But will reforms designed to achieve more for less money motivate the development of innovative solutions to nonadherence — or harm the highest-risk patients?”

Read the rest of the article here.

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