Yet despite these medical breakthroughs, a number of people in America are not benefiting from the treatment advances because of the persistent issue of poor prescription medication adherence defined as, 'the extent to which patients take medications as prescribed by their healthcare providers.' It is estimated that 50% of the 3.2 billion prescription medications dispensed every year in America are not taken as prescribed and the impact in morbidity and mortality is extensive. Affecting Americans of various socioeconomic levels, all ages, and both genders, non-adherence can lead to progression of disease, complications and reduced functional abilities. It is also associated with around 125,000 deaths every year. Non-adherence, along with suboptimal prescribing, drug administration and diagnosis - costs the health care system an estimated $290 billion each year in medical spending and lost work productivity, which translates into 13% of all health care expenditures.
The number of adults over the age of 65 increased from 35 million in the year 2000 to 40 million in 2010, a 15% increase. It is estimated that as many as 55 million Americans will be over the age of 65 by the year 2020. Because aging is correlated with an increase in the prevalence of chronic disease, America is witnessing an epidemic of people who experience multiple chronic conditions.
Due to this, a growing number of Americans are now taking numerous prescription medications daily, often times see more than one prescriber, and are at a significantly increased risk for drug interactions, adverse events and medication errors. Researchers and public health experts placed the avoidable costs associated with mismanaged medication use among people with multiple chronic conditions at $1.3 billion per year, an amount that will increase unless the quality of medication prescribing and use; including adherence to medications, is significantly improved. Half of the estimated 187 million people in America who take one or more prescription medication do not take them as prescribed.
In fact, studies have revealed that 20-30% of prescriptions are never even filled by people, while 50-60% of medications that treat chronic disease are not taken as they were prescribed. In terms of morbidity and mortality, lack of medication adherence is associated with poorer health outcomes, resulting in around 125,000 preventable deaths each year and as many as 40% of nursing home admissions in people who experience type 2 diabetes. From the perspective of the cost to the economy, research estimates that $105 billion is wasted every year on medication therapy non-adherence, of which 69% or $72.5 billion is spent on hospitalizations. Additional findings project that poor medication adherence, along with suboptimal prescribing, drug administration and diagnosis, cost the health care system approximately $290 billion a year in avoidable medical spending and lost work productivity which translates into 13% of total health care expenses.
Multiple Chronic Conditions and Poor Medication Adherence, The Perfect Storm
Driven by the aging of people in America and risk factors such as increased obesity, the prevalence of multiple chronic conditions is rising along with polypharmacy which is defined as, 'the use of multiple medications.' In America today, 27% of people live with multiple chronic conditions to include 1 in 15 children. The heaviest burden; however, is among people age 65 and older. Recent information shows that 68% of Medicare beneficiaries are receiving treatment for at least 2 concurrent chronic illnesses or 21.4 million people.
Among this population, the concurrent use of multiple medications to manage co-existing chronic conditions is common. It is estimated that 76% of people age 60 and over use 2 or more prescription medications and 37% take 5 or more. Studies have also documented an increase in the incidence of drug reactions from 6% in people taking 2 medications per day to as high as 50% in people taking 5 medications each day.
Due to the health issues these people face, multiple chronic conditions account for 66% of America's health expenses and are a major source of Medicare spending. Of the $300 billion Medicare spent in 2010 on health care, the cost for treating the 14% of people with 6 or more multiple chronic conditions was more than $140 billion. Nearly 60% of these people required hospitalization, accounting for 55% of Medicare's total spending on hospitalizations - 70% went to an emergency room while 92% saw a doctor. Nearly 46% had 13 or more visits. In all of these situations, poor medication adherence is common and places people at increased risk for medication-related issues. Costly emergency room visits and hospitalizations may result.
A number of social, behavioral, medical, economic and policy-related factors contribute to the problem. The factors must be addressed if medication adherence rates are to improve. Some critical concerns raised include:
Another concern includes potential breakdown in provider communications during the transition of care from the hospital to an outpatient setting.
A New Action Agenda for Adherence
Based on these findings, a need to advocate for an increased focus on the overlooked challenge of multiple chronic conditions is present. There are ten policy and programmatic solutions to improve medication adherence, beginning with establishment of medication adherence as a priority goal of all federal and state efforts designed to reduce the burden of these conditions. Because adherence is not viewed as an essential element of government initiatives to reduce the burden of multiple chronic conditions, a call has been made for adherence to be integrated throughout the range of efforts underway through a new HHS Multiple Conditions Strategic Framework to improve health systems change and facilitate new research efforts.
Reduce the Cost-Sharing Barriers for People: Lowering or eliminating co-payments for prescription medications used to treat the most common chronic diseases is called for. The cost of medications for some people is a barrier to filling their prescriptions and taking their medications as prescribed.
Eliminate Barriers that Impede the Ability of People with Multiple Chronic Conditions to Refill their Prescriptions: One of the reasons people fail to refill their prescriptions is the need to pick up prescriptions at different times and sometimes at different pharmacies. To reduce these obstacles implementation of the, 'pharmacy home,' model which provides people with a single pharmacy point of contact for filling prescriptions, as well as adopting refill synchronization - which allows people to fill different kinds of prescriptions at one time, is needed.
Incentivize the Health Care System: The reason for this is to incorporate adherence education and medication support as a part of routine care for people with multiple chronic conditions. Research has shown the interactions between people and their health care providers affect how well people manage their conditions. An expanded investment in people/provider education and engagement tools to help clinicians implement best practices for medication adherence and is needed, as well as counsel for people on the importance of following their treatment plans.
Promote Clinical Management Approaches: The approaches are tailored to the particular needs and circumstances of people with multiple chronic conditions. Since people with multiple chronic conditions differ in the severity of their illnesses, prognosis and functional status, health care professionals are encouraged to adopt the American Geriatric Society's guiding principles for treating older adults with three or more diseases. The principles call for eliciting and incorporating a person's preferences and choosing therapies that optimize benefits and minimize harm for people who are older.
Accelerate the Adoption of New Health Information Technologies that Promote Medication Adherence: Because significant innovations in health technology have the potential to improve the flow of timely and complete information on medicine use between people and health care providers, swift adoption of new standards for using electronic health records, incentivizing providers to use health information technology to identify people at risk of medication misuse, and expanded use of electronic reminders and personal health records to improve medication adherence are important.
Stimulate Rigorous Research on Treating People with Multiple Chronic Conditions: This needs to include focused research on medication adherence to promote the safe and appropriate use of different medications. There is not enough evidence-based information regarding how to treat people with two or more concurrent diseases who are taking medications developed and tested in people who have a single condition. Support exists for incorporating medication adherence throughout the research agenda for multiple chronic conditions and examining the best ways to treat the most prevalent clusters of concurrent diseases.
Address Multiple Chronic Conditions and Optimal Medication Management Approaches in Treatment Guidelines: Clinical practice guidelines commonly focus on managing a specific chronic condition and do not take into account the presence of multiple chronic conditions. Accelerated development of updated treatment guidelines where information is included on the most common comorbidities clustering with the incident chronic condition is needed, this may begin with the most combinations of multiple chronic conditions called, 'dyads,' and, 'triads,' which have already been identified by the Centers for Medicare and Medicaid Services (CMS).
Establish the Role of the Patient Navigator: Establishment of the role of the patient navigator within the care team to help people with multiple chronic conditions to navigate the health care system and take their prescription medications as prescribed is needed. Building on the patient navigator model now used in hospitals and cancer clinics across the nation, the plan advocates for pairing people treated for multiple chronic conditions with trained adherence navigators who will, along with people and caregivers, obtain the person's medical records, create an accurate medication list, setup medication counseling as needed, schedule follow-up doctor visits, and facilitate communication between the person and their different doctors.
Establish Medication Adherence as a Measure for the Accreditation of Health Care Professional Educational Programs: At this time, America's medical residency programs are moving towards and outcomes-based accreditation system where medical residents will be evaluated on the basis of required core competencies to include communication and interpersonal skills. From the standpoint of medication adherence, this represents an opportunity to integrate medication management and e-prescribing into the curriculum of medical residency programs while paving the way for establishing medication adherence skills as core competencies within the curricula of nursing, pharmacy, and other health professions as an accreditation measure.