Not taking medications as intended costs $290B a year, report says

Patients who don't take their medications as prescribed pay a price in poorer health, more frequent hospitalizations, and a higher risk of death. They also incur up to $290 billion annually in increased medical costs, according to a Boston-based health policy group that urges making the issue part of the national debate on overhauling health care.

A report released this week by the New England Healthcare Institute updates a 2001 analysis of the costs of what is called poor patient medication adherence. The new report is based on seven systematic reviews of the medical literature as well as interviews with 16 health care organizations, insurers, drug makers, and technology companies. The work was paid for by this group of stakeholders, but the report was written independently of them, institute executive director Valerie Fleishman said.

"Much of the discussion in health reform today is really about providing better outcomes for patients, and ultimately better health and medication adherence is a fundamental missing link to better outcomes," Fleishman said in an interview. "We believe that it's critical that adherence be woven into the fabric of the health reform debate."

From one-third to one-half of patients in the United States don't take their medications as their doctors intend them to, the report says. Some don't pick up or renew prescriptions, some don't take their medicine in the proper doses or at the right times, and others stop taking them altogether, the report says. The many reasons include cost, unpleasant side effects, confusion about the regimen, forgetfulness, language barriers, and feeling "too good" to need medicine.

People who have chronic illnesses such as diabetes or high blood pressure are less likely to take their medications as intended than people being treated for an urgent problem. One study cited in the report found that the death rate among diabetic and heart patients was 7 percent among patients who took their medications diligently but 12 percent among patient who didn't. Hospitalization rates showed similar gaps.

Rigorous research on the dimensions of the medication problem and its causes is more extensive than research on what might work to help alleviate the problem, the new report says. Small studies have pointed to some promising approaches. Simplifying drug regimens, which could mean prescribing pills to take once a day instead of four times a day, could help patients, particularly those on multiple medications. Educating patients about their disease and their drugs, especially as they leave the hospital, also appears to help. Case managers and pharmacists can also play a role, some studies say. Lowering costs also can improve adherence.

The health care institute recommends some systemwide changes, such as revamping how health care providers are paid. Rather than reimbursing doctors based on the number of patients they see, they could instead be paid based on how well their patients are doing.

"If physicians and other care providers are reimbursed for better health outcomes, we believe that will go a long way toward driving adherence because providers will have incentives to invest in the time and resources and counseling and technology and other tools that are really needed to educate patients and in some cases to change their behavior and to really move the needle on adherence," Fleishman said.

Other recommendations include using health information technology to monitor what happens after the electronic prescription is beamed to the pharmacy and to manage multiple medication regimens.

Dr. Jerry Gurwitz, a University of Massachusetts Medical School geriatrician who has researched drug errors, said keeping patients on the medications they need is a pressing problem, especially among older people who live alone and might suffer from age-related cognitive impairment. He was not involved in the New England Healthcare Institute report.

"I think any person who is practicing medicine is going to say it's one of the biggest challenges and frustrations of providing care to patients right now," he said. "In terms of directly providing care to patients and seeking the best outcomes, this is just overwhelming. I can give an anecdote for every day I see patients."

Today he saw a patient who needs to take potassium supplements because her blood-pressure medication leads to lower levels of the essential nutrient. Her lab tests had showed low potassium levels, so he increased her prescription from four to five pills a day and scheduled another lab test. She missed that test and told him she's not taking what he already prescribed. Now he's worried that she'll take either too little or too much.

"I can give her her medications for free and it's still not going to change," he said. "I can have a nurse or a care management person call, but I need a family member in the house."