Improving Medication Adherence

Starting with basic needs to improve chronic conditions during COVID-19 and beyond

By Matt Phillion

Winston Churchill famously said, “Never let a good crisis go to waste.” In the current healthcare climate, one crisis is front and center on everyone’s mind—COVID-19. But this crisis also offers a chance to reexamine long-term challenges for providing quality care, many of them worsened by the pandemic.

One longstanding problem in American healthcare is medication adherence. This “was a problem before the pandemic, during the pandemic, and will be a problem after the pandemic—people don’t take their meds,” says Jason Rose, CEO of AdhereHealth. “And this causes over a half-trillion dollars in annual unnecessary medical costs.”

A host of additional snares have arisen during the past year, but Rose points out that, pandemic or not, patients struggle with three main medication adherence challenges: The patient never takes a prescribed medication at all. This can occur for a number of reasons such as misunderstanding their chronic diagnosis or the need for taking a medication.

1. The patient takes a medication, but not per evidence-based guidelines and doctor’s orders. Instead, they might split pills or miss doses.
2. The patient doesn’t discontinue taking drugs when advised. For example, if they’re prescribed a statin drug, then later prescribed a replacement statin, they might not realize they should stop taking the first drug.

All of these issues contribute to that half-trillion dollars in annual medical costs, as nonadherent patients often need rehospitalization, emergency treatment, or other interventions. But as we’ve come to understand in recent years, social determinants of health play a huge part in successfully keeping patients on their meds.

“The reason for these medical costs isn’t the patient’s genetic code, it’s their ZIP code,” Rose says.

Rose frames the problem in terms of Maslow’s Hierarchy of Needs, with a healthcare-specific angle. Patients need the basics: food, shelter, health literacy, and access to care. “If you look across the world, you’ll see we’re talking about the same issues for people,” he says.

COVID-19 has created a seemingly endless array of issues with regard to hospitalization. But, Rose contends, if the industry focuses on the core issues of basic needs and access to care, it can prevent a great deal of sickness, hospitalization, and mortality.

“I kept wondering when the story would come out to back this up,” Rose says. Eventually, the CDC figures showed that 94% of COVID-19-related deaths involved issues stemming from chronic conditions. “I asked, who are these people? The elderly, minorities, people residing in the ZIP codes with social determinants of health referenced earlier in the year.”

And this presents an opportunity to make a difference.

Contributing factors

It’s tempting to simply look at the communities most impacted and whether they have access to doctors or healthcare facilities, but the challenge with medication adherence starts long before that. Looking back at Maslow’s Hierarchy of Needs, it begins with the very basics. These core needs take precedence even over economic factors, like paying for the medications involved.

Chief among the core needs is food. “If you don’t have food in your fridge, if you can’t feed your family, if you’re rationing food, you’re going to make that your priority, not taking a drug on a daily basis that you need,” Rose says.

“Some of these patients will have zero-dollar copays due to their government-sponsored health benefits, so it’s not always about cost,” he observes. These patients may need help accessing or learning about food programs, such as Meals on Wheels or local pantries, to move up that hierarchy of needs in their medication adherence journey.

The other absolute basic need patients often lack is shelter. “Medicaid patients are often nomadic,” Rose explains. “They move around a lot.” Programs exist for medication delivery, but that only helps so much if the patient doesn’t have a stable home to deliver to.

And even if they have a residence established, environmental issues can exacerbate chronic conditions, including conditions that have come into play for many COVID-19 patients. “In a shelter, they may not have the best environment to live in,” Rose says. “There may be issues with dust or uncleanliness that lead to respiratory issues, for example. And for some, they may not understand how important those environmental factors are.”

If the patient isn’t educated or can’t make sure their environments are consistent and clean, they are likely not in a position to pay attention to something further up the hierarchy, including taking their meds.

Access to care

Once the most basic building blocks of healthy living are provided for, it will be more possible to help patients address a longer-recognized problem: access to doctors and healthcare facilities. Many live in “pharmacy deserts,” where the issue is a lack of convenient access to medications and trained pharmacists. Unfortunately, COVID-19 has shuttered many businesses, making these pharmacy deserts even more common.

“So they may no longer have access to a local pharmacy, in addition to no access to a private-courier or mail-order option,” Rose says.

Rose adds that his organization believes pharmacists should be on the front line of care. “They are so effective for patients to understand the drugs they are prescribed, why they’re important, what would happen if they don’t take them,” he says. “And then coordinating with the doctor if adjustments are needed. They really are the experts in medications.”

Some states, such as Ohio, have started to put pharmacists on the primary care team, moving in the direction of coordinating all aspects of care for high-risk, high-cost patients.

Delivery isn’t enough

Roughly 25% of patients who struggle with medication adherence fall into the aged, blind, or disabled (ABD) category. They may have a stable living situation and a place to have medication delivered, but “because they are ABD, they may literally not be able to walk to their mailbox,” Rose says.

Once again, COVID-19 has made a problematic situation worse. Many ABD patients have lost their caregiver due to the pandemic—a dangerous situation for patients who often need medications hand-delivered to them.

Telehealth, meanwhile, has been a savior for many patients, but it may be less helpful for chronically ill patients at greater risk, including patients who struggle with medication adherence.

“Telehealth is great, but is limited,” Rose says. While video telehealth calls have been popular during the pandemic, the vast majority of telehealth calls are telephonic—and this means the patient not only needs a phone, but the plan minutes to use it. “The patients we focus on often get phones from the local or state government as part of their Medicaid benefits,” he notes. “But they run out of minutes by the end of the month.”

Another issue with telehealth: It’s not focused on managing chronic conditions.

“It’s great that you can call a doctor. Many systems or practice groups have been income-damaged by the pandemic and switched over to telehealth. But the problem is they’re not geared today toward managing chronic conditions,” Rose says. “Telehealth [has] nearly completely focused on subacute issues, like the sniffles or a rash, rather than helping manage an ongoing condition.”

Tying it all together for better care

Managing chronic conditions can be an administrative challenge—the average Medicare patient sees 5.2 doctors per year, and health records are rarely connected enough to enable, for example, a telehealth line or walk-in clinic to know the patient’s full medical history. The underlying issue centers around data. If the health records are not connected, the data won’t offer a seamless look at the patient, so a doctor seeing the patient for the first time won’t have the background they need to make a fully informed decision. The patient may not be able to explain all the medications they’re on, let alone articulate whether they are keeping up with their doses.

So who has this data? “The health plans,” Rose says. “It’s the claims data. If you look at the data from the health plans, it’s pretty solid in terms of accuracy and timeliness.”
The problem, though, is making full use of the data. “There’s a lot of killer apps out there,” Rose says. “Apple watches and portals, wellness apps. But these apps don’t have integrated claims data. They’re hitting the peripheral, not the core issues.”

AdhereHealth partners primarily with health plans. Their clinical workflow tool, Adhere, pulls patient data into a workflow for patients who have the gaps in care discussed above. It bridges a key technology gap for patients—documenting issues with accessing food, making copayments, or even having bus fare to get to their doctor for follow-up visits and filling medications—to enable follow-up and tracking.

“You click through, drop down, and now you have a plan with discrete data that integrates real-world patient responses from right now, along with pharmacy and medical data,” Rose says. “The artificial intelligence within the system will say, ‘Call the patient back within 14 days. Make sure they have food, shelter, scheduled a doctor’s visit.’ And if they haven’t, now we take a more proactive approach—arrange a call right now. Coordinate with Meals on Wheels. You really need a holistic point of view of the patient: their background, what’s occurred with them during and after their visits, and if they have follow-up.”

All of this is designed to help patients stay on track with their health, from their very base needs to remembering their daily medications.

“You don’t need a Bluetooth-enabled pill bottle,” Rose says. What’s needed is a synchronized system. “If you go back to all these issues, it’s the patient experience,” he says. “If we tackle these hierarchy-of-needs and medication issues, we can really plow some ground.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.