Why the Fervor Over Medication Adherence? Why Pharmacy Should Care?


Drug adherence is one of the hottest topics in pharmacy today. What is driving this and what does it mean for community pharmacies?

Everywhere you turn — in industry publications, academic research, conferences, and even the mainstream press — there is mention of “drug adherence.” (A Google search of this term generates over 10 million hits.) It seems that increasingly drug adherence is a priority for the government, Medicare Advantage plans, private payers, pharmaceutical companies, PBMs, ACOs — and pharmacies.

But why is drug adherence getting so much attention lately? And why should community pharmacies care about it?

Why Adherence? Because Non-Adherence Remains a Huge Problem

Medication adherence is not a new issue, but remains an enormous problem. Half of the 4 billion prescriptions written annually are not filled in their entirety.[i] And, recent studies confirm that the failure to take medications as prescribed has a costly impact on the U.S. healthcare system, with estimates that the current cost could be as much as $290 billion annually — or 13% of total healthcare expenditures.[ii]

Even though the problem of non-adherence to prescribed drugs has been known and researched extensively, the rates of non-adherence have not changed much in three decades.[iii]

A few salient facts that illustrate the continuing adherence problem[iv]:

  • Nearly two-thirds of Americans who take medications do not take them properly.
  • 64% percent of Americans who take medications don’t always take their medications as prescribed; only 33% say they never miss taking their prescription medications.
  • Those who must manage multiple medications are most likely to not adhere; 70% of individuals who take 3 or more medications do not take them properly.

“Drugs don’t work in patients who don’t take them.”

— C. Everett Koop, former U.S. Surgeon General

Why Adherence? Because It Has Been Proven to Work

There is better and better evidence showing the adherence-focused interventions can work. A recent Health Affairs blog posting on adherence[v] highlighted three 2011 studies that showed associations between medication adherence and cost savings; the savings was attributable to lower medical utilization. When people were more adherent to their medications, their overall medical costs declined. These studies included patients with CHF (congestive heart failure), hypertension, diabetes and dyslipidemia. Even though spending on medications increased, there were corresponding decreases in hospitalizations and emergency department visits yielding benefit-cost ratios ranging from 3 to 1 (for dyslipidemia) to even 10 to 1 (for hypertension).

Further, according to a recent Congressional Budget Office (CBO) report, a 1% increase in the number of prescriptions filled by Medicare beneficiaries would cause Medicare spending on medical services to fall by roughly 0.2% ($1.7B).[vi]

“CBO reviewed dozens of newer studies and determined a body of research now demonstrates a link between changes in prescription drug use and changes in the use of and spending for medical services.”
— CBO Report, November 29, 2012

The evidence base increasingly shows that better drug adherence leads to a reduction in healthcare costs, and has a positive return on investment.

Why Adherence? Because Multiple Stakeholders Are Now Focused on It

A key reason adherence is now getting so much attention is because multiple stakeholders are increasingly interested in it for varying reasons. Here is who and why they are interested:

    • Government. Health expenditures in the U.S. now represent 17.9% of GDP, total $2.7 trillion, and are continuing to rise. The federal government and state governments pay for much of Medicare and Medicaid, and they view the level of healthcare spending and the continued growth in spending as unsustainable. As a result, efforts are under way to change the payment system and to find ways to control costs. Data showing that improvements in drug adherence can improve outcomes and reduce costs are getting governmental attention as officials look for ways to reduce spending.
    • Health plans. Like the government, health plans are continuing to see costs rise and are aware that improved drug adherence can translate into improved outcomes and decreased costs.
    • Medicare Advantage plans. Per Health Affairs,[vii] health plans provide pharmacy benefits to about 12 million Medicare beneficiaries in Medicare Advantage (MA) programs. MA plans receive a “Star Rating” of 1 to 5, and are focused on receiving 4- or 5-Star Ratings because these plans receive additional payments, which can be significant, as well as marketing advantages.

Of the 53 measures of quality used to calculate Star Ratings, 3 deal with drug adherence. For the 2013 Plan Ratings, CMS assigned the highest weight[viii] to outcomes and intermediate outcomes due to their clinical relevance. Therefore, medication measures used by Medicare receive a “triple rating,” accounting for 45% of total Star Ratings within Part D Stand-Alone PDPs, and 20% for the Medicare Advantage programs.

The Star Ratings program is spurring new attention and investments in medication adherence programs among Medicare Advantage plans.

  • PBMs. Increasingly, PBMs are forming “preferred networks” of pharmacies. Previously, the main criterion to be part of a PBM’s preferred network was cost/pricing. But this is changing. Today and in the future, PBMs are expected to be increasingly basing network decisions on “performance,” which looks at outcomes and factors such as drug adherence.
  • Pharmaceutical manufacturers. Non-adherence costs pharmaceutical manufacturers tens of billions of dollars each year, giving pharma companies a significant incentive to improve adherence.[ix]
StakeholderWhy they care about drug adherence
Payers (government and commercial)To reduce total medical costs
Medicare Advantage plansFor good Star Ratings and bonus payments
PBMsNew definition of “performance”
Pharmaceutical manufacturersTo increase revenue

Why Adherence? Because There Are Significant Short- and Long-Term Benefits for Pharmacies

In addition to the many stakeholders interested in improving drug adherence, there are also distinct advantages for pharmacies. These include:

  • Benefits to patients. Certain studies have shown medical costs have declined and outcomes improved from better patient adherence.
  • Filling more prescriptions. Improvements in adherence will mean more patients are having more prescriptions filled, which will generate more fills and refills at the store level and help drive additional revenue, traffic and profit for store owners.
  • Advancing professionally. It is the pharmacist’s basic role to ensure that patients understand their medications and take them as prescribed. This is the right thing to do professionally. Importantly, pharmacists are well positioned in the healthcare system to play a key role in driving adherence, which is just one more way that pharmacy continues to evolve in serving as a valuable community health resource.

Why Adherence Matters

So, non-adherence to prescribed drugs remains a significant, costly problem. But when patients fill their prescriptions and adhere to them, the results include improved outcomes and lower costs. Many stakeholders see the value in drug adherence and are motivated to improve adherence. For community pharmacies, it is important to understand the factors driving the increased emphasis on adherence, the benefits to the pharmacy (more prescriptions filled), improved patient outcomes, and the role of a community pharmacy in improving drug adherence.

Stay tuned for a future article in SmartRetailingRx that will provide details around suggested best practices in drug adherence programs that are implemented by community pharmacies.

[i] David M. Cutler, PhD, and Wendy Everett, ScD, “Thinking outside the Pillbox—Medication Adherence as a Priority for Health Care Reform,” New England Journal of Medicine 362: 1553-155, April 29, 2010, http://www.nejm.org/doi/full/10.1056/NEJMp1002305
[ii] New England Healthcare Institute, “Thinking Outside the Pillbox: A System-Wide Approach to Improving Patient Medication Adherence for Chronic Disease,” August 12, 2009, website
[iii] Ashish Atreja, MD, MPH, Naresh Bellam, MD, MPH, and Susan R. Levy, PhD, “Strategies to Enhance Patient Adherence: Making It Simple,” Medscape General Medicine, 7(1), 4, March 15, 2005, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1681370/
[iv] Greenberg Quinlan Rosner Research Public Opinion Strategies, Lack of Medication Adherence Harms Americans’ Health: Results from a U.S. National Survey of Adults, May 2, 2013, http://pos.org/documents/cahc_2013_public_poll_memo.pdf
[v]Aaron McKethan, Josh Benner, and Alan Brookhart, “Seizing the Opportunity to Improve Medication Adherence,” HealthAffairs Blog, August 28, 2012, http://healthaffairs.org/blog/2012/08/28/seizing-the-opportunity-to-improve-medication-adherence/
[vi] Congressional Budget Office, Offsetting Effects of Prescription Drug Use on Medicare’s Spending for Medical Services, November 29, 2012, http://www.cbo.gov/publication/43741
[vii]Aaron McKethan, Josh Benner, and Alan Brookhart, “Seizing the Opportunity to Improve Medication Adherence,” HealthAffairs Blog, August 28, 2012, http://healthaffairs.org/blog/2012/08/28/seizing-the-opportunity-to-improve-medication-adherence/
[viii] 4 CMS. Medicare Health & Drug Plan Quality and Performance Ratings 2013 Part C & Part D Technical Notes. 8/9/2012
[ix] Liz Tierney, “Patient Non-Adherence Costs Underestimated,” Packaging World, March 22, 2013, http://www.packworld.com/print/54751
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