Medication Adherence: Taking Pills as Ordered

5/21/2019

Introduction

The Centers for Disease Control and Prevention (CDC) estimates that 60% of Americans live with a chronic condition and 40% have two or more. It is likely that most of us know or care for someone who fits this description. This demographic often manages their health with medication, sometimes taking multiple pills for different conditions. Researchers at the Mayo Clinic concluded that nearly 70% of Americans are on at least one prescription drug, and more than half take two. Furthermore, they estimate that 20% of people are on five or more medicines.

When people living with chronic disease do not maintain their medication regimen, their health can decline often leading to expensive care. Hospitalizations, nursing facilities and emergency room visits associated with chronic conditions are examples of direct costs in the health care system. According to the Milkin Institute, chronic conditions also lead to indirect costs. This is defined as lost income and reduced economic productivity, not only for the individuals living with a chronic condition, but also their caregivers. Given this context,  the combined total cost of chronic disease in the U.S. is equivalent to $3.7 trillion.

Chronic disease has a dramatic influence on the economy. Heart disease, stroke, cancer and diabetes are the leading causes of death and disability in the U.S. Therefore, state lawmakers may want to explore strategies to help people stay on track with their medication to mitigate the impact. A variety of barriers may prevent people from maintaining their regimen. This report highlights two approaches policymakers can consider to lessen those barriers.

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Medication Adherence

Some of the most common chronic conditions afflicting tens of millions of Americans–heart disease, stroke, high blood pressure, pulmonary conditions and mental disorders--can be controlled or improved by consistently taking medications as prescribed. Yet a significant number of such patients fail to take their medicine as prescribed, a practice called “nonadherence” or “non-compliance.” Up to one-half of all patients in the U.S. do not take their medications as prescribed by their doctors. In some cases, poor medication adherence can lead to preventable worsening of disease, shorter lives and even sudden death. It is also responsible for 33 to 69% of all medication-related hospital admissions in the U.S., at a cost of about $528 billion per year, according to one study from 2016.

One of the most important factors for medication adherence is the price of the drug. Some patients ration their medication because of worries about the costs of a future refill, or do not fill the prescription at all. Multiple sources have found that providing medications without copays increases adherence, and therefore leads to better health outcomes.

Medication adherence is especially difficult for elderly patients who are likely to have multiple conditions and take different medications with different dosing schedules, also called polypharmacy. This can be especially difficult after being discharged after a hospitalization and on a new treatment schedule. Because of this, more focus has been brought to how to help this population keep track of multiple medications they may be taking.

Increasingly popular "medication adherence programs" offer a one remedy. Such programs include identifying patients who may have trouble following their prescription dosing instructions and establishing a positive and trusting relationship between the patient and the professional, case worker or volunteer who will help them take their medicines as directed.

Read the original NCSL LegisBrief on this topic Published July 2010.   

Additional Resources and Reading

National Center for Health Statistics (NCHS) Databrief:  Strategies Used by Adults to Reduce Their Prescription Drug Costs - 2019

This report from the NCHS provides data on three primary methods that patients use to reduce the high cost of their prescription drugs to cope with out of pocket costs for name-brand drugs that average 30 dollars—asking their doctor for a lower cost alternative like a generic, using alternative therapies, or not taking their prescription as directed. However, the percentage of Americans ages 18-64 who do not adhere to their medication regimens has fallen over the last few years to 11.4%.

Pharmacy Led Interventions to Improve Medication Adherence Among Adults with Diabetes: A Systematic Review and Meta-analysis - 2018

According to this scientific review of multiple diabetes studies around the world and published in the Research in Social and Administrative Pharmacy, the pharmacist-led interventions with the most success to improve the health of people living with diabetes those that involved an integrated healthcare team, educational and behavioral strategies, and medication review. 

Blood Pressure Control: Helping Patients Take Their Medicine – 2016

According to this report, at least 25% of adults, ages 65 or older, with Medicare Part D prescription drug insurance are not taking their blood pressure medicine as directed. Health care providers, medical practices, pharmacies, hospitals, community health workers, and insurers can work with patients to make taking medicine easier by simplifying blood pressure treatment, involving the entire healthcare team at several points of care to ensure patients are taking medicine as directed, encouraging the use of home blood pressure monitors and addressing financial barriers like high co-pays and deductibles.

Eliminating Medication Co-payments Reduces Disparities in Cardiovascular Care – 2014

This study found that African-Americans and Hispanics generally have lower adherence rates and are prescribed fewer secondary heart medications but providing full drug coverage to these minorities after a heart attack improved their adherence and overall health outcomes while reducing overall health costs.

NCSL provides the following links to non-NCSL articles for informational purposes only; content does not necessarily reflect NCSL positions.

Medication Therapy Management

Medications save and improve people’s lives but, taken incorrectly, they have the potential to make patients worse and cause hospitalizations. Some patients have multiple conditions that require multiple medications that are overseen by different specialists and prescribers. With thousands of prescription drugs on the market, including popular over-the-counter products as well as an array of less-regulated herbs and supplements, it is often the case that no one prescriber knows the complete picture of a patient’s daily medications or supplements.

Published in the Annals of Internal Medicine, researchers estimate that not taking medications as prescribed, costs the overall health care system as much as $289 billion dollars annually and causes nearly 125,000 deaths each year. Medication non-adherence is caused by multiple factors such as:

  • Fear of potential side-effects and interactions with medications they currently use;
  • High costs that cause patients to ration or not take their medication;
  • A lack of symptoms and therefore not understanding the need for the prescription; or
  • Challenges keeping track of multiple prescriptions. 

To find and resolve problems for patients more at-risk for non-adherence, pharmacists and physicians have designed consumer-friendly consultation programs called Medication Therapy Management (MTM.) MTM is typically used when a patient is taking many (four or more) separate drugs, usually for multiple conditions such as high blood pressure, asthma or diabetes. It is typically delivered as a face-to-face visit between the pharmacist and patient where they talk about the prescribing regimen, look for unnecessary medications or harmful interactions between drugs, and give advice on how to stay compliant with dosing instructions.

The MTM consultation can be defined by statute or included in a Medicaid, state, or private insurance contract. MTM is billed and reimbursed as a professional medical service through insurance. These services can also involve caregivers and family members who help the patient with their medication.

What Does Medication Therapy Management Look Like in Action?

MTM Grahic of features

From the American Pharmacist Association: https://www.pharmacist.com/medication-therapy-management-services

The Core Elements of MTM 

An alliance of 10 organizations representing the pharmacy and pharmacist professions designed a uniform definition of MTM that includes reviewing a patient’s current medications including nonprescription and herbal agents, assessing medication-related problems and identifying cases needing intervention by collaborating with other clinicians.

 According to the Agency for Health Care Research and Quality, there are many patient centered tools available to healthcare providers as part of an MTM program such as:

  • Comprehensive Medication Review (CMR): a qualified caregiver provides information to a patient on the medications they are taking, addresses any concerns they may have, and gives them a sense of agency about their medication regimen. Physicians must be aware of cultural and language differences and be skilled communicators for this process to be effective in improving outcomes.
  • Personal medication record (PMR): a comprehensive, reconciled list of all the patient's medications that is given to the patient and other clinicians for self-management, care coordination and continuity.
  • Targeted Medication Review (TMR): continuous medication monitoring is used to track patient’s medication use and any problems that may arise.
  • Medication Action Plan (MAP): a detailed description of the patient’s responsibilities in taking their medications and what the provider needs to do to help them achieve that goal.
  • A Personal Medication List (PML): outlines all the medications a patient uses to be given to other providers when discussing their medications.
  • Intervention, Referral and Follow-Up: keeps lines of communications open between physicians and patients and makes it easy for patients to access personal medication management resources.
  • Online Resources and webpages with information on MTM.
  • Training Programs for healthcare providers that improve communication with patients.

State Level or Medicaid MTM Programs as of 2019

State

Type

Description and Notes

California

Medicaid

California has had a Comprehensive Medication Management program, or CMM, since 2015. It aims to be a more patient-centered approach than MTM and focuses on the diseases more than the just the medications themselves.

 

California also had an HIV focused MTM program from 2005-2010.  

Colorado

Medicaid

The MTM program is called an “Rx Review” program through the state’s Medicaid program. 

Florida

Medicaid

Florida implemented an MTM program that focuses specifically on mental health and psychotherapeutic drugs in 2005. The state also has a general MTM program as a way to reduce pharmacy costs where patients call in to review medications with a trained professional.

Georgia

Hospital
patients

Enacted the Safe Medications Practice Act in 2010 which provides for collaboration between hospital pharmacists and members of the medical staff on drug management therapy for a patient in an institutional (hospital) setting. 

Hawaii

University program

Hawaii created the Pharm2Pharm program which connects patients to hospital pharmacists and rural pharmacists to coordinate medication management through the University of Hawaii at Hilo College of Pharmacy Center for Rural Health Science.

Illinois

Medicaid

The Community Care Alliance runs and MTM program through Illinois’ Medicaid Services and provides a Comprehensive Medication Review and a Targeted Medication Review to enrollees.

Iowa

Private Contractor

Iowa’s MTM program is run by the company OutcomesMTM for its Medicaid program. OutcomesMTM also provides services for state employees and private insurers. The services they provide are medication synchronization, patient adherence consultations and opioid treatment education to pharmacists. Medicaid pays $75 for initial assessments, $40 for follow up problems and $25 for preventive follow-up. Read a study done on the effectiveness of Iowa’s program here.

Minnesota

Medicaid

Minnesota implemented MTM services for low-income patients with complex medical and drug-related needs who are not eligible for Part D.

Missouri

Medicaid

Starting in January 2008, the “Poly-Pharmacy Risk Reduction Program” is run by Direct Care Pro, a division of MO Healthnet (Missouri Medicaid).

Montana

State Plan Benefit

Hometown MTM is a program launched in 2018 that provides medication therapy management to those with state health insurance and their dependents. It is a collaboration between the state insurance plan, Montana Family Pharmacies and the Montana School of Pharmacy.

New Mexico

University program

The University of New Mexico Health Sciences Center runs a state-wide MTM call center that fields questions for the entire state in cooperation with insurance plans.

New York

Medicaid

New York has a drug utilization review program for Medicaid members that is  offered by some pharmacies covered by Medicaid and also through private insurance plans. 

North Carolina

Pharmacy Network

North Carolina provides related “enhanced medication management services” to patients with chronic diseases through the Community Pharmacy Enhanced Services Network (CPESN) through a grant from the Centers for Medicare and Medicaid Innovation to provide services like medication management.

Utah

Medicaid/ University Program

The Drug Regimen Review Center is operated through the Utah College of Pharmacy, contracted by the state’s Medicaid program, and operating since 2002. The Center provides drug utilization reviews to Medicaid patients and give evidence-based recommendations to prescribers.

Wisconsin

Medicaid/ Pharmacy Collaboration

Wisconsin’s Department of Health Services provides MTM services through the Wisconsin Pharmacy Collaborative to Medicaid members. Two insurance plan members also participate.

Research Studies on Medication Therapy Management

  • Findings from a National Survey of Medicare Beneficiary Perspectives on Medicare Part D MTM Published in the Journal of Managed Care and Specialty Pharmacy in 2019, this survey measured Medicare beneficiaries’ satisfaction with MTM services that they received.  Even with low response rates, 40-45% of users said it was it was very helpful or excellent for helping with managing their medications for aspects like keeping track of their medications and correctly using medications.  Forty-five percent of beneficiaries also said that they updated their medication list after their MTM visit.
  • In Connecticut: Improving Patient Medication Management in Primary Care – This study by Smith et al. published in Health Affairs in 2011 showed that pharmacists identified 10.4 drug therapy problems per patient and saved an estimated $1,595 per patient each year during a Medicaid project at federally qualified health centers. This translated to an annual savings of $1,123 per patient in medication claims and $472 per patient in medical, hospital, and emergency department costs. 

NCSL provides the following links to non-NCSL articles for informational purposes only; content does not necessarily reflect NCSL positions.

Medication Synchronization

Medication synchronization, also known as med sync, is a process where patients can “sync up” multiple medications by putting them on the same refill schedule. Pharmacies that offer med sync services will fill partial prescriptions of newly prescribed drugs so that patients can pick up all of their refills the next time they go to a pharmacy. This can prevent patients from making separate trips for each prescription and may increase medication adherence by making the prescription refill process easier. A study conducted by the National Community Pharmacists Association (NCPA) found that patients in a med synch program were 2.5 times more likely to be adherent than those that weren’t.

Furthermore, med sync can be an opportunity for pharmacists to develop closer connections with their patients as a part of “comprehensive medication management,” where they discuss treatment regimens with patients and monitor medication adherence. Pharmacists will often call a patient one week before their scheduled pickup date to discuss any possible changes to prescriptions for medication synchronization. This service is not offered by all pharmacies. The American Pharmacists Association provides a pharmacy locator to help people find a pharmacy that offers med sync services.

Med sync cannot be used for certain kinds of drugs like Schedule II controlled substances and antibiotics. In addition, med sync is often billed as another pharmacist service so any potential cost to patients may discourage them from using it. In response, 32 states have enacted laws that require private insurers to offer med sync at no additional cost to patients at pharmacies in their network and to prorate costs and copays for a partial fill of a prescription. Two other states – Idaho and Louisiana – have made medication synchronization available to patients through rulemaking by their Boards of Pharmacy.

 

Proponents believe it will improve adherence and health outcomes and potentially lower costs to insurers since patients with better medication adherence typically have lower hospital admission rates. Missing medication doses currently accounts for 10 to 25% of hospital and nursing home admissions.

Search for and view enacted medication synchronization bills on the NCSL Statewide Prescription Drug Database.

Additional Resources

  1. The National Community Pharmacists Association “Simplify My Meds” Med Sync Program for member pharmacies
  2. USA Today “Companies help patients manage multiple medications”, June 2014

 

NCSL provides the following links to non-NCSL articles for informational purposes only; content does not necessarily reflect NCSL positions.