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  • Alan Kellogg

Prescription Compliance and What it Means for You

There are presumably a myriad of questions one may have regarding patient prescription compliance. What exactly is prescription compliance? Why is it important? What are the long-term implications? And what can be done to positively impact medication compliance for your pharmacy benefits membership? This article answers these questions—along with others that may arise—to gain a full understanding of compliance and what it means for you and your clients.

Let’s first delve in to what compliance is. Compliance is, at its core, when a member or patient is diligent in following a medical provider’s instructions for medical care. This can start with taking the correct amount of medication they are prescribed. Other areas of compliance include completing physiotherapy exercises, staying on a physician recommended diet plan, and/or completing radiotherapy for cancer patients. Compliance also includes seeking treatment, following through on taking the prescribed amount of medication as directed, and any follow-up appointments or visits as necessary. The act of being compliant is somewhat broad, but doing one thing out of step from the physician prescribed plan—such as not finishing a round of drug therapy or being inconsistent with an ongoing drug therapy—would be considered non-compliant. Prescription non-compliance is a significant problem in what should be an uncomplicated, highly useful way of bettering the lives of people in need of medical care.

Non-compliance can show itself in many forms. The first, being patients not filling their prescription. Some people may not see the point in going out of their way to get a prescription filled if they don’t see their health condition as something major enough to remain compliant. Once the member has filled their prescription, though, non-compliance could mean missing a dose, taking their medication at the wrong times, using medication devices incorrectly, or not even using the prescribed medication at all once it has been picked it up from the pharmacy. Some patients may lose their interest in taking the prescribed amount if they start to feel better or might be non-compliant due to side effects from the medications, thus not completing the proper round of drug therapy. The consequences of non-compliance will certainly differ from person to person, but the results remain the same: increased health problems in the long run due to incorrect use of prescribed medications.

Why is proper medication compliance important, and how does it impact your Plan and its members?

To illustrate the importance of compliance, let’s look at the risk of non-compliance. If a member is non-compliant in taking medications that are used to treat heart conditions, diabetes, and hypertension, doing so could cause a myriad of more serious medical issues for members in the future, and in some instances, even rather quickly. Forgetting—or even choosing not—to take the prescribed amount of medication for these conditions could result in heart attack, stroke, kidney disease, or congestive heart failure. These issues could then, of course, require medical attention and can be extremely costly for the Plan; much costlier than the member taking their medication as originally prescribed by their physician.

Of course, even with the most diligent of members, there will be days where one may forget to take their medication, or not be able to for unforeseen reasons, and result in a life threatening situation. The real danger arises when non-compliance becomes a regular occurrence. Statistics show that 3 out of every 5 American adults take at least one daily medication, and from 2000 to 2012, the percentage of people taking five or more prescription medications doubled. The World Health Organization stated that about half of all patients with a chronic disease don’t take their medications as prescribed. This lack of adherence to their drug therapy is estimated to cause approximately 125,000 deaths per year, according to the Annals of Internal Medicine. The same study reports that 10% to 25% of hospital and nursing home admissions result from patient noncompliance. Prescription compliance not only benefits the well being of members, but the long-term financial health of the Plan as well.

When a client refuses to take their medication in the manner prescribed to them, there are a number of issues that could arise. Sometimes many more problems than they had initially. A great deal of drug therapies require regular doses to be effective. In some cases, it doesn’t take more than a few missed doses to develop negative symptoms, or to deem the medication ineffective altogether.

As an example of non-compliance that could come with a large and sometimes lethal amount of complications, a patient that receives an organ transplant and is non-compliant with their drug therapy could easily be signing themselves up for a lot of pain, suffering, and extremely high medical costs. After an organ transplant, patients are prescribed anti-rejection medications, at an average cost of $2500 a month, to ensure that their body does not reject the new organ. The cost of an organ transplant ranges from $260K to $1.2M and if a patient is noncompliant with their anti-rejection medication, they not only run the risk of having the new organ not work properly, but the member could possibly have to receive yet another transplant. This is extremely costly, timely, and totally preventable, should there be better—if not 100%—compliance.

While the example stated above is extreme, it illustrates just how dangerous non-compliance could be.

What are the financial impacts to a member being non-compliant?

For many fully-insured employers, more prescriptions filled by its members means higher Rx Plan spend. However, when considering the benefits of proper medication compliance amongst members, consistent fills can actually mean less Plan spend in the long run.

There are significant financial impacts to both the member and the Plan when a member is non-compliant. In the aforementioned Annals of Internal Medicine report, non-compliance has—in the past—cost the American health care system between $100 billion and $300 billion a year, representing 3%-10% of total healthcare costs in the United States. Of every prescription written up, 20%-30% of those are never filled.

A notable and especially relevant illustration of financial benefit is regarding a disease that affects more than a staggering 100 million Americans: diabetes.

The average cost of a compliant diabetic is $8,000 per year, with test strips and lancets to monitor their blood glucose levels, insulin, and oral medications costing around $700 a month. But if we look at the cost of a non-compliant diabetic, their expenditure can range from $20,000 - $150,000 per year in additional medical costs. A non-compliant diabetic member will have more complications surrounding the patient’s already abundant issues, frequent days off of work, disability claims, and a number of hospital stays, both short- and long-term. In extreme cases, members could lose a foot due to an untreated, open sore on the foot causing infection from walking around on it, which then leads to a foot ulcer. Perhaps this seems unlikely, but around 15% of all diabetics will develop a foot ulcer and nearly 24% of people with a foot ulcer will need to get their foot amputated. There is also a chance that the patient could slip into a diabetic coma from hypoglycemia, diabetic ketoacidosis, or diabetic hyperosmolar if they are non-compliant, which can result in a patient becoming brain dead or even lead to death.

Another factor in non-compliance is missing a dose of a medication that helps treat a virus. In recent years, there have been several medications released that have a 98% cure rate for Hepatitis C. These medications also have a high price tag ranging from $56,000 - $120,000 per treatment. The Hepatitis C virus is able to produce millions of copies of itself every day, causing the creation of a mutation that may be drug resistant. If a member misses a dose of the medication, it significantly increases the chances of the virus becoming drug resistant and the treatment may no longer be a viable option for the client to rid themselves of the virus. Once a member has tried and failed one treatment, they must try another form of treatment that could result in more doctor visits and is usually a more expensive alternative to the first.

These may seem like far-reaching examples of the high cost of non-compliance, but unfortunately, they’re more common than they should be.

How can you improve member compliance?

Education is one of the most successful ways of improving member compliance. By helping members understand not only the financial risks of not being compliant, but the long-term impact on their health as well, members can see for themselves what the many benefits of being compliant are. Reaching out to physicians regarding a members treatment plan, healthcare professionals that take the time and effort to educate their patients on the how and why of taking their prescribed medications, and making medications part of a patient’s daily routine are all key in member compliance.

Having access to medication in a convenient location, setting phone alarms, and having a “day of the week” pillbox have all been reported as being ways to keep members compliant with their medications, but if that doesn’t work, and as a consistent, reliable safeguard, there is compliance tracking. Compliance tracking—working with your pharmacy benefits manager and pharmacy consultant to provide compliance reporting—notifies both the member and physician when there has been a missed a refill on a medication. Used as an assistant that can aid healthcare organizations, compliance tracking has been an outstanding new technological tool in making sure that members are remaining compliant. There are a number of different ways compliance tracking can help keep tabs on member’s compliance: identifying where the non-compliance starts and taking steps to establish that it does not happen in the future.

MedGenMed, a medical journal, published an article titled “Strategies to Enhance Patient Adherence: Making it Simple” that uses the mnemonic acronym to assist with easiness in member compliance, choosing to keep it SIMPLE:

Simplifying regimen characteristics;

Imparting knowledge;

Modifiying patient beliefs;

Patient communication;

Leaving the bias; and

Evaluating adherence.

All of these ideas boil down to proper education surrounding the member’s drug therapy, because without the correct information, non-compliance wouldn’t seem like there is that much at stake, like life, limb, time, and/or money. These methods could also be kept in close sight with the use of compliance tracking.

A good question to ask regarding member compliance is why is the non-compliance happening in

the first place? There are a wide variety of reasons for non-compliance in patience, and—hopefully—with help, non-compliance can become less of a problem in the future. There are patients that don’t see the point in taking a daily medication if they’re not feeling/seeing symptoms. A member may need to take medication for asthma and they could feel they don’t need to take it daily if they don’t feel the symptoms of their asthma, but their lungs could still be inflamed and not adhering to the dosage could result in more problems in the future. Other members may have a stigma against taking prescription drugs, so they choose not to. The reason could even be as simple as a member not understanding how the prescriptions help them. In some cases, parents of children who require extensive medical attention don’t want their kids to be burdened by taking daily medication for the rest of their lives, when in reality, doing so would extend or quite possibly save their lives. Perhaps they’re non-compliant for religious reasons. Sometimes it’s simply the fact that the prescribed medication has a side effect they don’t like or that the patient may not have a daily reminder set up to let them know they need to take their medication at that time. If they’re on a round of drug therapy that requires them to take more than one pill per day, non-compliance is especially common. Identifying what the issue is issue and finding a better treatment plan that matches the patient’s habits and activities could be done easily with just a little bit of communication and evaluation.

To further aid in the health of members, plans have a wellness program in place. Plans that implement a wellness program usually see an increase in the overall health of their members. With corporate wellness programs in place, there is a higher chance of managing weight, cholesterol, blood pressure, and overall well being. Health maintenance helps employee productivity and retention and it can reduce both physical pain, like knee/leg pain and neck and/or back pain, in addition to conditions like depression. It has also been noted that wellness programs in the workplace lead to better sleep and hygiene at home, which can all alleviate the many stressors in daily life. Since unhealthy behaviors lead to health risks, which can then cause chronic disease—racking up healthcare costs,—it’s imperative to the health of patients, and the health of the Plan, better habits are implemented in all aspects of life. When implementing a routine in one component of one’s life, it can spill over to others as well. Members want to have a fulfilling life, and work environment is a large part of one’s livelihood, so putting a wellness plan into action in a place where members spend a lot of their time can contribute to accomplishing just that.

Prescription compliance shouldn’t be a complex web of questions, and with minimal tweaks to the system in place, it doesn’t have to be. Longevity of the Plan and its members is the main goal here, and with correct compliance through education, caring professionals, and close tracking, it is easily attainable.


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