The healthcare industry is facing a time of great regulatory uncertainty over the next four years under the Trump administration. Industry priorities that many have become accustomed to will be scrutinized and potentially replaced. Regardless of upcoming changes in policy and technology, the U.S. healthcare system must continue to find ways to improve patient outcomes while reducing the costs associated with delivering quality care.
Improving patient outcomes while reducing or managing costs is a problem that must be tackled from many angles, in part by focusing on specific areas of healthcare to identify sustainable solutions both in delivery and long-term impact.
Medication nonadherence is one area of healthcare that we know affects outcomes and costs and is often debated by various stakeholders in the industry. While many solutions have been explored, a “silver bullet” solution has yet to be discovered. Could pharma be the entity that leads the charge on this problem?
About one-half of all patients in the U.S. do not take their medications as prescribed by their doctors, resulting in poor clinical outcomes, progression of disease, and an estimated burden of billions per year in avoidable health care costs.
In a 2009 research brief, the New England Healthcare Institute estimated that medication nonadherence along with other medication-related challenges could result in as much as $290 billion per year in avoidable medical spending. Medication nonadherence is also a healthcare issue that can impact patients from all walks of life, from those with chronic diseases to patients recovering from an acute condition, such as a heart attack.
Non-adherence impacts the entire healthcare ecosystem
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
The problems associated with medication non-adherence are not limited to just general increases in overall healthcare spending. It also affects other stakeholders in the industry including hospitals, physicians, insurance companies and pharmaceutical manufacturers.
Hospitals and physicians are impacted by patient medication adherence in several ways, outside of general patient health concerns associated with care delivery. For example, medication nonadherence following a hospitalization can result in an increase in hospital readmissions rates, potentially leading to financial penalties that can reach into the millions of dollars a year.
Additionally, for physicians, poor clinical outcomes resulting from medication nonadherence can negatively impact the quality metrics that they are required to report annually to both public and private payers, who rely on those metrics to determine reimbursement rates.
For commercial payers, improving medication nonadherence takes priority when it comes to participating in and earning the highest Star Ratings possible for Medicare Advantage plans. Commercial payers who are approved by the Centers for Medicaid and Medicare Services (CMS) to administer Medicare Advantage plans are paid for this service based on a number of factors, including the quality of care delivered to patients who participate in the plan. CMS considers medication adherence rates for oral diabetes, hypertension, and cholesterol medicines when assigning Star Ratings to Medicare Advantage plans. Plans that earn at least four stars receive a 5% boost to their monthly per-member payments from Medicare—those with lower scores receive no financial incentive from CMS.
While the impact of medication nonadherence on pharmaceutical manufacturers may seem less direct, they may have it even worse than other stakeholders when it comes to bearing the brunt of the problem. That is because manufacturers often take the blame for problems experienced by providers and payers, in addition to the negative financial and organizational impacts that can occur when products are not used by patients appropriately or consistently. A new report from HealthPrize Technologies and consulting company Capgemini indicates that pharmaceutical manufacturers in the United States may lose up to $188 billion in revenue each year due to medication non-adherence for chronic illnesses.
Improving medication adherence may require a coordinated effort led by pharma
While there doesn’t seem to be any question that improving medication adherence would have a positive impact on patient outcomes and healthcare costs, why does it continue to be an ongoing problem? All stakeholders must work together to improve medication adherence. In particular, pharmaceutical manufacturers should feel empowered to lead the charge as a way to prevent downstream problems that would impact their organizations.
Traditional methods such as caregiver support and increased patient-provider engagement are important, but leveraging technology and other patient engagement approaches may help improve things faster. For example, many consumers are now used to technology playing a larger role in their daily lives, and as a result, patients may also expect and respond well to pharmaceutical manufacturers playing a larger role in their overall health.
To deliver on these expectations, payers and providers will also expect pharmaceutical companies to implement onboarding and educational support programs that will improve patient adherence to recommended treatments.
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