Next Time You Look Down Your Nose at Patients Who Lie About Taking Their Medications, Remember This...

AUGUST 30, 2017
Troy Trygstad, PharmD, PhD, MBA, Pharmacy Times® Editor-In-Chief
PATIENT NONADHERENCE: FROM AFTERTHOUGHT TO FRONT AND CENTER
Patient nonadherence has become a front-andcenter issue for pharmacists over the past few years, with Medicare Part D star ratings driving a sea change in awareness and subsequent motivation to act on the part of the pharmacy. Medication nonadherence, as measured by proportion of days covered (PDC), can drive reimbursement bonuses through incentives or disincentives, as is the case with direct and indirect remuneration (DIR) fees. Regardless of what you think of PDC and DIR constructs, it is likely you are paying attention to prescription fill rates and have put 1 or more processes into place in your pharmacy to attempt to increase PDC for at least 3 classes of drugs (HMGCoA inhibitors [statins], renin angiotensin system antagonists, and oral diabetes medications). This represents a significant shift in attitude and work process for an industry that barely acknowledged the problem existed even 10 years ago.

WHY SHOULD I CARE WHAT THE PATIENT DOES WHEN THEY ARE NOT IN FRONT OF ME?
Prescriber and pharmacist attitudes toward patient adherence can be an important factor in the patient– provider relationship. For decades, the prevailing attitude among prescribers was “My job is to diagnose and treat (by prescribing the right drug). What happens after they leave my office is not my doing.” In a fee-for-service model, that posture is not in conflict with the business model. However, in a population management–based system of reimbursement, what the patient does (or doesn’t do) between prescriber and pharmacy visits drives outcome metrics and, subsequently, reimbursement. This puts not only the existing practice model into question but also the business.

It’s also important to understand that patient nonadherence affects physician and other care team member metrics, either directly or indirectly. Seventeen of the 33 measures of success in accountable care organization–shared savings models are directly tied to how practices manage medication and medication taking.1

“I DON’T UNDERSTAND WHY PEOPLE DON’T TAKE THEIR MEDS”
All of us have been frustrated by patient nonadherence at some point in our careers, particularly when there is a clear connection between nonadherence and poor outcomes, even those that one might think motivate the patient to act, such as poor lab findings (glycated hemoglobin and low-density lipoprotein) or vitals (blood pressure readings) that they are told put them at risk for bad things down the road (heart attacks, stroke, blindness, amputation). Even when patients have immediate physiologic feedback (eg, depression, pain), they still often don’t do as we say.

It’s all too easy to throw your hands up and say, “Look, I can’t influence these patients. They don’t take care of themselves. They are not motivated to take their medications. It’s a patient problem— not a health system problem.”

“I DON’T UNDERSTAND WHY PEOPLE DON’T BRUSH THEIR TEETH AND FLOSS”
Well, before we judge our patients, let’s look inward for a moment. Interestingly, nonadherence to flossing recommendations mirror medication nonadherence. The first nationally representative analysis for determining how many individuals floss their teeth found that 30% floss daily, about 37% floss less than daily, and about 32% never floss.2 These rates of nonadherence fly in the face of a direct line between the activity (flossing) and poor and not-so-fun outcomes, such as cavities, gum disease, and, eventually, the need for dentures. You’d think that would be enough to motivate everyone to floss daily, right? Well, apparently not. And in this instance, there is no point in exaggerating adherence level when speaking to the dental hygienist.

HEALTH CARE PROVIDERS ARE NO BETTER
So what about this clearly nonsensical behavior of not doing what your health care providers tell you to do? Must be lack of education and understanding of the importance of it all, right? Wrong. Nonadherence rates among health care providers are just as poor as they are among patients. Every health-system employee will tell you that the cardiologists have the same smoking culture (and popular spots on campus for 15 breaks) as the front office staff and orderlies.

MASTERING THE MODIFICATION OF HUMAN BEHAVIOR IS KEY TO AN OUTCOMES-DRIVEN SYSTEM OF REIMBURSEMENT
These realities should cause us to think differently about patient nonadherence. We are all rational in our own minds, and motivational interviewing techniques provide helpful insights and bring us down to the patient’s level. All of us have unique patient goals, health concerns, life stressors, and environmental factors that strongly influence our behavior. It’s worth thinking about how motivational interviewing, as a training opportunity, may improve your practice—and perhaps your metrics.

PROBLEMS ARE OPPORTUNITIES, AND OPTIMIZING MEDICATION USE IS A SUSTAINABLE OPPORTUNITY THAT CANNOT BE FULLY REPLACED BY MACHINES
And the good news? Patient-centered and personalized humanto-human contact bucks the trend of industrially engineering the practice of pharmacy to death. As long as machines that fill pill bottles and computer software that detects and resolves therapeutic problems do not meet the full needs of patients, we should find opportunity for sustainable practice regarding the widespread and insidious problem of patient nonadherence.
Troy Trygstad, PharmD, PhD, MBA, is vice president of Pharmacy Programs for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.
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