While medications are one of the key tools physicians have for preventing and treating disease, there are financial, cultural, and structural barriers that prevent the prescriptions we write from being filled and used.
As physicians, we’ve seen it time and again: patients with chronic conditions who are not taking their medications as prescribed.In fact, 30% to 50% of patients with chronic conditions are not adherent to their medications and the ramifications are considerable: 125,000 deaths and at least 10% of hospitalizations in the U.S. each year can be attributed to medication non-adherence.
We see this among every socioeconomic and racial/ethnic group and the causes are varied and complex. Medication non-adherence is especially prevalent among those of lower socioeconomic status (SES) and people of color, populations that already have particularly high rates of chronic conditions. Within these groups, older people are at even greater risk given the prevalence of multiple chronic conditions in that population.
While medications are one of the key tools physicians have for preventing and treating disease, there are financial, cultural, and structural barriers that prevent the prescriptions we write from being filled and used. While physicians can’t solve these issues alone, it is critical that we are aware of the obstacles our patients face so we can take steps to help our patients overcome some of these barriers.
Obstacles to adherence
While the cost of medication is often a major barrier to adherence, there are a host of other factors that also influence whether patients take their medications as prescribed. For instance, distrust of the healthcare system, and of medications in particular, has deep historical roots among Black Americans who have been victims of unethical medical practices.
Language barriers and low health literacy can be additional obstacles because understanding the benefits and proper usage of medication is so essential to our patients’ willingness to follow their treatment plan. For example, a study of elderly asthma patients found that patients with limited English proficiency had poorer medication adherence and outcomes than patients who were proficient in English. While translators can be helpful in these situations, the time constraints of our practice environments are substantial and can limit our ability to have the thorough conversations our patients may need.
Approaches shown to improve adherence
Racial/ethnic and cultural factors can also impact the patient-physician relationship and the communication and trust needed for effective care, including medication behaviors. Studies show that racial/ethnic and cultural patient-physician concordance can help bridge communication gaps and build greater trust among patients. But what these studies also reveal is that the most important factors are the patient-centric communications and collaborative decision-making associated with race-concordant relationships. While there are far fewer physicians of color than can meet patient demand, physicians who take time to listen to their patients and work with them collaboratively can overcome some of the challenges of race-discordant relationships. Additionally, cultural competency training that enhances physicians’ understanding of and sensitivity to different belief systems has been shown to have a positive effect on medication adherence.
Physicians’ workflow and time pressures can make active listening and fully addressing patients’ questions and concerns challenging, but relying on ancillary support can help. For instance, some practices are utilizing community health workers to create stronger bonds with patients. Also, care teams that are racially and culturally diverse can provide extra support and enable physicians to more time to spend with patients during visits. A care team approach utilized at Humana’s senior-focused primary care centers has increased the average time physicians spend with patients to 40 minutes. Moreover, having a behavioral specialist as part of the care team helps address the behavioral health conditions that contribute to medication non-adherence.
Access to medication is another substantial barrier and lack of transportation, financial constraints, and pharmacy deserts are all factors that contribute. Actively encouraging the use of mail order pharmacies can help to improve adherence by increasing accessibility. Mail order pharmacies can also help overcome language barriers that impact adherence by providing information and translation services in multiple languages. Pharmacies—such as CenterWell Pharmacy and CenterWell Specialty Pharmacy, which have more than 100 frontline pharmacists dedicated to improving adherence—offer assistance programs to help patients pay for their prescriptions. Seniors have unique clinical needs and often take multiple medications, and these types of services are often included in Medicare Advantage and Medicare Part D stand-alone prescription drug plans. Additionally, Medicare eligible members can receive affordable insulin with predictable costs with their Part D plans in 2023.
The factors that cause medication non-adherence are complex, involve individual and systemic barriers, and contribute to disparities in health outcomes. Increasing our awareness of the unique challenges that each of our patients face can help us advocate for solutions that reduce the barriers to medication adherence that they face.
Kristin Russell, MD, MBA is the Associate Vice President of Clinical Transformation at Humana. She also provides clinical leadership for Humana's COVID-19 response and consultation to other lines of business, such as the Medicare Prescription Drug Plans (PDP). Prior to joining Humana, Dr. Russell treated patients at Massachusetts General Hospital & in private practice and held leadership positions at several digital health companies focused on clinical analytics and behavioral health. She is a faculty member at Harvard Medical School and an advisor to student entrepreneurs at Harvard & MIT. Dr. Russell is a member of the NCQA Committee on Performance Measurement (CPM), the AHIP Core Quality Measures Collaborative (CQMC) steering committee, and the Leadership Consortium at the National Quality Forum.