• Is medication nonadherence a medical condition?

    Zachary Marcum, Mary Ann Sevick, and Steven Handler in JAMA:

    Medication nonadherence is widely recognized as a common and costly problem. Approximately 30% to 50% of US adults are not adherent to long-term medications leading to an estimated $100 billion in preventable costs annually. The barriers to medication adherence are similar to other complex health behaviors, such as weight loss, which have multiple contributing factors. Despite the widespread prevalence and cost of medication nonadherence, it is undetected and undertreated in a significant proportion of adults across care settings. According to the World Health Organization, “increasing the effectiveness of adherence interventions may have far greater impact on the health of the population than any improvement in specific medical treatments.” How can adherence be improved? We propose that the first step is to view medication nonadherence as a diagnosable and treatable medical condition.

    Whoa! That was unexpected. It ought to spark conversation at the next cocktail party, that is if you happen to attend a cocktail party for doctors and health policy wonks.

    I don’t have a lot to add other than some questions: Are behaviors themselves medical conditions? Or are behaviors usually symptoms of the thing we call a condition? For instance, selling all your possessions to get high is an unhealthy behavior, but it isn’t the condition. Drug addiction is. Which do we treat? (That’s rhetorical.) Is medication nonadherence more like drug addiction or more like the thing drug addiction makes you do? If the latter, what’s the real, underlying condition?

    Related to all this is, why don’t drug companies do more to promote medication adherence? Don’t they have a business interest in people using more of their products? I think someone once wrote me about some legal obstacle to drug companies promoting adherence in some way, but I don’t recall what the issue was.

    Also, isn’t the hospital that is now at the center of an ACO much more interested in medication adherence than it used to be? Pre-ACO, the hospital earned greater revenue if its patients didn’t take their meds and ended up back in the ED or OR. Now, as an ACO, perhaps the hospital has a greater incentive to treat the condition more cheaply. If that’s possible with drugs, adherence should be paramount.

    Your thoughts welcome.


    • I don’t think it makes sense to see nonadherence as a medical condition due to the lack of a common physiological mechanism that causes the nonadherence. For one, there are many different reasons for nonadherence. The better course of action is to target the root- the actual reasons for the nonadherence.

    • I think one could consider patient non-adherence to a medication regimen to be a diagnosable condition in the prescribing clinician, who failed to adequately investigate and incorporate patient preferences and the patient’s social context, failed to explain what the medication would do and why it was important, and failed to ascertain if the patient understood and was on board with the shared decision…

      Just saying.

      Peter Elias, MD

    • Defining nonadherence as a medical condition seems inappropriate given that the effectiveness of medications for conditions varies widely. In addition, besides the behavioral phenotypes of nonadherence mentioned by the authors, nonadherence can result from problems accessing or paying for a medication. Identifying nonadherence is important, but medicalizing this behavior might not be as useful.

    • Well, after reading the full article, I don’t think the authors necessarily proved the headline, that nonadherence is a preventable and treatable medical condition.

      It’s certainly a detectable health behavior, though, and the authors do mention that six established screening tools to address various facets of nonadherence.

      As to why drug companies don’t do anything significant to promote adherence, I suspect it’s because they mainly don’t have close patient contact. Forbes did report that some of them are teaming up with health systems to promote adherence.


      In principle, if insurers had good communications with physicians, they could alert them to medication nonadherence. They do, after all, have access to medical and drug claims. They should have or should be able to hire some programmers and analysts to parse the claims. For example, they could see who had been diagnosed with diabetes, and then who regularly filled insulin scripts. I have no idea how many insurers do this, though.

      PS, ability or inability to process complex information is one cause of nonadherence. An earlier post discussed the influence of cognitive impairment and poor numeracy on sign up for the Part D low income subsidy. I would bet that cognitive impairment and low numeracy has an influence on medication adherence as they impair ability to process complex information.

    • Wouldn’t trust in a physician improve the likelihood of patient compliance? Making the physician into a widget, or a member of an ACO (very big and powerful HMO), or reducing the time a physician spends with a patient all work to make patients suspicious of physicians so ‘why follow the physicians advice?’ Look at how much money is spent on healthcare and then subtract the care not followed. That is a large amount of money and could pay for a lot of things.

      ” We propose that the first step is to view medication nonadherence as a diagnosable and treatable medical condition.”

      Being fat and drinking a 16 ounce coke must have a diagnosis attached to it as well. that might answer Austin’s first question.

      “Related to all this is, why don’t drug companies do more to promote medication adherence? Don’t they have a business interest in people using more of their products? ”

      That is an interesting question. Maybe since many have Rx insurance it doesn’t matter since people fill the prescriptions anyhow and when the cabinet is full they can give them away or sell them. But, we do see advertisements all the time on TV that work to get patients to ask their physician for a medication while reminding others to take theirs. Drug companies are very smart. They have been known to give lectures to physicians and have lawyers attend telling the physician a malpractice claim could be made for improper treatment if they don’t place the patient on a Statin.

      You have a point that hospitals and ACO’s would want patients to take those medications that would reduce hospital costs. But, don’t you think that doctors and hospitals always wanted patients to take their medication and in this situation just possibly a little bit more. Of course it could also mean that ACO’s want sick costly or costly patients to die because dead patients don’t rack up large bills. That was the problem we had with the HMO and I refer you to Ware JAMA 1996 Differneces in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. ACO’s and HMO’s have the same incentives.

    • Drug companies ARE interested in improving compliance, but haven’t found any cost-effective means for doing so.

      There are some available technologies (e.g. bottle caps that record when the bottle was opened), but they cost a lot (both purchase and administration).

      These get used sometimes when the cost of non-compliance is really, really high. An example might be a Phase III clinical trial in a notoriously non-compliant population like schizophrenics. Non-compliance there might mean the difference between a positive trial or a failed trial, in a program costing hundreds of millions of dollars.

    • No! If this is allowed, then it is a short hop skip and jump to say that smoking, obesity, and illicit drug use are just examples of medical advice non-adherence. These are behavioral problems that we have trouble treating now. Labellings these problems as a further condition only enables the individual who should be taking responsibility for their health. My two cents.

    • I’d argue that part of the problem in promoting adherence is that drug plans have the opposite incentive — they lose money the more scripts you fill. This suggests that ACOs should be allowed to enter into shared savings or preferred arrangements with Part D plans in Medicare.

      • What about an MA-PD plan integrated with an ACO?

        • What do you think about MTM as a solution to this potential problem too?

        • Insurance licensing laws I think prevent full integration between MA-PD plans and the current version of ACOs in Medicare, but I’d expect some MA insurers eventually to contract with ACOs, in which case they could clearly achieve this level of integration. In my ideal world, we’d add enrollment-based ACOs (which would still be provider-led and not licensed insurers) as an option for beneficiaries, which could at least strongly incentivize the use of a particular drug plan (and thus align incentives).

    • Before encouraging adherence it is necessary to ensure that a patient’s medications are appropriate, safe, and effective. Many patients are prescribed medications that cause drug therapy problems. I agree with Dr. Elias that non-adherence is a result of failure to individualize treatment.
      I think we would all agree that adherence is a problem. Less obvious is what to do about it. There are as many causes of non-adherence as there are patients. Studies to improve adherence are rarely effective because they often attempt to use a single intervention on every patient.
      Comprehensive medication management is a process that has been shown to improve outcomes and reduce overall costs associated with improper medication use. This is something that should be paid for any patient that is at high risk for poor adherence including complex medication regimens, not meeting treatment goals, or at risk for hospital readmission. This process incorporates patient preference, evaluates all medications (often prescribed by multiple clinicians), and identifies and resolves drug-related problem.

    • This is one of the areas in which HMOs (and ACOs) should be investing significant resources, since medications can be very cost-effective in reducing other costs, and resulting savings accrue in large part to the HMO, especially in well designed competitive markets (for example, in Medicare Advantage and the FEHBP). Drug companies, on the other hand, face a different calculus, especially for generics. It would presumably be very costly relative to likely profits of pennies per pill to try to promote more sales through direct intervention with patients and/or physicians, even if the company had patient-specific info. And the manufacturer doesn’t know why the scrip wasn’t renewed–it could have been due to switching to a therapeutic equivalent or to a generic, or some medical condition change. PBMs, as middlemen, don’t have an obvious role, and likewise don’t face a good cost-benefit calculus. Indeed, they are paid mainly to keep per capita drug costs low. So it really depends on an HMO or other entity that can benefit directly from keeping the patient out of the hospital, or on unpaid physician effort. This is an area where EHI is supposed to make a big difference, by keeping track of patient compliance, and helping physicians or pharmacies remind patients, but I haven’t seen any studies showing that this actually happens. (If anyone knows of one, please share it.)

      • I will bet that ACO’s and HMO’s will invest considerable resources in trying to save money on pharmaceuticals, but the question arises as to whether the benefit will exist for the patient. There are a lot of expensive medications out there with substitutes that are not as good as the more expensive pharmaceutical. The incentive in this case is to under treat and under treatment is difficult to prove.