As an employer responsible for our employees’ health care, we have wrestled with a problem every health care professional faces: how to get individuals with chronic diseases to adhere to treatment plans for chronic diseases.

How do employers confidentially and optimally encourage employees to be compliant with the treatment plans they develop with their physicians?

According to Dr. Cynthia Rand, Director of the Johns Hopkins Center for Adherence Research, “Medical nonadherence — failing to take medications according to directions — is a major healthcare problem, accounting for more than $300 billion in unnecessary medical costs annually due to adverse drug reactions, emergency department visits, and worsening health.”

Reasons for Medical Nonadherence

What can we do? We must understand why people stop adhering, and then we can devise strategies to address root causes.

Cost of pharmaceuticals is a huge obstacle, which is why we have reduced the cost of many brand-name drugs to reduce the cost-based obstacle to adherence. We have particularly focused on diabetes, cardio-vascular conditions, asthma, and behavior health conditions, and have had great success in reducing our overall medical bills for these diseases. Many health plans and employers increase patient co-pays to reduce short-term costs, but pay huge bills in later years because of non-adherence. We give patients multiple choices as to what drugs they can take, but we want them to take the most effective drug for them, and to adhere to treatment plans.

Cost reduction is only one of the necessary strategies. Other non-adherence root causes include unpleasant side-effects, difficulty of integrating a drug treatment into a daily routine, problems with drug delivery mechanisms, absence of symptoms (which reduces the urgency to adhere to treatment plans), cultural and communication barriers, and general distrust by many people with respect to prescription drugs. While a specific drug may be more expensive in its initial cost, it may turn out to be more cost-effective if the patient prefers the dosing schedule or administration method and is therefore more compliant than would be the case with a less-preferred cheaper drug.

I have lived with side effects of some drugs, so I understand how patients feel. However, there is usually another drug that works with fewer side effects, or an opportunity to reduce the dosage, the frequency, or the duration of the drug treatment plan.

Integration into a daily routine is a real challenge for two reasons: dosage frequency can result in forgetting to take medication, and the need to carry pills while on the go can be challenging. Fortunately, devices like cell phones have alarms to remind us to take medicines. I carry pills in a bottle in my briefcase, and put them in plain sight or in my pocket to remind me to take them. There is no single solution, because everybody’s routine is different, but a plan is necessary for everyone.

I believed that if someone could take a pill less frequently, instead of once-a-day, or three-times-a-day, adherence would improve. Apparently, research does not bear this out, as cited in the Destination RX Blog. Although once-a-day dosages are more likely to result in adherence than those requiring three-times-a-day dosages, decreasing the frequency beyond one-a-day actually results in decreased adherence.

I believe that packaging pills in blister packs rather than bottles helps with adherence because the patient can visually determine whether a pill has been taken. However, many elderly people with weak hands have trouble pushing pills out of blister packs. Nevertheless, some methodology that provides a visual cue for whether a patient is adhering would be great. I recently read a blog posting on Adherence is SIMPill that discusses the development of electronic pill boxes to help people remember if they have taken their medication.

The form in which drugs are administered can make a big difference, both in terms of effectiveness and adherence. Time-release patches may be a great idea for some, because they are easy to apply to the body, work more predictably, and do not create any unpleasantness relative to swallowing.

Ultimately, we should give patients choices of the drug delivery system that works best for them. That will add cost because of reduced production scale for each system, but the ultimate goal is adherence.

Diseases which lack symptoms, like hypertension, create the greatest risk of non-adherence. They need to focus considerable effort on education and outreach for these conditions.

With respect to cultural barriers, we now understand that people of different ages, genders, races, and ethnic groups require different channels and messages to drive adherence. In some cases, the channels may be trusted third parties that we have not previously tapped. For example, I have been told that many African-Americans are best reached for health messages through their churches.

We also need to understand that just as coping with addictions like alcoholism requires support groups and communities of like-minded people, driving adherence may require community support.

With respect to distrust of authorities, we should recognize that even individuals who distrust authority figures will trust someone outside themselves and their loved ones. By identifying trusted sources for every distrustful population segment, we can devise customized adherence strategies.

While HIPAA has done some good things to safeguard individual privacy, to some degree, HIPAA has complicated our ability to reach out to individuals, Some health communications techniques are not available unless we get permission from the patient to have that communication. We will need to borrow some successful marketing tools from consumer product marketing, like “permission marketing,” an approach based on gathering data and getting consent from people before marketing to them. Health care providers and payers, and self-insured employers need to build the trust sufficient to make permission marketing effective in this space.

Increasing adherence is a no-brainer as a solution to our out-of-control health care spending. We need to adopt strategies like those I have described in this blog.


  1. aimee monroy smith says:

    Sometimes, I think the lack of or partial adherence to drug regiments occurs because people do not understand how their drugs are specifically affecting their bodies. In this age of WebMD and prescription drugs that are accompanied with voluminous listings of side affects, there still seems to be much confusion over the purpose of different types of drugs and whether these agents are actually helping. For example, I have often come across people who will stop taking their antibiotics because they start to feel better or will misunderstand the point at which they should start to feel better. I have also heard people express confusion over whether an over-the-counter drug can be used while taking an antibiotic. I have also heard someone express confusion over the difference between their four asthma drugs. Additionally, this type of confusion can intensify if an individual is on a number of drugs due to a chronic condition. It would seem that the role of the pharmacist could address some questions related to possible interactions between drugs, but the pharmacist is only able to discuss the drugs in his/her computer system. What happens when a patient chooses to fill a prescription drug at a different location? An answer may lie in electronic medical records to be carried by a consumer, but hopefully, a patient with complex health care needs and accompanying drug regiments has one physician managing the relationship between all of these things. There seems to be great potential for confusion and possibly adverse consequences from those who are beginning complex drug regiments or from the individual who is on a couple of prescription drugs including an antibiotic and an over-the-counter medication.

    With the FDA choosing to recommend pulling over-the-counter cold remedies for children under six, there obviously needs to be a different approach for assisting consumers with the management of drugs whether prescription or not.

  2. To Aimee Monroy Smith:

    You make a number of great points:

    • I agree that the disclosure on side effects of drugs is flawed. Part of the reason is that the disclosures are written by lawyers to comply with laws, regulations, and court cases. Like many notices and disclosures, they are designed to protect the institution doing the disclosing, not to get the reader or the patient to understand the message. As a broader matter, whether we are talking about investment disclosures, language on drug side effects, or disclosures in financial documents, we need to re-think what we are trying to accomplish.
    • You also are correct that the side effects of drugs are different for virtually every person. Over time, the pharmaceutical industry is moving toward “designer drugs” to customize drugs and dosage levels to individuals. That day cannot come fast enough for me, and, I think, many other people.
    • You are also correct that people stop taking drugs, particularly anti-biotics, when they feel better. Years ago, a very wise doctor, our medical director, Dr. Julian Levine, deliberately gave patients a 3-day dosage for pills and he scheduled follow-up appointments, when he treated a condition requiring anti-biotics. He understood that, after three days, without his intervention, patients would frequently stop taking medication. Second and third visits reduced non-adherence issues. Today, Medicare and insurance reimbursement plans make this kind of approach more difficult because of the low reimbursement rates for primary care physicians.
    • Your other point, the fact that individuals get multiple prescription and over-the-counter drugs from multiple pharmacies is absolutely on target. Pharmacy benefit managers like Medco are trying to make sure individuals concentrate their drug purchases in one place. Beyond that, the Dossia personal health record initiative, which I chair, is designed to consolidate all health interactions, including both prescription and over-the-counter drug purchases, in one patient-controlled record. There are many good electronic health record initiatives, like Aetna’s, Kaiser Permanente’s, AHIP’s, and the more recent announcement by Microsoft. All are excellent initiatives, but ours is unique in both striving to provide a lifetime, universal, and portable capability (“portability” refers to the ability of an individual to take the record with him or her when he leaves one of these organization’s networks), and to get data brought in from all the major pharmacies.

    Thank you for you thoughtful comments.

    – mike

  3. Joy Russell says:

    It is a must that employers should take responsibility with the health conditions of their employees..

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