Patient nonadherence used to just frustrate doctors. But soon it could cost them money as well.
Last year’s passage of the Medicare Access and CHIP Reauthorization Act (MACRA) raises the stakes for nonadherence. The law mandates that beginning in 2019, in order to receive reimbursement from Medicare practices will have to make a choice: either adopt an alternative payment model—such as the patient-centered medical home—or participate in the new Merit-based Incentive Payment System (MIPS). Under MIPS, physicians’ Medicare reimbursements will be tied to performance metrics in the categories of quality, resource use, clinical practice improvement, and meaningful use of electronic health records.
While the government has yet to develop the rules for implementing MACRA, it’s virtually certain that under either option doctors’ reimbursements will be affected by patient outcomes—which in turn depend heavily on patients’ willingness and ability to follow treatment plans, says Emmy Ganos, PhD, of the Robert Wood Johnson Foundation.
“To the extent that payment is tied to the types of metrics having to do with health outcomes, then it will be important for doctors to do a good job of making sure the care plans they develop in partnership with patients meet their patients’ needs and lead to the outcomes they want,” Ganos says.
The challenge for doctors is made even greater by the continuing growth in the incidence of chronic disease. According to the Centers for Disease Control and Prevention (CDC), as of 2012 about 133 million Americans—half of the adult population—had one or more chronic health conditions, and one in four had at least two chronic conditions. In 2014 the National Health Council estimated that by 2020 the number of adults with at least one chronic disease would increase to 157 million.
“Chronic illness requires a lot of engagement from the patient,” notes Ana Maria Lopez, MD, chair of the American College of Physicians’ ethics, professionalism, and human rights committee. “It’s not ‘take a pill for a couple of weeks and then you’re done.’ We’re talking about lifestyle changes that in some cases may be going against the grain of the overall culture.”
The hurdles doctors face in obtaining that engagement are underscored in a CDC report issued late in 2015, showing that about 35% of the 78 million Americans requiring treatment for high cholesterol were neither taking medication nor making any changes to their diet or lifestyle.
The limited data available regarding the costs of nonadherence indicate that they are substantial. Findings presented at a 2013 CDC conference put the annual cost of medication nonadherence alone at between $100 billion and $289 billion, and $2,000 per patient in physician visits. A 2005 review article in The New England Journal of Medicine concluded that between 33% and 69% of all medication-related hospital admissions in the U.S. resulted from poor medication adherence.
So what can doctors do to improve adherence? The keys, experts say, lie in establishing trust and good communication: involving the patient in development of the plan, making sure the patient understands all the elements of the plan and the reasons behind them, and uncovering whatever reasons may be preventing the patient from adhering to the plan.
Barriers to adherence
Given that patients don’t seek medical treatment intending to disregard a provider’s advice, why does nonadherence occur? Physicians cite a variety of barriers to patient adherence, the most obvious being financial. “Medicines cost a lot, and more and more of that cost is being shifted to the patient,” says Pratibha Patel, MD, president of HealthCare Partners Medical Group in Long Beach, California.
Misinformation is another common reason for nonadherence. “One of the most frustrating things for me is I have the education and experience that let me make what I think is the best recommendation for the patient,” says John Meigs, Jr., MD, FAAFP, a family physician in Centreville, Alabama and president-elect of the American Academy of Family Physicians. “Then they won’t do it because Aunt Sally has a cousin who knew someone who took that medicine and they turned green and died. Some times, fear and ignorance trumps truth and facts.”
Greater media coverage of health issues and the easy availability of information via the Internet are contributing to the problem, says Adrash Gupta, DO, a family practitioner in Stratford, New Jersey. Patients can’t always distinguish between data that’s preliminary or anecdotal and that which is scientifically valid. “They hear some news that this pill causes some heart or liver issues and they don’t want to take it,” he says.
The lack of accurate information regarding a disease and its treatments sometimes leads the patient to a distorted risk-benefit analysis, notes Ripley Hollister, MD, a family physician in Colorado Springs, Colorado, and board member of The Physicians Foundation, a nonprofit grant-making and healthcare policy analysis organization.
Hollister cites the example of a patient with diabetes who, after learning of the possible side effects of a medication Hollister has prescribed, refuses to take it. “The patient doesn’t take into account the risk of the disease process, which is scarier to the physician because we understand this disease is leading to strokes and cardiovascular disease and dialysis,” he says.
A third contributing factor to nonadherence is lack of support. Stopping smoking, increasing exercise and changing eating habits are among the most difficult aspects of health improvement and usually require the support of spouses, family members, and friends. “If I want someone to change their diet, the patient himself may have buy-in but maybe the wife does the buying and the cooking. They can’t partner in the plan unless I include them,” Hollister notes.
Finally, an often-overlooked reason for nonadherence is depression. A 2011 meta-analysis of the association between depression and medication nonadherence published in the Journal of General Internal Medicine estimated that the odds of a depressed patient being nonadherent are 76% greater than a non-depressed patient. “There are patients with chronic conditions who will say, ‘I just don’t care, I don’t want to live, so I won’t do what the doctor recommends,’” Patel says.
A Broad approach
Physicians with experience in overcoming nonadherence recommend a broad approach to the problem that encompasses education, understanding the patient’s situation and any barriers to adherence he or she might face, and getting patients to see how adhering to a plan can improve their lives.
Hollister, for example, says he begins by asking new patients about their health goals and lifestyle, what they know about the medications they’re taking and other aspects of their current health regimen. Then he talks about his own goals for the patient. Hollister relies on his staff to gather preliminary information about the patient’s situation and current medications, and to ensure that lab and test results are available. By the time he enters the exam room, he says, he has formed his own goals for the patient, which then serve as a basis for dialogue. “When the patient leaves that room, my hope is we’ve partnered, we’ve shared in the decision-making. They understand my goals and I understand their goals,” he says.
Hollister even uses the possible financial consequences of nonadherence as a way of strengthening his relationship with patients, telling them that it could lead to a reduction in his reimbursement from the patient’s insurance company. “I’m using that therapeutic relationship to say a lot of people are watching this now, and what you do may reflect negatively on me. Sometimes it helps the patient do the right thing,” he says.
Finding what excites patients
As a physician practicing in the same small town where he grew up, Meigs says he benefits from his knowledge of the community. This serves him well in identifying the real reason for a patient’s visit and thereby develop a treatment plan the patient is more likely to follow. “A patient might come in complaining about a sore throat, but I know their brother-in-law died of a heart attack at age 50 two weeks earlier and that this patient has finally decided he’s worried about himself,” he says.
Even so, he admits, sometimes he has to engage in some “tough love” to persuade his patients to do what they need to do. “I have to remind some of my more hardheaded patients I’m not going to call them every day and ask if they’ve taken their pills. I’m not going to supervise their diet or find out if they went to the gym. It’s just not practical to do that,” he says.
For HealthCare Partners’ Patel, the key to ensuring adherence is tying it to what’s important to the patient. “Get the patient to talk about what excites them about their life, what do they want to live for?” she says. “Maybe it’s a granddaughter’s wedding or a grandson’s graduation. Then the physician can say, ‘would you like me to help you live another 20 years so you can see your granddaughter get married?’ No patient is going to say no to something like that.”
Once the patient becomes engaged in the plan, Patel adds, he or she is more likely to bring up any barriers that might prevent them from following it, such as not being able to afford the medications or not having transportation to get to follow-up appointments. At that point it’s possible to bring in, or refer them to, other resources such as social workers pharmacists, or—in the case of depression—mental health professionals to address the problem.
Helping patients improve their adherence not only improves the patient’s quality of life, Patel notes, but also can bring financial benefits to all involved parties in the form of fewer hospitalizations and emergency department visits. “It’s always cheaper to take care of patients than to have them go in the hospital,” she notes. Moreover, establishing the kind of strong relationships with patients that lead to better adherence can generate the positive word-of-mouth that brings in more patients.
“When the patient realizes we really care about them,” she says, “don’t you think they will tell others in their family and friends? So if you do the right thing, the financial always follows.”