As the population ages and the costs associated with funding the typical prescription drug benefit continue to increase, plans are more avidly focused than ever on maximizing their return on investment—getting the most out of the precious dollars allocated to prescription drug therapies for plan members.
Historically, this has been accomplished primarily by implementing cost containment programs or instituting benefit limitations, such as expanded formulary management, cost shifting to members, NDC lockouts, increased clinical oversight through prior authorization, pharmacy network optimization, and other benefit management techniques.
While it is true that these strategies remain as fundamentals of modern prescription drug benefit management, plans are increasingly considering prescription drug expenditures in the context of overall medical expenditures, and specifically whether dollars spent or plan design elements employed on the prescription drug benefit can beneficially affect medical costs overall.
One age-old problem given renewed focus and emphasis by plans, consultants, policy makers, PBMs, researchers, and other stakeholders is prescription drug non-adherence. Drug adherence is defined as the extent to which a patient acts in accordance with a prescribed medication dosage regimen.1 A patient is non-adherent if they fail to take their medication as prescribed either by missing doses, misinterpreting directions for use, or abandoning therapy altogether.
A substantial and growing body of evidence supports the [intuitive] notion that patients who adhere to their medication regimen have better health outcomes and lower total healthcare spending. For example, one study from 2011 showed that average benefit-cost ratios associated with patient adherence ranged from 3.1:1 to 10.1:1 for the chronic health conditions measured, with beneficial effects of adherence more pronounced (3.8:1 to 13.5:1) in older patients across most conditions studied.2
Despite this mounting evidence, overall average drug adherence in the United States is poor, especially with therapies used to treat chronic and costly medical conditions—the conditions that plan sponsors are particularly concerned about. Evidence supporting overall dismal adherence abounds. For example, one study found only 51 percent of patients treated for high blood pressure were adherent to their prescribed treatment.1
To address troublesome non-adherence at a plan level, benefit decision makers are increasingly pursuing data analytics and discussing potential solutions, such as implementation of case management or an adherence monitoring program, or both, by targeting therapeutic categories where a beneficial correlation exists between medication adherence and total medical costs.
Under a typical medication adherence monitoring program, patients and/or providers are alerted to probable instances of non-adherence and encouraged to use the drug therapy as prescribed. This is usually accomplished through real-time pharmacy claim surveillance. Other elements can be incorporated into this basic intervention, including referral to case management, copay rewards for adherence, copay penalties for non-adherence, and other tactics.
Improvements in medication adherence increase pharmacy spending. Accordingly, an adherence monitoring program is not a wise choice for a plan focused solely on pharmacy cost containment; rather, these programs are designed for plans that manage employee benefit costs in a “non-siloed” or holistic manner, and have the access and ability to measure medical cost changes over time in specific therapeutic areas.
For those plans interested in learning more about medication adherence in general, including specific studies and articles addressing the problem of non-adherence, or are interested in learning more about the Serve You Adherence Monitoring Program, please see your Serve You account manager.
Our next adherence article will describe the therapeutic categories typically subject to adherence monitoring, and how medication adherence is customarily measured and benchmarked.
Editor’s note: This is the first in a multi-part series about prescription drug adherence, adherence monitoring, and the Serve You Adherence Monitoring Program.
1. World Health Organization. Adherence to long-term therapies: evidence for action. http://www.who.int/chp/knowledge/publications/adherence_report/en/ Published 2003. Accessed May 27, 2015.
2. Roebuck CM, Liberman JN, et.al. Medication adherence leads to lower health care use and costs despite increased drug spending. Health Affairs. 2011; 30(1): 91-99.