Jason Z. Rose, MHSA, is CEO of AdhereHealth, an innovative technology company dedicated to transforming healthcare.
Anyone who’s worked in healthcare for a substantial length of their career is familiar with the “Triple Aim for Healthcare Improvement,” first published in 2008 by then CEO of the Institute for Healthcare Improvement (IHI), Don Berwick. The idea—revolutionary at the time, but now an essential organizing framework for healthcare organizations across the country—was that healthcare should focus on improving population health, bettering patient experience and reducing per capita healthcare costs.
Around a decade later, the idea of a “Quadruple Aim” was introduced, adding in the objective of improving clinician experience. This turned out to be an incredibly prescient addition, as the Covid-19 pandemic led to unprecedented levels of clinician burnout. Healthcare organizations still struggle to find methods to improve clinician job satisfaction, and many believe this ties to enabling them to achieve better outcomes for their patients.
Just over a year ago, the IHI published the “Quintuple Aim for Health Care Improvement,” with the fifth major area of focus being the advancement of health equity. Here again, the pandemic underscored the challenge facing the healthcare sector, as Covid-19 outcomes showed much higher hospitalizations and mortality rates depending upon ethnicity, geography and socioeconomic status … it’s not the genetic code, it’s the zip code.
Medication Adherence: A Surprising X Factor
Nearly 20 years ago, many healthcare leaders were surprised to learn how much of a difference a simple checklist could make for surgical outcomes. While healthcare organizations were focusing their energy on the latest tools and techniques, it turned out that hospitals were able to save lives and money by ensuring that surgical teams completed simple steps like washing their hands and applying sterile dressings.
Similarly, medication adherence is a seemingly simple—yet startlingly powerful—factor in health outcomes that is often overlooked. As published in the Annals of Pharmacotherapy, nonadherence to chronic disease medications causes over $500 billion dollars of annual medical costs in the United States. Improved medication adherence can certainly have a positive impact across all five Quintuple goals, but it’s particularly interesting to consider how adherence is directly connected to health equity issues. The causality here goes both ways: Different communities face different challenges when it comes to accessing and adhering to their medications; and then those disparities in adherence exacerbate the differences in outcomes for people living in those communities.
Researchers have found that African American and Hispanic individuals are significantly more likely to report difficulty affording medications than non-Hispanic white individuals. In one study (among a mountain of evidence in other peer reviewed publications), during a 2.5-year period, average medication adherence among Black and Hispanic people was at least 7.5% lower than that of white people. Even when researchers controlled for demographics, health status, out-of-pocket costs, and the convenience of refilling prescriptions, they found a racial adherence gap of between 4 and 6 percentage points.
Why Adherence Is Such A Challenging Problem
For those who haven’t spent a great deal of time working on the problem, medication adherence might seem relatively straightforward: Once people have access to the appropriate medication, the thinking goes, all they have to do is take it. But those of us who are closer to the issue understand just how vexing it can be.
For one, many people in underserved communities live in “pharmacy deserts.” There isn’t a pharmacy close to them, and they lack the reliable transportation needed to regularly refill their prescriptions. Also, even what most people think of as a nominal cost for a medication refill ($4, say) can present a financial burden for someone on a fixed income on multiple medications per month. If a person is living on welfare, and they need to refill eight different $4 prescriptions, they may need to make a hard decision about whether to spend that $32 every month on their medication, or on food for their family.
Finally, many patients have unseen issues that prevent them from adhering to their medications. For instance, someone might take their pills for two or three days, realize that the medication makes them feel poorly, and then simply abandon the course of treatment. The healthcare sector needs to find better ways to intervene in these situations and ensure that patients are able to find medications that work for them.
A Holistic Approach To Solutions
There’s no “silver bullet” solution to medication adherence: If there were, it wouldn’t be such a vexing problem. I believe medication adherence is the result of not achieving the most basic needs in life and specifically overcoming the two bottom elements (i.e., physiological and safety/health) layers in Maslow’s hierarchy of needs (I have to use my B.S. in psychology somehow). Many patients simply have other priorities that they need to achieving good health and that ultimately includes adhering to their medication schedules. Both identifying the barrier of care by listening to these vulnerable Americans and then tackling each of them to overcome physiological needs can accelerate the individual healthcare adherence journey. Obstacles to good health include the physiological foundations for the Maslow hierarchy of needs: food, water, shelter, but then move up the triangle hierarchy to safety/health and this requires access to providers, pharmacies, medication affordability and health literacy.
Instead of expecting these foundations of human needs and related health inequities to magically not exist, it is important for providers to focus on addressing each of them. To accomplish this, they must leverage data analytics to help identify people at high risk of nonadherence and conduct proactive outreach to determine what unique issues each individual is facing. It’s critical for plans and providers to have the ability to take immediate action while on the phone with these individuals and quickly identify any potential unused health plan benefits; and connect people with community-based resources that offer free food, low-cost transportation, safe shelter or drug discount cards; or offer medication adherence support via home delivery, compliance packaging or medication synchronization.
By working with patients to address the circumstances leading to medication adherence issues, we can help to solve those problems in a practical, sustainable way—and, ultimately, address the health equity component of healthcare’s Quintuple Aim.
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