America’s Quiet Crisis

Troyen A. Brennan, M.D., M.P.H., executive vice president and Chief Medical Officer, CVS Health, offers his perspective on the growing problem of medication non-adherence in the United States, and how CVS Health is tackling this public health challenge. 

Let me tell you a story that’s happening today – and everyday – in America. A man in his 50s wakes up in a sweat. His chest hurts, and he’s out of breath. He goes to the ER. He’s having a heart attack. He survives and is sent home with several prescriptions to manage both his hypertension and high cholesterol to avoid future cardiac events.

Despite the risks associated with leaving his chronic conditions untreated, there’s a nearly 50 percent chance that within six months this man will no longer be taking the medicines he was prescribed. Maybe he’ll forget to refill the prescriptions, or he will be too busy to remember to take them every day. He may think it’s not worth the hassle as he doesn’t feel any better when he is taking his medications. Perhaps the expense will discourage him. Whatever the reason, if he doesn’t take his medications as prescribed, he will be what we call “non-adherent.” Now, the chances have grown significantly that he will suffer another heart attack or even a stroke and find himself back in the emergency room. Next time, however, he may not survive.

Big Problem, Bigger Opportunity

Unfortunately, this scenario is common. In fact, many Americans do not adhere to their medications, forgetting pills accidentally, choosing to stop taking medication, or never even getting started on a therapy. Believe it or not, up to one-third of prescriptions written for maintenance medications are never filled.

Medication non-adherence is a major problem in our health care system – it costs nearly $300 billionThinking outside the pillbox, New England Healthcare Institute. August 2009. and tens of thousands of lives each yearMcCarthy R. The Price You Pay for the Drug Not Taken. Bus Health. 1998; 16(10): 27-8, 30, 32-3.  but it also presents an opportunity. If people just take their medicines as prescribed, we can improve health outcomes, save lives and significantly reduce medical costs for individuals and the entire health care system.

The economics boil down to this: Medicine, even if it’s more expensive than we’d like, is a lot cheaper than hospitalization or dealing with other adverse events associated with non-adherence. Annual pharmacy spending for hypertension, for example, is approximately $400 per year. But for each adherent hypertensive patient taking their medication as prescribed, overall health care costs are reduced by nearly $4,000 annually.Roebuck CM, Liberman JN, Gemmill-Toyama M, Brennan TA. Medication Adherence Leads To Lower Health Care Use And Costs Despite Increased Drug Spending. Health Aff. 2011; 30(1):91-99.  If you do the math, keeping the entire American population on prescribed medicine would result in enormous cost savings for this country.

We’ll never get to 100 percent compliance, of course. But if we could improve our rates by only a few additional percentage points, the benefits would be immense.

Using Insights to Inform Solutions

ScriptSync InfographicSince 2009, our CVS Health Research Institute has been collaborating with academic institutions such as Brigham and Women’s Hospital in Boston to research the causes and impact of medication adherence. In addition, we rely on input from our more than 24,000 pharmacists, as well as behavioral insights uncovered by analyzing prescription data from our millions of customers and those with CVS Caremark pharmacy benefits. Together, this trove of data is invaluable and helps inform our adherence tools and programs to help make it easier for our patients to take their medication as prescribed.

For example, in one of our studies that was published in the Archives of Internal Medicine, we found that patients with chronic diseases taking multiple medications may make numerous trips to the pharmacy each month for refills making it harder to keep track of their prescriptions and stay adherent.Choudry NK, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, Pakes J, Brennan TA, Shrank WH. The Implications of Therapeutic Complexity on Adherence to Cardiovascular Medications. Arch Intern Med. 2011; 171(9): 814-822. These learnings informed ScriptSync™, a new pharmacy service that enables eligible patients with multiple maintenance medications to pick up their prescriptions in a monthly CVS Pharmacy visit by aligning patients’ prescription fills. Once aligned, prescriptions are refilled on the same day, and prior to the pickup date, patients can receive a call or text message when their order is ready.

In another study, we found that simple electronic reminder systems can help patients take their medications and improve adherence.Misono AS, Cutrona SL, Choudry NK, Fischer MA, Stedman MR, Liberman JN, Brennan TA, Jain SH, Shrank WH. Healthcare Information Technology Interventions to Improve Cardiovascular and Diabetes Medication Adherence. Am J Manage Care. 2010; 16 (12 Spec No.): SP82-SP92. Based on this, we evolved our CVS Pharmacy mobile app to help users manage their prescriptions more easily from their smart phones. In fact, the app now reminds users to refill and pick up their prescriptions by sending text alerts. In 2014 alone, we delivered more than 165 million text messages to help our patients remember to pick up their medications.

We are also using insights from our data and predictive analytics to more effectively target medication adherence interventions, improve health outcomes and reduce health care costs. For example, we recently launched our vulnerable patient index, a tool that uses pharmacy claims data to identify those patients most likely to generate high costs due to poor medication adherence and enable tailored interventions that address individual medication use challenges.  And in communities where we have affiliations with medical centers and health systems, we are able to share pharmacy data on these interventions with patients’ primary health care providers through electronic health records to help connect and coordinate patient care across the health care continuum.Medication adherence is a major public health challenge, and we aren’t going to solve it overnight. However, by helping to make it a little bit easier for people to take all of their medicines as prescribed, we are working to improve our nation’s health.