Pharmacy-related wasteful spending topped $403 billion in 2010, up from $163 billion in 2009, according to the 2010 Drug Trends Report by Express Scripts. Between 2010 and 2014, estimates put the figure at more than $1.2 trillion.

The chief source of this wasteful spending is not what most advisers would cite first, namely higher-priced brand-name medications or higher costs associated with retail rather than home delivery. Express Scripts estimates that more than half of the pharmacy-related waste - a staggering $258.3 billion - is from patients who do not take their medications as prescribed.

This number may seem like a wake-up call, but non-adherence is nothing new. "We're finding that medication compliance has stayed relatively stable over the last four or five years," says Andy Szczotka, senior vice president of clinical services at HealthTrans. "We haven't seen any major swings in patients becoming more or less compliant as a population in general."

Experts point to a range of causes behind medication non-adherence, from financial pressures to behavioral issues. Most people agree that non-adherence is a concern, but they also admit to being lax. One study conducted for the National Community Pharmacists Association showed that while 90% of respondents think non-adherence is a serious problem, 31% of those same respondents reported not filling prescriptions, 49% said they had forgotten to take their medications, and 29% stopped taking medications early.

However, the costs of non-adherence - higher medical expenditures among them - continue to weigh on plan sponsors, and brokers are increasingly looking for ways to partner with pharmacy benefit managers to help their clients improve patient compliance.


Plan design

Experts largely agree that the impact of copay structures on compliance can't be ignored. "The more you raise copays, the lower your adherence, across the board," says Scot Giambruno, chief executive of Ponte Vedra Beach, Fla.-based consultancy PENSA Health Management. He says that people often don't budget for prescriptions, which means that higher copays are eating into funds that would normally go toward other things.

"Unless they've got a lot of chronic illnesses where it's a big chunk of their budget, it's discretionary income, and there's only so much of that to go around. As you continually increase those copays, you're going to have less and less compliance because people are going to start stretching it out so they can afford [it], or they simply won't get them filled."

Even with reduced copays, John Mitchell, president of Alternative Risk Management, an Arlington Heights, Ill.-based TPA, says that if out-of-pocket expenses are too high, "the sick people get sicker." In his experience, companies don't want financial barriers getting in the way of chronically ill employees having access to their medications, and he suggests that by creating a mechanism to waive copays for those with chronic conditions, compliance will likely improve.

Within the disease management framework, Mitchell believes the company's perspective is likely to be, "Your out-of-pockets [should] go away, because we want you to take your drugs, [and] because you're going to get real expensive if you don't."

"Making sure the copays are designed appropriately for the level of income of the employee base is one of the main things that we [tell] our plan sponsors," says Heather Sundar, senior director of clinical programs at St. Louis-based Express Scripts. However, she believes that noncompliance results not just from financial incentives or plan designs, but also from multiple behavioral issues, such as procrastination when it comes to refilling prescriptions and a simple lack of time to coordinate doctor's visits and trips to the pharmacy.

She says that a home delivery program addresses many of those issues by removing many of the common hurdles. "Patients don't need to refill as frequently, so we eliminate things like procrastination." Brokers should discuss what additional services may be offered through a PBM's home delivery channel to determine if compliance-inducing things such as auto-refills are also available, she suggests.

Mitchell says that, as plan sponsors look for cost savings, they may be tempted to reduce the number of approved pharmacies included in the plan. That, however, can decrease compliance among patients who continue to use local pharmacies. Easing pharmacy restrictions may lead to better adherence for those patients interested in the convenience offered by nearby retailers.



Forgetfulness contributes to non-compliance in a variety of ways, and brokers should discuss all available solutions with their PBM to determine what will work for each employee population.

"I know there are a lot of companies now that have phone banks, and they'll actually call people to remind them to take their shot if they're a diabetic, or to take their medicine," says Tim Elenz, CEO of Benefits Age, a brokerage in Chicago. "They'll actually call your phone and remind you, 'Hey, it's two o'clock, time for your pill.'" He says that many patient behaviors are difficult to change, but simple solutions such as daily reminders may be all that's needed to keep some patients on track.

"Think of yourself as a new patient who's suddenly been told you need to take this hypertension medication twice a day," says Sharon Frazee, vice president of research at Express Scripts, "and suddenly you have to remember to do that." She believes there are a number of barriers to adherence, many of them centered on behavior, and figuring out which type of assistance will work for each patient is important.

One of the ways that Express Scripts determines how best to support patients is through predictive modeling and the Express Scripts Adherence Index. Frazee says they're "borrowing from some of the best of the science in other industries," and that, similar to how credit scores are determined, "we've kind of taken that model to basically build an adherence score."

Once the PBM has an understanding of what an employee's non-adherence "triggers" are likely to be, a range of options exist to increase their therapy compliance. Potential solutions might include the use of simple pillboxes, or more active reminders such as a device that gives audible alerts when it's time to take a medication. "What we're doing is identifying those high-risk patients and offering up a number of personalized interventions once we understand what their barrier to adherence is," Sundar says.

As mobile devices become ubiquitous, brokers should be on the lookout for PBMs that are aggressively researching ways to send out reminders and other adherence-boosting communications via e-mail and text messaging.

"If you were to get a text from your benefit plan . . . that says, 'Our records indicate you need to get your prescription refilled. Would you like us to call in your refill or have your pharmacy have it ready for you on your way home from work?' and you can text 'Yes' back, you're going to increase the compliance significantly, because now all the employee has to do is show up," Giambruno says. Any communications sent in this manner must be opt-in only, he adds.

HealthTrans already offers electronic reminders, though Szczotka doesn't believe they meet the needs of every patient at every time. "We know that not one delivery mechanism works for everybody," he says. When patients don't want to opt in, his group encourages them, as part of their educational process, to put simple reminders on their phone or computer. "If you take a medication daily in the morning, it'll show up at eight o'clock or whatever your time is, to remind you to take it. So, it's specific for you."


Patient education

Educating employees on the importance of therapy adherence is a key component of boosting compliance. Elenz says that resources exist that can help brokers provide the information patients need to commit to changing non-compliant behaviors.

Many insurance companies and PBMs have health education programs and will send health educators to employer sites to conduct workshops and answer employee questions, he notes. He encourages brokers to leverage these readily available and well-informed resources as part of any adherence improvement program.

Disease management programs also present opportunities to introduce educational material to employees. "We have seen benefit designs where educational programs are involved in those disease management programs as part of their health benefits package," Szczotka says. "If we can identify ways to transfer that knowledge base to the patient so they can understand their disease state, to help patients understand why they're taking the medications, it removes the key barriers that we see that occur with the compliance issue."

While the physician's role in patient education shouldn't be underestimated, Sundar says that PBMs may have more frequent opportunities to influence patient compliance.

"In many cases, we do communicate with the physician that there is an adherence issue, but frankly, we have many more touch points with the patient throughout the year than the physician does," she says. "Another important tool that we've found is to make adherence information available to the nurse case managers that may be working for the health plan that the plan sponsor uses, or the disease management or wellness company that the plan sponsor is contracted with." She says that her team has found that coordinating care and making adherence information widely available is "a very powerful way to improve adherence."

"In terms of educating people, people don't realize the resources that PBMs have," Mitchell says. "They tend to believe their physician knows everything about all the drugs in the universe, and the challenge is not to break that relationship with the provider, but to introduce another resource to the patient that is a significant one." He says that brokers should work to create an understanding in patients of the depth of knowledge available through their PBM, because "then patients would be much more willing to be compliant" when confronted with challenging issues such as step therapy. Mitchell believes that smaller accounts tend to have closer relationships between brokers and employers as well as brokers and employees, which often allows for better educational programs.

"In those kinds of environments, I think brokers could do a better job by spending more time on pharmacy," he says, adding that providing information to patients that helps them understand the connection between pharmacy management, outcomes and cost may push employees toward better adherence.


Goals and timeframes

How can broker-advisers help their clients spot success in a therapy adherence improvement program, and what frame should be put around goals and expectations?

"Initially, they should work with their PBM to understand what the compliance programs can bring to their clients," Szczotka says. "One [expectation] is that they potentially can increase overall medication costs, obviously because a more adherent or compliant patient will be taking the medications more frequently, therefore leading to increased expenses." He says that brokers will need to focus on translating that information back to their client in way that helps them understand that increased pharmacy costs could be offset by decreased expenses on the medical side as a result of the reduced need for care.

Using Medication Possession Ratio to measure medication adherence, Frazee says that generally the industry views a score of less than 80% for MPR as poor adherence. "Our current recommendation to clients is to strive for MPR greater than 80% in key therapy classes for chronic conditions," she says. After evaluating MPR in combination with predictive modeling and other pilot research efforts, Frazee says her team, "can now identify which type of adherence intervention has the largest statistically significant increase in adherence for a given Adherence Index score."

"Measuring changes in medication adherence is a challenging metric to track," Sundar cautions. "To adequately evaluate the impact of a potential solution, we look at the data over the period of at least one year, as it is difficult to get an accurate measure in a shorter period of time using Medication Possession Ratio ." She says that when testing other programs, such as home delivery or transitioning patients to less expensive medications, her team may use shorter time intervals to measure the effects.

Increasing adherence may be a tough road, but Szczotka offers encouragement to brokers preparing to tackle the topic.

"What we have found is that for brokers that work with their clients that are focused on the compliance and education portions, we have seen compliance increase in those targeted disease states. Usually, there's a spillover effect in other disease states as well," he says.

Knudson is a freelance business writer living in Arlington, Wash.

Roadblocks to compliance

The reasons a patient doesn't adhere to a therapy regimen vary widely, but some common causes include:

Financial limitations or concerns


Delays in seeing a doctor

Other priorities or time pressures

Unpleasant side effects

General resistance to taking medication

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