How confident are you that your employees are taking the prescribed medications your plan pays for? Research suggests you’d be right to have some doubts.
An average of 20% to 30% of prescriptions across Canada are never filled, and about half of chronic disease medications are not taken as prescribed.1 In pre-pandemic 2019, one survey found that 39% of Canadians were not taking their prescription medications properly, with 25% taking less than prescribed or not filling their prescriptions, 21% stopping medications before they were supposed to, and 19% adjusting the dose, size or frequency without speaking with a healthcare professional first.2
The pandemic exacerbated non-adherence, in part because it reduced access to healthcare professionals who play an important role checking in with patients to see whether medications are effective, suggesting ways to manage side effects, and asking directly if they are taking prescribed doses on time. Between 2017 and 2021, TELUS Health measured a noticeable adherence decline among people with depression, diabetes, gastrointestinal conditions/ulcers and cardiovascular/cholesterol conditions (see table).
The difficulty is, it’s very clear that failing to adhere to medications can negatively affect both employees’ health and your plan’s bottom line.
How does non-adherence affect health?
The U.S. Centers for Disease Control and Prevention (CDC) found that when patients with a chronic illness neglect their medication, their treatment plans fail between 30% and 50% of the time, resulting in 125,000 deaths per year.3
Meanwhile, a report by the World Health Organization (WHO) has highlighted the potential for improved adherence to improve quality of life and enhance patient safety. In fact, it states that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”4
One study that looked specifically at non-adherence in people with cardiovascular disease found that weak or no adherence “leads to unfavourable outcomes for the patient,” which may include more outpatient visits, more hospitalization and re-hospitalization, and a rise in morbidity and mortality.5
A broader systematic review and meta-analysis of the link between non-adherence and adverse health outcomes in people age 50 and older found a significant association with all-cause hospitalization. On the other hand, “good adherence was associated with a 21% reduction in long-term mortality risk.”6
One reason for these associations is that non-adherence can lead to a cascade of problems. It may mean a medication isn’t as effective as it could be, so someone remains sicker than they should. Their condition may get worse. It may become harder to treat. Comorbidities may develop or be exacerbated.
It’s also possible someone who doesn’t follow a prescription’s instructions will need to take a medication for a longer period of time (and deal with any associated side effects) or move to a potentially riskier higher dose.
How much does non-adherence cost your plan?
At work, people may be less productive or may not be able to come to work at all if they’re not managing symptoms as well as they could be or if they’re getting sicker because they’re not taking their medications as prescribed.
One study found that adherent employees with conditions including diabetes, hypertension and asthma missed between 1.7 and 7.1 fewer days at work and spent between 1.1 and 5.0 fewer days on short-term disability.7
Meanwhile, a literature review compiled in 2018 by Concerto Groupe Santé and Pivot Strategic Transformations8 found that, overall, medication non-adherence costs employers between two and 10 missed work days and between $1,000 and $5,000 in salary losses per employee every year.
Those researchers ran calculations assuming adherence rates based on clinical studies of 63% for hypertension drugs, 61% for diabetes drugs, and 43% for depression drugs. Even at those relatively low levels, the medications saved employers:
- 3.5 days and $714 among employees with hypertension
- 16.1 days and $3,306 among employees with diabetes
- 9.1 days and $1,870 among employees with depression
And what if you could boost medication adherence rates to 80%? That’s still not perfect, but the researchers found it has the potential to generate $2,200 per employee more in net savings – even after factoring in the extra medication costs incurred with more frequent refills.
Some of the extra costs associated with non-adherence are because people who don’t take their medications as prescribed have to step up to more expensive drugs sooner. For example, when TELUS Health looked at the claims history for more than 3,000 people who were taking a biologic for rheumatoid arthritis, we found that all of them had begun their treatment with a first-line therapy costing about $200 annually.
Yet, strikingly, the step up to the biologic, with an average annual eligible cost of about $15,800, happened years earlier among claimants who did not refill their prescriptions on time. Specifically, people who didn’t reliably take the first-line therapy started on the biologic after one to two years – while people who took the first-line therapy consistently didn’t need the biologic for four to six years.9
What causes non-adherence?
It’s evident that non-adherence comes at a high price to employee health and to employer-sponsored benefits plans. Understanding why it happens is critical to developing solutions to address it.
Here are six key reasons people don’t end up taking their medications as prescribed:
1. Too many other priorities
In a survey of Canadians conducted by Leger for TELUS Health10, one-third of respondents had missed picking up their prescription medications on time in the past year. Nearly 60% said it was because it slipped their mind, and almost 50% said it was due to work and family commitments.
2. Won’t fit in the budget
At least as far back as 2012, we’ve known that cost was the issue driving non-adherence for almost one in 10 Canadians who received a prescription.11 While a benefits plan can help immensely with this, high co-pays and deductibles can be barriers.
3. Worried about side effects
People may stop taking a medication if they get unpleasant side effects. They may not even fill a prescription if a family member or friend tells them about a negative experience with that drug or a similar one.
4. Misunderstanding the medication
Sometimes, people don’t fully grasp the reason they need a medication and think it’s less important than it is. They may also not know to expect side effects, and the signs to look for that require a call to their healthcare provider.
5. Symptoms are resolving
Once someone is feeling better, they may think the medication has done what it needed to do and they don’t have to take it anymore. A related problem is when a medication doesn’t feel like it’s making a noticeable difference – they may simply give up on it.
6. Job and life stress
The 2020 Sanofi Canada healthcare survey published by Benefits Canada identified an association between medication non-adherence and either a lack of job satisfaction or a high level of stress.12 It makes intuitive sense that worries about work or home life could interfere with adherence.
Strong relationships with pharmacists help, too
A report by the National Community Pharmacists Association in the U.S.13 rated adherence among adults age 40 and up who were taking medications (an average of four) for a chronic condition. Those patients got an average score of 79% (C+) for their adherence over the previous 12 months.
Then the researchers used regression modelling to test the strength of the connection between different variables while all other factors were kept constant. The top predictor of better medication adherence was the patient’s personal connection with a pharmacist or pharmacy staff.
In fact, that had a bigger effect than any of the other tested variables, including whether they could easily afford the medications, how much continuity they had in their healthcare, how important they felt it was to take their medications exactly as prescribed, how well informed they felt about their health, and how much their medications caused unpleasant side effects.
This suggests that employers who encourage strong connections with pharmacists among their employees have a great opportunity to move the needle on medication adherence.
Addressing non-adherence makes sense on many levels
Helping to cover employees’ drug costs is good for employers for several reasons. A drug plan is an in-demand and much-appreciated benefit that supports attraction and retention of the best talent. It helps ensure that talent stays as healthy as possible. It can also reduce costs related to productivity, absenteeism and disability.
However, unless employees take their medications as prescribed, they can’t get the full benefit of the drugs their plan pays for. Especially because the problem of non-adherence is so widespread, that makes this an important issue for employers to tackle as they work to get the most value from the cost-intensive drug component of their benefits plan.