- Before leaving the exam room, each of Stuart Goldberg’s patients is asked about their medication adherence – how often do they fill prescriptions? Take their pills? How do patients manage the cost of drugs? For Goldberg, a practicing oncologist based in New Jersey, this is all part and parcel of building relationships with his patients.
“Medication adherence is certainly a very important part of taking care of patients today,” Goldberg said in an interview with PatientEngagementHIT.com. “It starts with, hopefully, getting trust between you and the patient, that when the patient comes in to see you for their appointment they will give you a true answer.”
That might sound simple, but the truth of the matter is that building patient trust is at the core of the elusive patient-provider relationship. As Goldberg noted, it’s “part of the art of being a physician.”
Using a history of shared medical experiences, good patient-provider communication, and a foundation of respect, providers can work to establish this trust.
Providers must also recognize instances in which they can dig deeper with patients, and instances in which providers cannot.
If Goldberg is seeing a patient for the first time because he is covering for another provider at the practice, he knows he won’t yield a very meaningful conversation about medication adherence. Goldberg knows not to hem and haw about this, but to instead make a note to the regular physician.
“Trust also depends on the type of disease and how often you see the patient,” Goldberg said. “It’s very hard for me to come in as a covering physician and try to address this issue when I’m just seeing a patient when my partner is out.”
The task of creating and leveraging patient trust becomes much easier when Goldberg visits with his own patients who he has been treating for a while. In these cases, Goldberg knows the patient health history, social issues, and other mitigating health factors.
Goldberg also credited the emergence of healthcare technology in making it easier to track and detect medication adherence challenges.
Providers have the advantage of EHR technology to help them flag patients who need more extensive medication adherence talks. The EHR contains information about when patients last refilled their prescription. If too much time has passed, Goldberg knows he needs to discuss this topic extensively with his patient.
But the EHR is not a panacea, Goldberg added. Doctors can’t rely on the technology to tell them everything there is to know about an individual patient’s medication habits, but the EHR can prompt providers to have a more relevant conversation.
“The EHR gives you the ability to walk in and really challenge the patient to find out why they haven't filled the prescription for many months,” Goldberg explained. “The patient might have a real reason – that they were getting the drug from a different pharmacy or that I forgot that the patient was in the hospital before and they stockpiled some medicines. The EHR gives me a chance to start that conversation.”
Through patient conversations, Goldberg is usually able to uncover the barriers patients have in maintaining good medication adherence. Although every patient is different, Goldberg has conducted research that has medication adherence barriers nearly down to a science.
Goldberg’s research, published in 2011, included a self-reported survey in which patients stated whether they were adherent to their medications, and if not, why.
Forgetfulness was overwhelmingly the most common reason why patients had poor medication adherence, Goldberg found.
“I try to establish with patients some routine – making taking medications part of their routine,” Goldberg recommended. “Take the medication the same time every day. Put it by your toothbrush. If you have a pattern, you won’t forget medicines.”
Other common reasons for poor medication adherence were drug costs and adverse side effects.
But of course, most providers don’t have patients engaged in a self-reported survey study. Instead, Goldberg said providers need to find out these trends one patient at a time using patient trust and good communication.
“I’ll ask patients what medicines they are on,” Goldberg offered. “If they can’t name them, that’s often a red flag. Patients who don't know what they're supposed to be taking may not be taking their medications.”
Goldberg also asks patients about how they manage medication cost and side effects.
If a patient reports that she is not experiencing any side effects, that individual is either extremely lucky or is not taking her medication, Goldberg noted, placing the higher likelihood on the latter option.
Likewise, ambivalence toward or lack of awareness around cost can be a significant red flag.
As an oncologist, Goldberg treats patients who are on extremely costly medications – a $10,000 prescription is burdensome for anyone, he asserted. If a patient doesn’t appear bothered by a medication cost, or doesn’t know about the cost or have a plan for paying, Goldberg can infer that the patient probably hasn’t tried to obtain the prescription.
When a patient does report cost and affordability issues, Goldberg has to manage another set of problems.
“There are a lot of different things that patients do to get around the costs,” Goldberg explained. “One of them, unfortunately, is saying ‘I’m doing okay on a pill a day, so maybe I’ll do okay on a pill every other day, and that way I don't have to pay as much for my drugs.’”
When discussing the cost of medications, Goldberg needs to balance the total cost of the drug and the out-of-pocket expenses the patient might incur.
For example, Goldberg recently saw a leukemia patient whose insurer wanted her to switch to the generic medication. The generic drug would indeed lower costs for the payer – and even yielded a smaller copay for the patient. But because of patient assistance programs from the name-brand drug, the patient still would incur higher overall costs if switching to the generic.
“Very few patients pay sticker price,” Goldberg pointed out. “The question then becomes what will be the actual out-of-pocket cost depending on their insurance plan and depending on what patient assistance programs are available.”
Healthcare providers walk a very fine line of selecting the most effective drug and the most affordable drug. Clinicians have an imperative to prescribe their patients the most promising treatment, but when cost barriers present a significant issue, clinicians need to make careful considerations.
“If you don't take the medicine, it doesn’t matter. You can pick the best treatment but if the patient doesn’t pick it up from the pharmacy because they can’t afford it, that doesn’t help the patient,” Goldberg said. “If the patient does pick it up and she doesn't take the pill, that doesn’t help the patient either.”
Ultimately, discussing medication adherence with patients is going to depend on bringing the conversation to the table, Goldberg said.
“I know we only have a few minutes to see a patient today. Time is important,” he conceded. “But one of the questions that you should not let a patient walk out of the room without asking is ‘did you take all your medicines in the last month?’”
For too long, healthcare providers practiced under the assumption that their patients were taking their medications. Goldberg credited this to naivete, stating that as he has been in practice longer he’s realized that patients do not always follow directions.
On a lighter note, Goldberg is also noticing that medication adherence is getting more attention because there are more tools for patient and provider use. Of course, the EHR serves as a tool to help providers flag limited medication adherence.
On the patient side, healthcare consumers have access to a litany of tools to remind them about their medications, measure adherence, and track overall disease progress. Looking toward the future, Goldberg said these tools can help aggregate more data helping providers to uncover the secret to facilitating good medication adherence.
“The good side is that we're getting more and more tools,” Goldberg concluded. “These new electronic gismos will hopefully make our ability to understand medication adherence better. There are even now some studies and emerging technologies where there are little microchips in the pills so that we can track patients if they've taken the medicines.”