Medication Concordance – What Does It Mean and Why is It Essential to the Care We Provide at Emtiro Health?

By Patrick Johnson, PharmD

A Tale of Two Grandmas

I am fortunate to still have both of my grandmothers in my life. However, having me as a grandson is just about the only thing they have in common. Grandma J. is traditional and mostly keeps to herself while Grandma R. is independent and enjoys expressing her opinions whenever the opportunity is presented. As a result of these personality differences, their medication-taking behaviors differ considerably as well. Being a pharmacist, I try to review their regimens every few months to see if anything has changed or if any new issues have arisen (which is often the case!).

I was recently looking over Grandma J.’s medications and asked her about a new brand name drug on her list. She explained that due to the cost of the medication, she is only taking it every other day to save money. When I asked her if she mentioned this to her doctor, she divulged that she didn’t want to disappoint him and this way she could report that she was indeed taking the prescribed drug if ever questioned.

Just a few weeks later, I got a call from Grandma R. who immediately began telling me that her blood pressure had been high lately and that her doctor had added a new medication to help get it under control. She went on to tell me that as soon as she arrived home from her appointment, she began researching the drug online and asking all her hypertensive friends about it. Based on their feedback, she not only decided to not start taking the medication, but she also chose not to first discuss this decision with her doctor. Instead of asking me for my thoughts on her new antihypertensive medication, she was calling to ask about an herbal supplement that she heard could help with overall heart health.

Scope of the Problem and Past Attempts to Solve It

The famous quote from former United States Surgeon General, C. Everette Coop, certainly still holds true today that “drugs don’t work in patients who don’t take them.” A vast majority of the population takes one or more medications for chronic conditions and just 50% of those medications end up being taken as prescribed (with nearly a quarter of new prescriptions never being filled at all). As a result, this is an issue that affects every one of us, be it directly or indirectly. Unfortunately, the costs of non-optimized medication therapy (which includes medication non-adherence) are only becoming more pronounced as this problem is now responsible for approximately 275,000 deaths, at least 10% of all hospitalizations, and over $500 billion each year in this country, all of which are completely preventable.

While I would argue that the problem of suboptimal medication adherence in our care system does not get nearly enough attention, there have been numerous attempts to address it at a population-level. Examples of interventions that have been widely applied include reminder alerts, simplified dosing, incentivization, and adherence packaging. While many of these interventions have shown modest benefit on adherence rates (with educational interventions and case management having the most consistent evidence), results vary both between and within individual studies. Most importantly, few interventions have definitively shown significant improvements on overall morbidity and mortality. Therefore, it is my belief that there is not an issue with the interventions themselves, but with the attempt to generalize their utility from patient-to-patient.  This is where Emtiro Health truly makes a difference in patients’ lives.

The Answer to Medication Non-Adherence is Medication Concordance

Medication concordance is defined as “an agreement reached after negotiation between a patient and a healthcare professional that respects the beliefs and wishes of the patient in determining whether, when, and how medicines are taken.”

Emtiro Health champions this patient-centered care approach of medication concordance and treats each patient as an individual possessing certain medication-taking behaviors that are unique to them. This approach, which emphasizes two-way communication, has been shown to improve patient satisfaction, patient knowledge of their conditions and medications, adherence rates, and overall health outcomes.

Long gone are the days when a clinician would tell the patient what medication to take without much consideration paid to the patient’s thoughts or concerns. That paternalistic model was practiced for decades and was inarguably unsuccessful, as evidenced by the low adherence rates and poor outcomes we see today. Ultimately, the healthcare professional cannot guarantee that a patient will take a given medication as prescribed, but why not increase the likelihood that they will by empowering them and giving them a voice in the decisions being made? After all, isn’t it the patient’s own health and wellbeing that are being affected by these decisions? 

The Emtiro Way

There is an inexhaustible list of barriers to medication adherence. Some examples are variations on the following: fear of side effects, cost, culture, access, regimen complexity, forgetfulness, lack of appropriate education, limited symptoms, and mistrust of the healthcare system.

Emtiro Health care managers and other team members assess each one of these factors upon initial patient interview, obtain details specific to the patient, and update this information on an ongoing basis. Once the patient’s individual combination of barriers has been identified, we provide patients with choices that allow them to make informed and collaborative decisions on how best to proceed.

At Emtiro, we have found that in most cases, patients who make the conscious decision to discontinue therapy do not inform their prescriber. Emtiro Health demonstrates its value in improving medication adherence by tailoring interventions such as face-to-face medication education, linkage to community-based resources, consultation with the patient’s healthcare team, and more to the individual patient. These interventions result in the patient feeling heard and more likely to seek concordance with their healthcare provider. The patient’s primary care provider is involved throughout this process, which ensures that they are not only aware of the issue, but that they are part of the agreed-upon solution as well.

Medication Concordance Saves the Day for Grandma

In order to address the medication-related issues that my grandmothers were having, my motivational interviewing and medication concordance training was put to the test.

Grandma J.’s issue came down to not only keeping costs low on a fixed budget, but also to ensuring that she fully understands the benefits of the medications she is prescribed. For that reason, I started off by first talking with her about the importance of this medication for her long-term health and explained how to manage a few of the common side effects, should she experience any. With that newfound knowledge, she was now fully on board with taking it on a daily basis. Now we were only left to address the issue of price. Since she is a Medicare enrollee, she wasn’t eligible for the manufacturer coupon. However, we were able to send her provider a message about the issue and after some talk about samples and pill cutting, they ultimately decided together that it was best to switch the medication to a cheaper alternative. Grandma J. was unknowingly increasing her health risk because she was afraid to disappoint her doctor. By asking the right questions and providing a little encouragement, she now feels comfortable playing an equal part in these important healthcare decisions.

Grandma R. on the other hand was not going to be as easy. I know that she puts a lot of stock into her friends’ experiences, so I attempted to clear up any misconceptions about both the prescription anti-hypertensive and the herbal supplement. But I quickly realized that I wasn’t getting anywhere. Since we have a close relationship, I was able to challenge her a bit more as to the reason why she was so opposed to taking this particular medication. She eventually admitted she was afraid of adding yet another drug to her pillbox. She equated more drugs (herbals “don’t count”) with becoming sicker and losing her independence. While these concerns were not initially shared with her provider, she decided that she would tell him at her upcoming appointment. She is also planning to propose a trial of lifestyle modifications which include enrolling in SilverSneakers and getting rid of some of the high salt content snacks in her pantry. Grandma R.’s doctor may not have asked all of the right questions initially and Grandma R. may not have been completely forthcoming with him either, but my hope is that their two-way communication will continue to improve for their mutual benefit.

Emtiro Health, Medication Concordance, and You

Medication non-adherence is a massive issue with our healthcare system and represents a tremendous opportunity for improvement. While individual interventions have shown promise, the key to making a sustained difference in this area will be accomplished through the practice of medication concordance where the patient is empowered to speak, and the healthcare professional is willing to listen. If you want the patient care approach at your practice to be known for its shared-decision making and medication concordance, contact Emtiro Health today so we can provide you more information on how we can help make that a reality.

Brea Neri