For those who missed it yesterday, a new study reported that when a group of heart attack survivors was offered prescription medication fully covered by their health plan, fewer than half took the drugs. In fact, the researchers struggled to even get enough people signed up to take part in the study.
Coverage by the Associated Press produced what surely must be the health care quote of the month, from one of the researchers who was involved in the study: “My God, we gave these people the medicines for free and only half took it.”
A quick summary: The study involved 5,855 adults who had recently been hospitalized with a heart attack and who had been prescribed one or more medications afterwards to lower their risk of another cardiac event. About half of them were prescribed preventive medications with no out-of-pocket costs; the rest were given prescriptions with the usual co-pay. At the end of one year, fewer than half of the patients overall were actually filling their prescriptions – and there were only minor differences in the adherence rate between those who had a co-pay and those who didn’t.
So what is up with that? Are patients so unwilling to comply with taking their prescribed medication that they can’t even be motivated by free drugs?
That’s certainly one way to interpret this study. But I suspect there’s more going on here than a straightforward case of collective noncompliance.
Adhering to a medication regimen involves multiple, interrelated steps. For starters, patients have to buy into the notion that they need medication and that it will somehow benefit them. They have to fill the prescription at the pharmacy. They have to remember to take the drugs each day, and take them correctly. They have to remember to get refills. They might have to deal with unwanted side effects. Adherence can go off the rails at any one of these critical points.
Although it’s often assumed that cost is a major influence on whether patients get their prescriptions filled, the NEJM study suggests that it perhaps isn’t as important as other factors – and that if clinicians want to devise effective strategies to encourage adherence, they need to do more than address the money angle.
I’m aware of at least one study that found a surprisingly basic reason for why some patients don’t take their medication: They simply don’t like the idea of taking a lot of pills each day.
It would be interesting to know the extent to which psychology might be contributing to medication non-adherence. The patients in the NEJM study had all recently had a heart attack. On average, they were 53 years old. Among at least some of them, perhaps their vision of themselves was that they were mostly healthy. Perhaps they weren’t emotionally ready yet to accept that their health had changed or that they were going to need medication for the rest of their life.
On top of this, there are strong American cultural attitudes about aging and infirmity. We tend to regard disease as a burden on society and often blame the sick for “not taking better care of themselves.” Should we be surprised when people resist taking prescription medication because, consciously or not, they don’t want to be perceived as one of those sick, costly individuals?
The study in the New England Journal of Medicine did reinforce that when patients stuck with their medication regimen, they were less likely to have a second cardiovascular event. Overall, health care costs for these people also were somewhat lower. The savings weren’t huge but then again, it often can take years to see a measurable payoff from this kind of health intervention, and the study wasn’t designed to track long-term results.
Did the elimination of co-pays help some patients more than others? It’s probably safe to assume that it did, at least among those for whom cost was the main barrier. For other folks, though, it’s clearly going to take more than this to raise the adherence rate. A better understanding of both the practical and emotional issues involved might be a good place to start.