© Copyright 2002 Rogers Media. The following article first appeared in the April 2002 edition of BENEFITS CANADA magazine.

"Consider [Nash's] situation. He's a classic paranoid schizophrenic. His symptoms are very much worse when he doesn't take his medication, and much improved when he does. Over time he remains compliant and as [new] medication becomes available, he becomes more and more functional."

Prescription drug non-compliance is about more than simply not taking meds, though. The term encapsulates a whole range of improper usage--not taking enough of a drug, taking too much, not filling a prescription, discontinuing use early, and not taking a drug as prescribed, such as on an empty stomach or with alcohol. It also includes a phenomenon common in cases of long-term chronic diseases, where patients initially take their medications as directed, but then fall into an alternating cycle of complying and not complying with their drug regimen. Regardless of what form non-compliance takes, the result is that the medication does not have the effect it should on health outcomes.

"Creating a [drug], writing a prescription for it and reimbursing someone for that prescription is not enough," says Coambs. "We can have great efficacy. Once that [drug is] in the bloodstream we see good results."

The problem of non-compliance is much more common than most realize. Robyn Tamblyn, an associate professor in the department of epidemiology at McGill University in Montreal, says estimates for non-compliance range between 30% and 40% of people who take prescription medication in Canada. Rates can vary widely, depending on a number of factors, including the type of health problem being treated and the medication being used. For instance, Tamblyn says people with mental illness often have difficulties with compliance because, if they don't take their medication, their ability to think clearly is diminished and the cycle repeats itself.

Patients taking drugs for conditions that have no obvious symptoms are also less likely to be compliant, she says. "If you're taking medication for blood pressure . . . you [may not] feel it one way or another. But if you're taking [medication] for arthritis, you can't get out of bed if you don't take the medication." While the complexity of the drug regimen and number of drugs the patient is taking does have a significant effect on compliance, the severity of the condition being treated, surprisingly, does not. "Even people who have AIDS aren't necessarily compliant," says Tamblyn. "And that's a very serious disease that can kill you."

Other demographic factors, such as gender, age and income, don't seem to play a part in whether an individual will take his or her drugs properly, adds Coambs. "The amazing thing is that there's no single group that is in worse trouble. It doesn't matter who you are, if you check your medicine cabinet, you'll see trouble. We've seen the enemy and he is us."

IMPACT ON EMPLOYERS
The consequences of non-compliance run much deeper than a few unfinished bottles of pills. For employers, the costs can be enormous, not only in terms of the health of their employees, but also in terms of their bottom line.

A 1995 report, Costs of non-compliance and inappropriate use of prescription medication in Canada, co-authored by Coambs pegs the cost of this problem at $7 billion to $9 billion annually for Canada's healthcare system--making it one of the country's most expensive problems. The figure includes both direct expenses, such as hospitalization, medical visits, interventions and homecare, as well as indirect costs. "The indirect costs, which are all lost productivity-related, together amount to about $3.53 billion to $4.49 billion," says Coambs. "Those are the costs that are largely paid for by the employer in the sense that the employee is not as productive."

Steven Schachter, senior consultant of health strategies with Aon Consulting in Toronto, agrees that non-compliance can have a dramatic impact on employers. "If asthmatics don't comply with their medication, they tend to have more sick days associated with the lack of adherence to the medication regimen. From an employer perspective, that translates into indirect costs associated with absenteeism and lost productivity."

Employers aren't only affected when their members use drugs reimbursed by the plan improperly--they also pay the price when employees' family members aren't compliant. "When the child is losing time from school, the parent is usually losing time from work," says Coambs, noting that employers haven't made an effort to measure these absenteeism-related costs. "They need to because it's hard to see the benefits of improving your employee's health if you don't track it properly."

LOOMING PROBLEM FOR DRUG PLANS
Then there are the costs of the drugs themselves. Employers often foot the bill for unused or misused drugs that line the medicine cabinet shelves of their plan members. "If patients aren't taking a costly medication properly, then essentially, employers are paying while the employee isn't getting the benefit of the medication," says Schachter.

To illustrate this point, Coambs uses the example of statins--cholesterol-lowering drugs. "There's a significant compliance drop-off with these medications, but they don't really have clinical benefits until about 18 months [of use]. If you start with 100% of patients actually filling and taking their prescription, at the end of 18 months most of them would not be taking their medication any more. So we fill a lot of scripts and reimburse a lot of medications and [for] nothing--no return out of it at all. This is the case with a lot of chronic care drugs, and the situation's getting worse."

This growing problem has yet to register on the radar screens of most employers. Instead, organizations have directed their attention to keeping the direct cost of drugs under control. "[Employers] are focusing on managed formularies, co-pays, communication about drugs and healthy workplace initiatives. As an industry, they don't have their minds around compliance. Certainly not my plan sponsors anyway," says Carolyn MacDonald, director of benefits for the Nova Scotia Association of Health Organizations in Halifax, which administers health benefits to 9,000 healthcare employees across the province.

But cost-containment measures such as deductibles may, in fact, be part of the problem. "One of the biggest drivers of non-compliance is the way in which drug plans are structured," says Tamblyn. "When co-pays were put in place in Quebec for asthmatics, we saw a big drop in inhaled steroid use," she says, pointing out that asthmatics who don't have their condition under control average one sick day per month. "[Plan sponsors] are creating another barrier [by limiting coverage of a drug] that actually prevents employees from taking days off."

Aon's Schachter agrees that drug plan cost-cutting strategies can sometimes be counterproductive. "It may seem like heresy, but the reality is using medication may be the most economical way of containing costs. What we're trying to emphasize is that while costs may rise, if an employee takes his or her medication properly, you're going to see fewer drug-related problems."

Plan sponsors can have an impact on the issue in other ways. "Employers really can be proactive and do something about this issue by implementing educational outreach programs. Our approach is to look at key determinants of health within an employee population. We look at what the root causes are. It's a holistic point of view," says Schachter.

MacDonald agrees that communication is probably one of the most effective strategies available to plan sponsors, but she adds that communication efforts need to be tailored to the specific health needs of the workforce population being targeted. "One thing insurers have done well over the years is deliver some good comprehensive reports that help you identify where [drug] usage is. If you focus your communication to where the usage is you should be able to address it."

Coambs concurs. "It's OK for the employer to be selfish about this. They can focus on the medications that are costing them the most money. For example, filling scripts for migraine medications and not using them is very expensive for the employer. So encouraging good compliance around migraine can be very cost-effective, and it's cheap to do. The drugs, as we know, are not cheap."

GROUP EFFORT
Employers can't solve the problem of prescription drug non-compliance alone. Other stakeholders have to play a role as well. MacDonald believes the best place to start is at the pharmacy. "Certainly with the electronic environment we're in today, if an individual is moving from one physician to a specialist, the physician perhaps is not always aware of what is going on at the specialist's office. Pharmacists are the common link. They can certainly look at the non-compliance issues closer than physicians."

Coambs says pharmaceutical companies also have to spend more effort ensuring consumers use their medications properly, "just the way other manufacturers care about how their products are used." He adds that pharmacists, physicians and policymakers all need to do more. And, most importantly, the patient has to be part of the solution. "We have to make sure the patient is not filling scripts frivolously. Patients have to be more involved and empowered in the process of using their medications properly."

Non-compliance stems from "a lot of small effects creating small influences,"adds Coambs. "We can't just say, 'Oh it's the doctors, we're going to get docs to do more and that will fix the whole problem.' There's no magic here. It's a lot of little things. When you put those little things together, you start to make serious progress." BC

The Romanow Commission has released its final report on the future of healthcare in Canada.

For Commissioner Romanow's recommendations, click here.

Click here for Senator Michael Kirby's report, "The Health of Canadians – The Federal Role: Recommendations for Reform."