It's up to you, people. All we doctors can do is examine you, diagnose you, write prescriptions for you and give you our best advice on how to prevent, treat or cure you. We're not Nurse Ratched in "One Flew Over the Cuckoo's Nest," lining up patients, handing them a paper cup of water along with a pill, and watching for the Adam's apple to bob as they swallow. It's just not possible for doctors to make every patient take pills as prescribed. Research points to some things the healthcare system can do to help, but at some point, the ball is in your court.
Sure, you probably did some research to get to what you see as the finest healthcare team available for your condition. You ask questions, you go through diagnostic procedures, and you listen to advice.
But some of you disappoint on the follow through. Maybe you've read something on the web that contradicts what your trusted physician said. Or maybe you don't want to put up with a side effect of a drug. Maybe you have trouble remembering to take your pills, or you don't have the money to pay for them, or you just don't like taking pharmaceuticals.
As many as 40 percent of you — especially older adults — don't take prescribed drugs as directed, or at all. You ignore physician advice, becoming what the medical community calls "noncompliant" or "nonadherent." And while that's your own business, noncompliant patients cost the healthcare system $290 billion a year.
The High Cost of Drugs
Enough lecturing. Let's look deeper at why some people don't take their physicians' advice. Among the leading reasons is the cost of prescription drugs. As medical costs have risen, health plans have asked patients to pay higher co-pays for their pharmaceuticals. Higher out-of-pocket costs can be a significant burden, especially for older patients who take several drugs.
Many newly diagnosed people delay filling their first prescription because of cost. When researchers looked at three common conditions that depend greatly on drug therapy for control — high blood pressure, high cholesterol and diabetes — they found that those who had a higher co-pay ($10 compared to $5 per prescription) often delayed filling their first prescription for several months.
Of patients with hypertension, when the co-pay was $5 per prescription, 55 percent filled the first prescription within the first year, but when the co-pay doubled to $10, that number dropped to only 40 percent. For high cholesterol, those numbers were 40 percent when the co-pay was $5 and 31 percent when it was $10. And when the diagnosis was diabetes, 46 percent of patients filled their first prescription within a year with the lower co-pay, but only 40 percent filled it that soon when the co-pay was $10.
In one survey, a quarter of patients on Medicare reported not getting their prescriptions filled because of cost. But some people try to save money by being just a little noncompliant: They'll fill one or two of the three or four prescriptions they have, or they'll skip doses, or take reduced doses, to make a prescription last longer.
With all categories of drugs, studies consistently show that 20 percent to 30 percent of the prescriptions patients clutch in their hands as they leave their doctors' offices are never filled, and half of the patients don't take the drugs as directed.
Other Reasons for Not Following Doctors' Orders
It seems that the more prescriptions a person has, the more likely he or she will skimp on some or all of them. Patients with high blood pressure, asthma and depression, for example, are less likely to strictly comply with doctors' orders. Cultural attitudes toward medications are a significant factor. And, surprisingly since women go to doctors more regularly than men do, women are less likely than men to consistently take their medications for high blood pressure. Side effects like dry cough, diarrhea or sexual dysfunction also can discourage people from taking the drugs that can protect their health and prolong their lives.
Some areas of noncompliance are truly shocking. For example, a woman fighting breast cancer likely has already been through the difficulties of surgery and chemotherapy. Studies have shown that hormonal therapy taken for one year after treatment reduces the risk of recurrence by 12 percent; after two years, such therapy reduces risk by 29 percent; and up to five years of hormonal therapy reduces the risk of recurrence by almost half. Yet one study of women taking hormonal therapy after breast cancer treatment found that after four years, compliance rates dipped to 50 percent. Another study found that among women prescribed tamoxifen, which can improve the 10-year survival rate for breast cancer patients, 17 percent stopped taking the drug after two years.
As we ponder why a breast cancer patient might be reluctant to follow through and increase her odds of long-term survival with a drug regimen, there's an equally puzzling group of patients. About one quarter — between 22 percent and 28 percent — of kidney transplant patients don't comply with their anti-rejection drug regimens. After surviving a waiting list for a transplant and enduring the surgery, and with the ax of lifelong kidney dialysis hanging over their heads if the organ fails, some recipients fail to follow through by taking the drugs that allow their bodies to accept the donated kidney. Persistent low compliance with these drugs costs an estimated $33,000 over three years for each noncompliant patient.
Another head-scratching example of nonadherence with medical recommendations — this one not involving medication — involves vasectomy. One study followed 1,892 men who opted for the male contraceptive procedure and found that 644 of them, or 34 percent, never went back to the doctor to test a semen sample. They went through the emotional, psychological and physical efforts required of such a procedure, then never bothered to find out if it worked.
This is a significant and costly problem, and research is beginning to provide some answers for improving patient compliance. Doctors and patients should be having honest discussions about cost, since that's the number one reason people don't take their medications as prescribed. In some cases, physicians can try to find appropriate generic or lower-cost drugs. Doctors can ask patients if they are taking their medications as directed, and can educate patients about the importance of compliance.
Pharmacists also can take note when ongoing prescriptions are not refilled. Some health systems make phone calls to see if patients are following orders. Phone calls or email follow-up can uncover problems with cost or side effects, and begin to offer possible solutions. For instance, many pharmaceutical companies have programs to provide medications on a compassionate or reduced-cost basis to patients who cannot afford them.
Patients tend to take their prescriptions more reliably if the routine is easy, so physicians can look for slow-release drugs, once-a-day regimens, or combination pills that can make things easier. Simplifying drug regimens when it comes to medication for high blood pressure, for example, increased adherence by up to 20 percent.
As our healthcare system slowly begins to make the changes necessary to keep it afloat, you might get more nagging phone calls from your doctor's office, or even from your pharmacist. Take them in the spirit in which they're offered, and please discuss your concerns with your healthcare provider. In the long run, following medical advice will save money and protect your health.