The Social Determinants of Prescription Drugs: Taking Medicines in Real Life

We talk a lot about the price of prescription drugs in the U.S. There is bipartisan support among Americans for Medicare’s ability to negotiate drug prices on behalf of older people covered by the plan. In the Inflation Reduction Act of 2022, there are several provisions for lowering the price of medicines, which marks an historic event in terms of health reform legislation focused on drug costs.

While the price of prescription drugs is a hot topic in both mainstream media and social media, there is not the same amount of chatter about the costs of not taking our prescribed medicines.

And that cost is worthy of more discussion given that the impact of medication non-adherence or avoidance takes a toll on Americans’ health, individually and as a society.

For example, the estimated annual cost of drug-related morbidity and mortality as a result of nonadherence to prescribed medicines is more than $500 billion—about 16% of total U.S. healthcare spending. For employers, medication nonadherence links to lower productivity: lost work time, absenteeism, and disability leaves from work. Costs to employers ran $940 per employee per year directly connected to medication nonadherence, based on research conducted at the University of Michigan Center for Value-Based Insurance Design collaborating with the Integrated Benefits Institute (IBI).

Considering Social Determinants of Health and Prescription Drugs

Recently, Dr. Mauricio Gonzalez-Arias explained a useful way to frame the challenge beyond considering only the costs of medicine: through the social determinants of medication adherence.

Social determinants of health (SDOH) have been called, “an overlooked barrier to medication adherence.”

As we’ve come to better understand the role of SDOH for healthcare services (especially during the COVID-19 pandemic), Dr. Gonzalez-Arias of NYC Health + Hospitals has talked about the social determinants of prescription drugs in light of a medicine-affordability crisis facing patients.

For example, consider:

• Location: An individual’s ZIP code can be more important than a person’s genetic code and predisposition for diseases.
• Sociocultural factors: Trust in the healthcare system and providers and beliefs about disease and healing can make an impact.
• Behavioral health: Cognitive function, mental illness, stress and substance abuse all play a role in medication adherence.

Patients also face risks from other variables, such as:

• The person’s specific disease or condition (or multiple morbidities), and the duration of illness, and severity/acuity of the diagnosis and prognosis
• The medication itself, including potential adverse events, the complexity of the regimen (e.g., the number of pills, and how often to take)
• Storage requirements (e.g., a refrigerator or cool place in a hot summer apartment)
• System factors, such as access to care, cost and copay shares

Within the patient’s home-health ecosystem, there are five aspects of SDOH risks that influence medication adherence, according to Richard Resnick, CEO of Cureatr.

• Economic instability (where a person experiences fluctuating income, such as from an increase or decrease in shift work, or works in the gig economy)
• Job security (separate from economic stability, when an employer does not cover health insurance)
• Housing stability and security (where housing instability has been associated with skipping medicines)
• Lack of transportation (unable to get to a retail pharmacy to pick up a prescribed medication)
• Literacy skills (understanding why a medicine was prescribed and the benefits of taking it as-prescribed)

Literacy skills have many layers pertinent to medication adherence beyond understanding the why and how to take a prescribed drug. Digital literacy is important for patients who may need to do e-refills via a pharmacy app, or need to apply online for Medicare Part D as a patient ages into the health plan. Financial literacy underpins a patient’s ability to understand copayments or high-deductible allowances when paying for prescription drugs, often dissuading the patient as the payer to postpone or avoid filling the Rx due to out-of-pocket cost burden.

Peer-reviewed studies have also suggested  lack of social support to be a barrier, preventing some people from taking prescription medicines. Mental health is also a factor for patients feeling self-agency (the feeling of being in control) and lower stress, increasing their adherence to medication when managing chronic diseases.

Heartbroken: The SDOH of Heart Disease Drugs

People who take maintenance medications for chronic conditions are at-risk of not adhering to regimens over time. For example, consider prescription drugs for cardiac/heart health. This is a huge area of opportunity and risk for medication nonadherence: Half of all adults in the U.S. have hypertension, but less than half adhere to anti-hypertensive medications.

A recent study in Mayo Clinic Proceedings found a significant impact of SDOH factors on patients’ ability to sustain control of hypertension due to medication adherence barriers.

“Social determinants are prevalent in the patients we manage with hypertension, and really anybody with chronic disease,” noted lead author Dr. Richard Milani of Ochsner Health. The research used digital health tools including smartphones, wireless blood pressure devices and an app-based program for patients dealing with high blood pressure. Researchers collected patient-generated data along with survey responses regarding their daily behaviors—including nutrition, alcohol use, mood, medication adherence, and physical activity—along with heath literacy factors and perceived financial stress related to paying for medications.

Regardless of race, having any three of these risk factors compromised the patient’s blood pressure (hypertension) control. Patients with poorly controlled blood pressure and no barriers reached 73% BP control at one year. Sixty percent of patients had controlled blood pressure when dealing with one risk factor, and only 55% of those patients with two or more risk factors reached blood pressure control at one year.

Another study published earlier this year also provided evidence of the relationship between social determinants of health and antihypertensive drug adherence among patients enrolled in Medicaid. In this population, two-thirds of people had suboptimal adherence, which directly related to the number of “social adversities” the patient faced. The research calculated each patient’s AHMA (their Antihypertensive Medical Adherence index) over a year or until the end of their Medicaid coverage, whichever came first. It is important to note that this study was conducted among people enrolled in the District of Columbia Medicaid program, which does not require a copay for any covered prescription medications; thus, it was unlikely that non-adherence was related to cost-sharing policies or “self-rationing” due to cost.

“If we want to reduce the cardiovascular health disparities that we observe among socially disadvantaged populations, we must address the social, economic, and environmental risk factors that do not promote healthy behaviors, including medication adherence, at the individual, community and policy levels,” the researchers concluded.

Going Beyond Cost to Bolster Medication Adherence

At the national U.S. policy level, there is the recently passed Inflation Reduction Act, which addresses some aspects of drug pricing. The law’s focus on prescription drug prices is on insulin costs, out-of-pocket spending for Medicare enrollees, and the federal government’s power to negotiate prices on some of the costliest prescription drugs.

The provisions go into effect over the next few years starting with insulin price caps in 2023. Drug price negotiations do not go into effect until 2026.

“Because of the four-year gap before the law is fully implemented, policy and legal experts fear that pharmaceutical companies may have ample time to go on the offense and—if they don’t try to get the law thrown out in court—figure out ways to sidestep provisions that affect their ability to maintain their high profits,” according to an NBC News analysis of the Act.

To complement the public policy focus on prescription drug prices at both the national and state levels, the private sector—via health plans, employers, retailers and the pharma industry itself—can explore value-based care approaches to lowering patients’ barriers to prescription medication access and adherence.

In the vein of creating health where we live, work, play and pray, an ecosystem approach to reducing SDOH barriers to adherence can leverage an omni-channel approach. Just as consumers have chosen to shop, learn and work in hybrid ways via different platforms and experiences, “the pharmacy,” broadly speaking, is also adapting to this concept.

One of the cardiac med adherence research studies cited above leveraged the use of consumer-facing digital health tools to bolster patients’ self-care effectiveness from the home. Increasingly, a key healthcare channel is indeed the person’s home. Prescription drug manufacturers, health plans and health systems taking on financial risk for population health (say, for heart conditions or diabetes) have a variety of tools and apps with growing evidence bases supporting good outcomes. At the simpler but quite effective end of this tech-continuum is texting on phones, which has proven to be another useful touchpoint for communicating with patients for adherence and chronic health management.

Beyond technology, for some patients, face-to-face and brick-and-mortar pharmacy and community places are constructive on-ramps toward adhering to medications in trusted spaces. Thinking outside of the typical healthcare real estate for those trusted spaces, consider the barber shop or beauty salon, the YMCA, or workplaces (employers are enjoying a high trust equity these days based on the latest 2022 Edelman Trust Barometer).

Finally, consider moving the solution to the health citizen’s home. Earlier this month, Albertsons, the grocery chain, announced a partnership with WinnCompanies, a housing developer, to deliver prescriptions and groceries to peoples’ homes. Albertsons is the second-largest supermarket operator in the U.S., with 20 store banner brands in 34 states and Washington D.C., and more than 1,700 pharmacies. Their chief digital officer and EVP of health, Omer Gajial, noted in the program’s press release, “We recognize that many people in our communities face challenges that prevent them from shopping in our stores. As a neighborhood grocer, we’re privileged to partner with WinnCompanies to make nutrition, wellness and pharmacy services more accessible and convenient for residents.”

Let me conclude by repeating the two job focuses of Mr. Gajial of Albertsons: He’s both the chief digital officer, as well as the executive in charge of health. Prior to his leadership work at Albertsons, he worked at Amazon and, prior to the e-commerce giant, PepsiCo.

If I could design a background for a job description optimal for addressing the social determinants of medicines, here it is: retail, health, pharmacy, food and nutrition, consumer goods, digital tech, and e-commerce. It will take an ecosystem or cooperation and a convergence of many minds and talents to crack the code on medication adherence.