Medication adherence: Access and burden (part 1, access)

There are obviously many factors that can cause patients to not follow their medication regimen. That can — and typically does — lead to less-than-optimal clinical and quality-of-life issues.

In this ongoing blog series, we’ve been focusing on those factors that can impact medication adherence. After extensive literature review on medication adherence, RxLive has categorized major contributing factors into six buckets — cost; side effects; skills; understanding and knowledge; social and behavioral factors; access to care and burden of regimen. 

As a resource to our pharmacists — and through RxLive, the physician practices we affiliate with — designed to identify and positively impact patients’ medication adherence issues. RxLive has created an online platform with suggested interventions within each of the major buckets above. This blog post is the first of a two-part series that examines the access and burden bucket, starting with access. 

Access and burden can significantly influence patient medication adherence by obstructing the receipt of treatment or by posing as significant disruptions in daily life that challenge the therapy. Access to care and treatment is the initial step towards management of patient health.

Access: Influence on medication adherence

Access to health consists of four elements: coverage, services, timeliness and workforce. Coverage through health insurance or healthcare programs is a primary component of access, facilitating entry into the system. A study published in Health Services Research found that delays in obtaining prescription drugs was reduced by 7.7% with Medicaid enrollment. 

A usual source of services and continuity of care is correlated with improved health outcomes, reduced costs, better patient satisfaction, and less disparities according to Healthy People 2020. The quality of care over time is enhanced by ongoing cooperative relationships between patients and their physician-led healthcare team that’s familiar with those patients’ specific history and health behavior.

The timely delivery of care and treatment when needed can reduce morbidity and mortality, and is dependent on both the healthcare system and patient ability. Also, studies show certain conditions such as chronic pain, mental health and HIV can come with stigmas which are barriers to timely access to treatment. These stigmas can stem from both provider or patient actions and reactions to associated perceptions.

The healthcare workforce can affect access to care and medication adherence through the lack of provider or facility availability. The National Rural Health Association reports that the primary care physician-to-patient ratio in urban areas is 53.3 physicians per 100,000 as opposed to 39.8 physicians per 100,000 in rural areas, illustrating a regional disparity and a potential overall barrier to availability.

How pharmacists can identify access as an adherence barrier

Pharmacists should be aware of the potential barriers to access of their patient population by becoming familiar with regional statistics regarding the number of providers — both primary and throughout the specialties — as well as healthcare facilities and pharmacies in their locality. Additionally, examination of the patient profile and medication records can reveal lack of insurance, prescriptions from multiple prescribers, and medication transfers between pharmacies that can signal a potential gap in care continuity or a coverage barrier.

How pharmacists can improve medication adherence relating to access

Coverage For patients without insurance coverage or who have limited coverage, pharmacists can create and provide resource documents listing federal or nonprofit assistance programs, prescription discount cards, pharmaceutical company prescription programs, and prescription coupons.

Services: Continuity of care — Cooperative healthcare management between patients and the care team over time can improve medication adherence through relatedness, knowledge of patient history, and the building of patient satisfaction, motivation, skills and health literacy. Continuity of care can also prevent treatment delays from stigmas associated with certain medical conditions, due to the existence of a familiar and ongoing relationship between the patient and a healthcare team that’s knowledgeable of and sensitive to their disease state. 

Pharmacists can actively participate in the continuity of care in a clinical setting by performing medication reconciliation, hospital discharge follow-up with the patient and provider, and coordination between the hospital and dispensing community pharmacy to optimize post-emergency treatments. A community pharmacist can offer patients medication-list templates to complete and take between providers, as these dispensing pharmacists develop ongoing relationships with their patients and, hopefully, coordinate with prescribing emergent and primary care physicians.

Timeliness and workforce — Access to care regarding both workforce and timeliness can be addressed through telehealth services from physicians, nurses and pharmacists. These services can be highly effective in filling in the gaps where there are few physicians — such as a rural area — enabling long-distance but personal provider contact across a broader population. 

Telehealth additionally reduces patient barriers that can make in-office appointments difficult due to time burdens, lack of transportation or childcare issues. It is also extremely effective in pandemic times such as these, with offices accepting fewer appointments and with patients who may be fearful of in-person medical care unless it’s essential.

Collaborative agreements between physicians and pharmacists for pharmacist-led telehealth appointments, such as those provided by RxLive clinical pharmacists, enable physicians to provide more-extensive treatment monitoring to promote medication adherence, increased access, and positive health outcomes. 

Pharmacy implementation of timely prescription delivery is another effective measure to address access and timeliness by enabling prescriptions to reach patients without delays. Mail-order services or courier medication delivery eliminates patients’ inability to pick up their medications due to time or transportation issues or from another a perceived burden.

Summary: Access critical to optimal outcomes

Medication adherence can be dramatically impacted by access to care, comprised of coverage, services, timeliness and workforce. Pharmacists should be aware of local and regional information about available healthcare providers, hospitals, clinics, support programs and prescription-delivery services to help identify and offer expert advice regarding the potential access barriers their patient population could face. 

As with virtually any other aspect of delivering healthcare, collaboration, communication and cooperation are critical to optimize options. In this case, primary care physicians who provide pharmacist-led telehealth services for medication regimen management, counseling, follow-ups and adherence monitoring can make a significant impact on patient health, finances, convenience and satisfaction while also addressing the other buckets of non-adherence.


About Rural Health Care. NRHA

Access to Health Services: Health People 2020

Chartbook on Access to Health Care. AHRQ

Stigma in Health Facilities: Why It Matters and How We Can Change It. BMC MedicineThe Effects of Medicaid on Access to Care and Adherence to Recommended Preventive Services.HSR

Author avatar
Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.