Despite hundreds of millions of blood-pressure prescription fills in the U.S. each year, medication adherence among patients with hypertension remains low. Recent research shows the effects on medication adherence of the ways in which BP-control drugs are prescribed, who prescribes them and how they are paid for.
Published in the Centers for Disease Control and Prevention (CDC) journal Preventing Chronic Disease: Public Health Research, Practice and Policy, “State and Regional Variation in Prescription and Payment-Related Promoters of Adherence to Blood Pressure Medication” was co-written by the AMA’s Gregory Wozniak, PhD, and Stavros Tsipas, along with experts from the CDC and Oak Ridge Institute for Science and Education.
Using hypertension medication fill data from Symphony Health’s 2017 Integrated Dataverse, the researchers examined how prescription- and payment-related factors that promote medication adherence varied across the U.S. They found that 706.5 million BP prescriptions were filled. This accounted for $29 billion in total spending, with 17% incurred by patients.
Here are ways to improve hypertension medication adherence to improve BP control.
Prescribe fixed-dose combinations
Adherence may be affected by how medications are prescribed—most patients with hypertension require more than one medication to control their BP. To overcome this, physicians can prescribe fixed-dose combinations. This has been shown to increase medication adherence by reducing the number of prescriptions patients need to fill. It also decreases the number of pills the patient needs to take each day.
Fixed-dose combinations comprised only 12% of all national BP medication fills in 2017. This number also varied significantly by geography and market segment, with low concentrations being observed in the South and West, which are regions with high rates of nonadherence.
“Expanding insurance formulary restrictions or tier status of certain medications, such as generic fixed-dose combinations, within preferred drug lists and covering 90-day prescriptions and use of mail order pharmacies can help reduce barriers to adherence,” says the study.
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Improve affordability of medications
Another barrier blocking hypertension medication adherence is affordability. There was minimal variation in generic medication concentrations across markets, which suggests access to lower cost therapies is widespread.
“Lower out-of-pocket spending was more concentrated in public insurance markets, especially Medicaid,” says the study. “Higher copayments and out-of-pocket costs were observed among patients with commercial plans.”
The South exhibited the highest rates of out-of-pocket spending per therapy year among commercially insured. These higher costs for medications create a significant barrier to adherence, particularly for low-income patient populations because even low costs can be prohibitive. High costs combined with complex medication regimens add to low adherence rates as well as low BP control rates and higher rates of cardiovascular disease morbidity and mortality, says the study.
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Adopt standardized clinical guidelines
“Health care systems and medical practices could consider incorporating evidence-based strategies that focus on increasing uptake of adherence promotion factors among their prescribers,” says the study.
For example, Kaiser Permanente, an AMA Health System Program Partner, improved BP control rates by prioritizing generic and fixed-dose combination drugs as first-line hypertension therapies in their standardized treatment approach. They also used multidisciplinary care teams to better reach their patients with hypertension.
Additionally, in Minneapolis, BP control rates improved from 30% to 70% through collaboration with insurance companies, health care institutions and government agencies. This involved collectively developing and adopting clinical guidelines and shared goals for hypertension management.
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Change health insurance incentives
States can also work with insurers to improve adherence among patients with hypertension. This involves creating environments through health insurance market policies with incentives for adherence-promoting prescriptions. For example, coverage for mail-order fills and low copays.
In the short term, these measures may contribute to higher costs for insurance companies. However, in the long term, insurance companies can lower costs by preventing hospitalizations for expensive acute events, says the study.
The AMA has developed online tools and resources created using the latest evidence-based information to support physicians to help manage their patients’ high BP. These resources are available to all physicians and health systems as part of Target: BP™, a national initiative co-led by the AMA and American Heart Association.
Target: BP offers annual, recurring gold-level recognition for all participating sites that achieve hypertension control rates of 70% or higher among their adult patient population, and participation level recognition for those sites that prioritize improving BP control each year and submit data. In 2020, more than 1,000 organizations were recognized for their efforts focusing on BP control within the populations they serve.
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