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How Much Does Medication Nonadherence Cost the Medicare Fee-for-Service Program?

Lloyd, Jennifer T., PhD*; Maresh, Sha, DrPH*; Powers, Christopher A., PharmD; Shrank, William H., MD, MSHS; Alley, Dawn E., PhD*

doi: 10.1097/MLR.0000000000001067
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Background: Medication adherence is associated with lower health care utilization and savings in specific patient populations; however, few empirical estimates exist at the population level.

Objective: The main objective of this study was to apply a data-driven approach to obtain population-level estimates of the impact of medication nonadherence among Medicare beneficiaries with chronic conditions.

Research Design: Medicare fee-for-service (FFS) claims data were used to calculate the prevalence of medication nonadherence among individuals with diabetes, heart failure, hypertension, and hyperlipidemia. Per person estimates of avoidable health care utilization and spending associated with medication adherence, adjusted for healthy adherer effects, from prior literature were applied to the number of nonadherent Medicare beneficiaries.

Subjects: A 20% random sample of community-dwelling, continuously enrolled Medicare FFS beneficiaries aged 65 years or older with Part D (N=14,657,735) in 2013.

Measures: Avoidable health care costs and hospital use from medication nonadherence.

Results: Medication nonadherence for diabetes, heart failure, hyperlipidemia, and hypertension resulted in billions of Medicare FFS expenditures, millions in hospital days, and thousands of emergency department visits that could have been avoided. If the 25% of beneficiaries with hypertension who were nonadherent became adherent, Medicare could save $13.7 billion annually, with over 100,000 emergency department visits and 7 million inpatient hospital days that could be averted.

Conclusion: Medication nonadherence places a large resource burden on the Medicare FFS program. Study results provide actionable information for policymakers considering programs to manage chronic conditions. Caution should be used in summing estimates across disease groups, assuming all nonadherent beneficiaries could become adherent, and applying estimates beyond the Medicare FFS population.

*Center for Medicare and Medicaid Innovation

Cigna-HealthSpring, Baltimore, MD

University of Pittsburgh Medical Center, Pittsburgh, PA

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies.

C.A.P. is currently employed by Cigna HealthSpring. W.H.S. was previously employed by CVS Health (Woonsocket, RI). The remaining authors declare no conflict of interest.

Reprints: Jennifer T. Lloyd, PhD, Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Mail Stop WB-06-05, Baltimore, MD 21244. E-mail: Jennifer.lloyd@cms.hhs.gov.

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