Editor's note: The following article is adapted from Michael A. Watkins' doctoral work for Walden University. Click here to access the full, original work.

Every primary care administrator has seen the pattern. A patient with hypertension or diabetes leaves a visit with a prescription, and the practice’s next contact is a call from the emergency department, a hospital discharge summary or a nurse trying to reconcile a medication list that no longer matches what the patient is taking. Somewhere between the visit and that call, the medication stopped — never filled, filled once or taken until the copay came due. The clinical consequences are well documented. The administrative ones are counted less often: the outreach calls, the repeat visits, the care coordination hours, the reconciliation work and the share of the resulting care that is never collected.

My integrative review, completed for my Doctor of Healthcare Administration degree at Walden University, asked one question: What strategies could be implemented in an integrated primary care clinic to reduce administrative costs related to patient medication nonadherence? This article condenses the review’s evidence base and recommendations for the people who run those clinics.

The scale of the problem

Medication nonadherence contributes to about 125,000 deaths and 10% of hospitalizations in the United States each year.¹ Other widely cited estimates attribute up to 25% of hospitalizations and as many as half of treatment failures to patients not taking medications as prescribed.² The avoidable spending attached to those outcomes has been estimated at $100 billion to $290 billion annually.³ A 2025 review of 43 systematic reviews reached the same conclusion across disease areas: nonadherence is consistently associated with higher mortality, more hospital admissions and higher direct and indirect costs for patients and for the systems that care for them.⁴

The per-patient numbers matter more to a practice than the national ones. In a systematic review of 79 cost studies, Cutler and colleagues found that the adjusted annual cost of nonadherence ranged from $949 to $52,341 per person, depending on disease and comorbidities, and that the typical nonadherent patient requires about three extra medical visits a year, adding roughly $2,000 in treatment costs.³ Those extra visits are where the administrative burden lands: more scheduling, more rooming, more documentation, more prior authorizations and more follow-up, much of it for patients whose condition has worsened in the interim. Among Medicare patients, chronic medication nonadherence has been linked to potentially preventable hospitalizations and emergency department (ED) visits and to the spending that goes with them.⁵

Two structural facts make this a primary care problem specifically. First, the conditions that drive preventable utilization — diabetes, hypertension, heart failure — are managed in primary care, which makes the clinic the point of contact most able to notice when a patient stops a medication and to do something about it. Second, primary care is underfunded relative to that role. Less than 5% of U.S. healthcare spending goes to primary care, and when community health centers and primary care clinics lack the resources to staff up or stay open, patients lose their first line of defense for chronic disease management and routine screening.⁶

The burden is also unevenly distributed. Nonadherence is higher among Black, Latino and other minority populations, driven by structural, social and economic factors — affordability, pharmacy access, health literacy and trust that has been eroded both outside and inside the healthcare system.¹ A meta-analysis of social determinants of health found consistent associations between those determinants and lower adherence.⁷ For a practice, the patients most likely to fall off therapy are often the same patients whose care generates the most uncompensated administrative work.

Where a practice could be

Kleinsinger's 2018 assessment still holds: Nonadherence affects 40% to 50% of patients prescribed medications for chronic conditions, yet it is barely on the radar of most practicing physicians and is widely treated as a patient problem rather than a practice or system problem.⁸ The same article describes an integrated system that raised adherence above 80% through a combination of approaches centered on the electronic health record (EHR).⁸ The integrated system described by Kleinsinger illustrates what coordinated adherence efforts can achieve.

The ideal state I defined for the review is a coordinated, patient-centered and data-driven operation. Integrated EHR data and real-time monitoring identify patients at risk for nonadherence early. Providers, pharmacists and support staff share the work of intervening. Standardized but flexible workflows support medication reconciliation, patient education and structured follow-up. Leadership addresses cost, access and health literacy barriers and evaluates performance on adherence, utilization and cost metrics. That description aligns with the Agency for Healthcare Research and Quality (AHRQ) care coordination framework, which identifies coordination, health information technology and patient engagement as drivers of better outcomes and less unnecessary utilization.⁹

How I approached the review

I used general systems theory as the lens.^10,11 The theory treats an organization as a set of interconnected parts operating as an open system — exchanging information with its environment, running on feedback loops and capable of self-correction. Applied to a clinic, it means medication adherence should be analyzed as a property of the whole operation (technology, staffing, workflows, patient circumstances and measurement) rather than as a series of separate fixes.

The literature search covered PubMed, Web of Science, Scopus and EBSCOhost for January 2020 through December 2025, using Boolean combinations such as “medication nonadherence” AND “targeted strategy” AND “cost-reduction”; “chronic medication nonadherence” AND “web-based management” AND “preventable spending”; and “system-based” AND “medication adherence” AND “clinic costs.” Inclusion criteria were English-language empirical and nonempirical full reviews addressing medication nonadherence in patients. I excluded studies limited by patient age, forgetfulness, personal beliefs, a single health condition or a specific insurance type. The search identified 1,892 articles. Ninety-seven were analyzed in the literature review, and 29 were retained for quality appraisal using the Johns Hopkins Nursing Evidence-Based Practice Model. Twenty-two of the 29 were qualitative and seven were quantitative; all were rated Level III evidence of high or good quality. Thematic analysis of those 29 sources produced four themes and the subthemes shown in the table.

What the evidence shows

Theme 1: Implement adherence technology

The literature supports digital tools embedded in clinical workflows as a way to improve monitoring and operational efficiency. A scoping review found a growing body of work applying machine learning to clinical, claims and sensor data to predict and monitor adherence,¹² and a meta-analysis of mobile apps for cardiovascular disease found that apps tended to increase adherence — with the caveat that the interventions varied widely in design, content and delivery.¹³ A systematic review of digital health interventions also found generally favorable effects on costs and health outcomes.¹⁴

Predictive tools add a second layer. Artificial intelligence and related approaches can be used to measure adherence, flag patients at higher risk and direct outreach where it will do the most good.¹⁵ Risk factors for nonadherence are mapped well enough across specialties that interventions can be matched to them.¹⁶ One finding deserves a caution: A hospital that implemented an EHR saw reported medication errors rise rather than fall, because detection improved.¹⁷ Leaders should expect measured nonadherence to look worse before it looks better once a practice starts looking systematically.

In practice. Most groups can start with what they have: a reliable way to identify patients on high-priority chronic medications whose refill history, missed visits, disease burden or recent utilization suggests risk, and a workflow that puts that signal in front of someone with the authority to act. Refill gaps, missed follow-ups, ED visits, high copays and complex regimens are reasonable trigger points. The signal should feed pre-visit planning, huddles, care management queues and post-visit follow-up. Every alert needs an owner — a medical assistant, nurse, care manager, pharmacist or provider — or it becomes noise for the clinic team. A small measurement set is enough to begin: refill gaps closed, outreach completed, barriers resolved and acute-care utilization among the flagged cohort.

Theme 2: Deliver targeted interventions

Across the evidence, interventions tailored to the individual patient outperformed generic ones. A meta-analysis in patients with schizophrenia or bipolar disorder, where adherence is especially difficult, found that successful interventions combined educational and behavioral strategies rather than relying on either alone.¹⁸ Motivational interviewing, a structured counseling approach that works from the patient's own reasons for change, has been tested in randomized trials across chronic conditions with positive effects in many, though not all, of them.¹⁹

Cost and access are the barriers most directly within a practice's reach. A systematic review of 79 articles found a consistent negative effect of higher cost-sharing on medication initiation and continuation; the authors concluded that cost-sharing is a blunt instrument that curbs necessary and unnecessary use alike.²⁰ Patients with chronic conditions, especially diabetes, cope with cost by cutting back on basic needs, skipping doses or asking for samples, and cost conversations during the clinical encounter are both important and acceptable to patients.²¹ In head-to-head comparisons, multicomponent approaches that address more than one barrier have shown the greatest success.²²

In practice. A patient who cannot afford a prescription needs a different response than one who does not understand the dosing schedule, fears side effects, lacks transportation or distrusts the care team. Treat nonadherence as a barrier-diagnosis problem: Identify the reason, then match the response. A short, repeatable script works at prescribing, at follow-up and at refill requests — “What might make this medication hard to take every day?” — with the barrier documented in a standardized field. The next steps are familiar: formulary review, lower-cost alternatives, pharmacy delivery, refill synchronization, teach-back, side-effect counseling, transportation resources or referral to a pharmacist or care manager. Cost, access, literacy and trust are operational barriers, and naming them lets leaders design the workflow instead of assigning blame.

Theme 3: Strengthen care team coordination

Personalization is only sustainable when the work is distributed. A meta-analysis of 40 randomized trials found that pharmacist-led interventions significantly improved adherence in older adults, with larger effects when the intervention included medication education and when some component was delivered in the patient’s home.²³ Among adults with depressive disorders, a multiprofessional collaborative approach was more effective at improving adherence than primary care or mental health teams working alone.²⁴ A systematic review of interdisciplinary team-based care — defined as a dynamic, collaborative approach in which professionals from several disciplines address patients’ complex needs together — found positive effects for chronically ill patients and, at the organizational level, more efficient healthcare utilization.²⁵

Team structure also changes how technology performs. In a team-based simulation at a global medical technology firm, system-optimization strategies — collaboration and data-driven decision-making among them — improved both financial and quality performance.²⁶ Taken together, these findings favor team-based technology implementation over leaving individual clinicians to manage new tools independently.

In practice. Adherence should not live in the physician’s memory or in disconnected portal reminders. Build it into the team’s rhythm: Pre-visit planning identifies medication gaps; the clinician confirms the regimen and discusses barriers; a care manager, nurse, medical assistant, pharmacist or designated medication champion closes the loop afterward. Define who screens for nonadherence, who checks refill history, who conducts teach-back, who discusses cost, who contacts the pharmacy and who follows up after a medication change. Without that clarity, adherence work gets pushed to the margins in clinics where staff are already stretched. Groups without an embedded pharmacist can designate an adherence lead, build a relationship with a community pharmacist or reserve pharmacist referrals for the highest-risk patients.

Theme 4: Implement system-level strategies

The evidence favors adherence programs that address several barriers at once rather than relying on a single intervention. Addressing nonadherence requires an approach that combines multiple strategies — simplifying regimens, reducing barriers, using technology and applying behavioral principles.²⁷ A complex multidisciplinary intervention to improve initial medication adherence in primary care, now being tested in a cluster-randomized trial, was built on that premise, with a process evaluation that measures implementation fidelity alongside outcomes.²⁸ Across the sources I retained, multicomponent interventions consistently outperformed single ones.^22,27

In practice. A reminder app, a counseling script, an EHR alert and a pharmacist referral can each help; durable improvement comes from combining them into something measurable. Start with one high-risk population — patients with diabetes, hypertension, heart failure or multiple chronic medications. Establish a baseline for refill gaps, adherence rates where available, ED visits, hospitalizations, no-shows and patient-reported barriers. Then run the program the way you would run any performance improvement effort: a monthly review of which barriers appear most often, which patients keep falling through, which staff steps are working and which are adding burden, and which interventions reduce utilization. Refine the workflow from what the data show instead of piling on disconnected tasks.

Three recommendations for practice leaders

From the themes and subthemes, I developed three recommendations.

1. Implement an integrated, technology-enabled adherence program that combines EHR monitoring with predictive risk identification. EHR-based monitoring gives the team visibility into adherence patterns and strengthens coordination across providers; predictive tools let the practice find high-risk patients early and allocate scarce staff time where it prevents an avoidable visit or admission.^12,15

2. Deliver targeted, patient-specific adherence interventions that address individual barriers such as cost, access and understanding of medications. Patient individualization and comprehensive intervention are each necessary; generic reminders alone are not.^18,22

3. Establish a coordinated, system-level adherence strategy that integrates interdisciplinary care teams, technology and continuous performance evaluation. Interdisciplinary care lets professionals across roles pool their expertise and produces the coordination a single-discipline approach cannot.²⁵ Regular review of adherence, utilization and cost metrics is what keeps the program improving.

Who bears the cost

The costs of medication nonadherence are not evenly distributed among patients or the practices caring for them. They also reflect how unevenly the problem falls. Nonadherence disproportionately affects patients facing affordability, access and trust barriers,^1,7 and cost-sharing — a lever practices do not control but can help patients navigate — consistently suppresses both starting and staying on therapy.²⁰ A practice that builds barrier screening and cost conversations into its workflow is doing equity work whether or not it calls it that, and it is reducing the uncompensated administrative load that follows those patients through the system.

Limitations

This was an integrative review. No primary data were collected, so I could not correct for biases in the underlying studies, and the findings may not generalize beyond the contexts in which they occurred. Several retained sources were systematic reviews or trial protocols rather than completed trials, and most cost estimates in this literature are descriptive rather than full economic evaluations; Cutler and colleagues cautioned that methodological differences make an accurate estimate of the true magnitude of nonadherence costs impossible.³ 

Conclusion

The purpose of this review was to identify cost-reduction strategies for medication nonadherence that a stand-alone integrated primary care clinic could realistically implement. Four themes emerged: technology integration, targeted intervention, care team coordination and system-level design. The review found that technology, patient-specific interventions and team coordination work best as parts of a broader adherence program.

The failure modes are familiar. Individual technology tools get implemented but never fully integrated into the organization, or practices fall back on generic interventions because they are stretched too thin to do more. The macro-level drivers of nonadherence — coverage, drug prices, primary care funding — require long-term policy work. Practices do not have to wait for it. Systems thinking can be applied within a single clinic, and medication management can be tailored to individual patients with the staff and tools most groups already have. The evidence suggests that doing so pays back in fewer avoidable visits, less reconciliation and outreach work, and healthier patients. For practice administrators, the goal is to improve medication adherence and patient outcomes while reducing the avoidable utilization and administrative work that nonadherence creates.

References

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