Diabetes Core Update: Special Edition – What's Next: Adherence to Medications – Challenges and (Some) Solutions

Date: December 18, 2025
Host: Dr. Neil Skolnik
Guests: Dr. Susan Kucera (Family Medicine), Tess Carey, PharmD (Amazon Pharmacy Clinical Advisor)

Episode Overview

This special episode of Diabetes Core Update dives into the pervasive and complex challenge of medication adherence among patients with diabetes and other chronic diseases. Host Dr. Neil Skolnik is joined by primary care physician Dr. Susan Kucera and pharmacist Tess Carey to explore real-world experiences, consequences of nonadherence, structural and personal barriers, and evolving solutions—including the potential role of digital and online pharmacies. The conversation is geared toward healthcare professionals, with a focus on actionable insights for clinical practice.

Key Discussion Points & Insights

1. The Real-World Scope and Nuance of Nonadherence

• Patient Examples (02:13) — Dr. Kucera:
  • Missed doses often go undetected; even when clinicians ask, patients may not disclose nonadherence out of embarrassment or a desire to please.
  • “It makes adherence such a complex issue…especially a lot of emotional context for patients…So, yes, I see it all the time. I’m sure I miss it all the time. And it’s really complicated.” (03:15)
• Consequences include inappropriate dose escalation or additional medications if the real issue—missed medication—is not identified.

2. The Prevalence of Nonadherence (04:16)

• Tess Carey shares data:
  • "Roughly 50% of patients with chronic conditions do not take their medication as prescribed long term.”
  • For inhaler-dependent patients (e.g., asthma, COPD), adherence can drop below 30%.
  • “For diabetes…every 10% that adherence decreases, we see an increase in A1C and an increased risk in hospitalizations.” (04:48)
• Primary nonadherence is an invisible but formidable issue:
  • “One in three prescriptions goes unfilled or not picked up from the pharmacy.” (05:35)

3. Consequences of Nonadherence (06:27)

• Poor adherence results in:
  • Worse health outcomes and a 2-3x increased risk of hospitalization for diabetes patients.
  • National healthcare costs: $100–300 billion annually due to medication nonadherence.
  • Overprescribing and polypharmacy resulting from clinicians not recognizing nonadherence: "Trying to manage a chronic condition that appears uncontrolled…probably drives a lot of this increase in hospitalizations.” (07:04)

4. Barriers to Adherence – What Gets in the Way? (08:21)

• Top barriers (Tess Carey):
  • Access: Pharmacy deserts; transportation and work-hour challenges.
  • Affordability: 30% of patients cite price as the reason for nonadherence; leading to skipped doses or delayed refills.
  • Complexity and Forgetfulness: Especially with multi-medicine regimens or new diagnoses.
• Barriers are layered and sensitive:
  • “A patient may have transportation issues, but they also can’t afford that medication…and maybe skeptical about taking the medication to begin with.” (09:12)
• Clinician-side challenges:
  • Trusted relationships and nonjudgmental inquiry are essential for "diagnosing" nonadherence, which is often hidden. (09:33)
  • Navigating formularies, prior authorizations, and insurance complexities also impact adherence.

5. A Framework for Understanding Adherence Issues (10:55)

• Dr. Skolnik divides barriers into three "buckets":
  • Structural: Access and affordability.
  • Interactional: Quality of communication, trust, patient education.
  • Patient-level: Individual beliefs, health literacy, life chaos vs. organization.

6. Structural Solutions: Pharmacy Options and Innovation (13:04)

• Traditional Community Pharmacies:
  • Since 2019, 7,000 have closed—almost half of US counties are now "pharmacy deserts."
• Mail Order:
  • Good for established therapy; takes a week to ten days for delivery.
• Digital/Online Pharmacies:
  • Offer rapid home delivery and 24/7 pharmacist support, though underutilized due to lack of awareness among both patients and providers.
• "Pharmacy is not just prescription fulfillment or prescription delivery. The pharmacist is the heart and soul of a pharmacy." (15:12, Tess Carey)

7. Pharmacist Access: A Changing Landscape (15:12–19:57)

• Digital pharmacist access:
  • 24/7 support via chat or phone, staffed by licensed PharmDs. Private, pressure-free conversations, even for sensitive questions.
• Advantages over the traditional model:
  • “Patients are so perceptive…and that’s scary because then those questions aren’t being asked…For me, having a digital resource where that pharmacist is dedicated to answering patient questions is so important.” (18:17, Tess Carey)
  • Dr. Kucera notes digital communication may encourage honesty from patients regarding adherence or embarrassment.

8. The Importance of Timely Support (20:20)

• Questions often arise at home, not at the pharmacy or doctor’s office.
• “When a patient is motivated and feels encouraged to take that medication…they’re so much more likely to start their medication and stay on that therapy.” (21:17, Tess Carey)
• Digital pharmacies can meet this need by being accessible at the patient’s moment of uncertainty.

9. Does Digital Access Improve Adherence? (22:06)

• “One of the keys to adherence is optionality—that a patient has the different options to meet where they are.” (22:06, Tess Carey)
• Getting the medication in the patient’s hand—through whatever avenue works best—is the critical first step.

10. Closing Thoughts and Practical Takeaways

• Dr. Kucera:
  • "Assume [nonadherence] is happening…lead with a very nonjudgmental curiosity…We should be educated to employ all of the resources out there to help patients with this—including digital options." (22:41)
• Tess Carey:
  • “Medication adherence is so complex…It’s going to take us working as a team—providers, pharmacists, and patients—to help problem solve.” (23:21)

Notable Quotes & Moments

• On the pervasiveness and challenge of adherence:
  • "It happens all of the time…We take care of human beings who have complex lives outside of our office." — Dr. Susan Kucera (02:13)
• On the magnitude of nonadherence:
  • “Every 10% that adherence decreases, we see an increase in A1C and an increased risk in hospitalizations.” — Tess Carey (04:48)
• On the hidden nature of primary nonadherence:
  • “It’s clinically invisible in so many ways…One in three prescriptions goes unfilled or not picked up from the pharmacy.” — Tess Carey (05:35)
• On the future of patient support:
  • “The pharmacist is the heart and soul of a pharmacy.” — Tess Carey (15:43)

Timestamps for Key Segments

| Topic / Segment | Timestamp | |-------------------------------------------------|--------------| | Opening and introductions | 00:02 | | Real-world patient nonadherence examples | 02:13 | | Prevalence and data on adherence | 04:16 | | Primary (initial) nonadherence | 05:35 | | Financial and outcome consequences | 06:27 | | Barriers: literature and practical perspective | 08:21 | | Clinician–patient trust and uncovering issues | 09:33 | | Three-bucket framework for adherence | 10:55 | | Structural solutions: mail order, digital Rx | 13:04 | | Pharmacist access: digital vs. in-person | 15:12 | | Digital pharmacies and the potential for honesty| 18:17 | | Importance of timely, on-demand support | 20:20 | | Final thoughts: nonjudgmental curiosity | 22:41 |

Conclusion

This episode underscores medication adherence as a multifaceted and high-impact challenge in chronic disease management. Addressing it requires clinicians to maintain nonjudgmental curiosity, enhanced communication, and a willingness to leverage evolving pharmacy solutions—especially digital platforms that broaden access and provide timely patient support. Ultimately, as Dr. Skolnik reflects, solutions begin with asking the right questions and fostering trust, while remaining open to the changing possibilities for patient care in a digital age.