Medication adherence has been called the least-appreciated aspect of medicine but its impact is certainly noteworthy.
A recent report, “Adherence and Health Care Cost,” characterized it as “an important public health consideration, affecting health outcomes and overall health care costs” and estimated between 20 and 50 percent of patients are non-compliant with drug therapy.
Additionally, poor medication adherence following hospitalization costs the U.S. healthcare system roughly $100 billion annually, according to a New England Journal of Medicine study.
As our healthcare system moves to value-based reimbursement, technology will help improve medication adherence rates. With this in mind, KNB Communications recently interviewed three leaders in healthcare technology – Propeller Health Co-founder and CEO David Van Sickle, RxAnte Founder and CEO Dr. Josh Benner, and RxREVU Founder and CEO Carm Huntress – to get their insights on this important topic.
Q: What are some solutions for addressing the top reasons for medication adherence failure:
- Medications never getting to the patient
- Medications not being taken correctly
- Medications not being refilled
DVS: At Propeller, we focus on respiratory disease. We spend all of our time and attention trying to figure out ways to help people with asthma and COPD better and more effectively use the medicines that they take to prevent symptoms from occurring.
These are daily medicines that are subject to factors such as: people forgetting to take them; people not understanding them; people thinking that they’re taking them correctly but not, in fact, doing so; or people trying to negotiate or even intelligently adjust their regimens in one way or another, to benefit their life or for their own understanding of medicine.
Propeller builds devices that capture information about the day-to-day use of those medications and attempts to understand the patterns with which people are taking them or not. Then, we’re able make use of that information through digital interfaces and experiences, to try to encourage, educate, coach, and remind people about how to better manage their condition.
Across the market we’re seeing the creation of digital interfaces and experiences that are tightly coupled to medications that aim to make them more personal, more accessible, and more convenient. These start from thinking about medications from the patient’s perspective, and asking the question: How can you simplify and strengthen these regimens in ways that makes them easier for people to understand and use?
JB: The adherence failures you identified are an all-too-common cascade of risks for anyone prescribed a medication. If the patient never fills a new prescription, we call it “primary non-adherence.” This happens for 20-30% of new prescriptions written. Of those who fill a prescription, about 50% don’t take it correctly, or stop prematurely. Effective solutions need to understand why these failures occur, and prevent them from happening. Our perspectives on this are informed by decades of research and our direct experience managing 8 million people’s medication adherence for health plans around the country.
Some of the reasons people don’t take medications are because they’ve decided, for what they think are good reasons, not to take the medication. This is actually most of the non-adherence that we observe in our work managing population-level adherence. People either think that the medication didn’t work for them, that they experienced a side effect or fear a side effect that someone else told them about, or they made a choice not to pay for it because of its cost. Essentially, they considered the risks, the benefit, the convenience and the cost, and made a conscious decision not to take the medication.
Other patients want to be adherent but may be forgetful, have complex regimens they don’t understand, are inadvertently taking a drug incorrectly, can’t get access to the pharmacy or the product, or they want to take it but can’t afford it. That’s a different set of barriers.
Our approach is generally to predict who is at risk of these failures, determine the likely barriers, and then deliver an appropriate intervention that can overcome the barriers.
For patients who may choose not to adhere to their therapy, the answer is education and close follow-up, to make sure that they understand why they’re taking the medicine, how to take the medicine, what to expect from the medicine, so that they know it’s working or know it’s not working. Close monitoring of lab values or clinical signs and symptoms can show them whether the medication is having the intended effect for them, and help them put that benefit in perspective relative to any side effects they may be feeling. The goal here is to prevent non-adherence.
We published some work several years ago showing that in patients starting a cholesterol medicine, if you get them back into the doctor’s office within the first three months for a cholesterol test – their likelihood of being adherent over the subsequent year is far higher than if they don’t return for another lab test in that time period. This notion of demonstrating the benefit of treatment early in therapy is really important because it balances against what they might perceive to be as the expense or the inconvenience or the side effects. And it prevents non-adherence.
For the patient who is already receptive to therapy and wants to be adherent, we use interventions that address different barriers. This is where things like reminders, pillboxes, special unit-dose packaging, financial assistance programs, and home delivery can be helpful. We’re trying to make it possible for the patient to be adherent to the regimen.
CH: I think when it comes to the refill issue and even first-fill challenges; the thing we really looked at is cost.
Our data indicates about a third of abandonment issues are usually due to cost concerns for an individual patient. A lot of that has come down to transparency. Any technology that can help bring that transparency, not only to the patient but also to the provider at the point of care, is going to be critical in creating a successful engagement and encouraging the patient to fill that medication and continue to take it.
Sadly, in many cases, there are alternatives that are less expensive that would still be clinically effective for the patient. But the provider and the patient are just unaware of what’s covered, what it would cost, and any programs that may enable the patient to get that medication at a lower cost. And so, I think that addresses that third point. In terms of the first point, what we look at is the friction from the point of prescribing to the pharmacy, to that fulfillment.
Today, there’s a huge amount of friction that really needs to be removed from the process, leading to abandonment and poor adherence. Many times, there’s a prior authorization on a drug and there is another drug that doesn’t have a prior authorization, so the patient gets to the pharmacy, can’t get it filled, and has to go through the prior authorization process, which can take days or weeks to complete.
We think that situation leads to poor adherence and has to be solved. Technology that can not only support that process and speed it up for the patient but ultimately solve it at the point of care, dealing with the PA immediately and not burdening the provider and the patient afterwards will be critical to the success of increasing that patient’s adherence. I also think about site of fulfillment, which can make a huge difference if that pharmacy a patient’s using is in network or out-of-network. Where is it on their plan?
Many times, the patient’s unaware or their provider is unaware of that. And so, technologies that can bring that information forward and help guide that patient to the right site of fulfillment are critical. It can be an actual physical pharmacy or even mail order. Anything from a technology standpoint that can address those issues is really going to have a massive impact on adherence.
About David Van Sickle
David Van Sickle is co-founder and CEO of Propeller Health – the leader in respiratory digital health. David received his PhD in medical anthropology. His dissertation research, funded by the National Science Foundation, examined the rising prevalence of asthma and allergy in India. He was then an Epidemic Intelligence Service officer at the Centers for Disease Control and Prevention in Atlanta, where he was assigned to the Air Pollution and Respiratory Health Branch. During this time, he provided epidemiological support to the National Asthma Control Program, and investigated the health effects of a variety of environmental exposures. In addition, he helped establish emergency illness and injury surveillance in coastal Mississippi after Hurricane Katrina. David was also named a Champion of Change by the White House for his work on innovation.
About Josh Benner
A leading voice on medication adherence, Dr. Benner’s award-winning research and numerous publications have shed new light on the problem of nonadherence and identified promising approaches to improving it. He is the founder and CEO of RxAnte, the leading provider of predictive analytics and targeted clinical programs for improving medication use.
Before joining RxAnte, Dr. Benner was Fellow and Managing Director at the Brookings Institution’s Center for Health Care Reform, where he focused on medical technology policy.
Prior to Brookings, Dr. Benner was principal at ValueMedics Research, an analytic and consulting services firm. Following the acquisition of ValueMedics by IMS Health in 2007, he served as senior principal in health economics and outcomes research and global lead for medication adherence at IMS. Dr. Benner received his Doctor of Pharmacy degree from Drake University and his Doctor of Science in health policy and management from the Harvard University School of Public Health.
About Carm Huntress
Carm Huntress is an entrepreneur and strategic leader with over 20 years of experience in startups focused around consumer and enterprise technology. His first web development and hosting company he started while in high school was eventually acquired in 2001. After finishing his degree in electrical engineering at Northeastern University in 2004, he went on to work for PlumVoice, an IVR and voice technology startup, where he ran their network operations. He later was asked to run product development at My Perfect Gig, a Northbridge and Commonwealth Venture start-up.
After two years as CTO at Reef Partners, where he ran the technology for a number of portfolio companies, he became CTO at Audiogon.com, the largest high end audio site in the world. He managed the transition of the core technology platform and team for growth. In 2013 he moved to Denver where he founded RxREVU.