Promoting Adherence: From Force to Finesse

The figures vary a little, but the consensus hasn't changed much in the last decade: non-adherence, in the US alone, is at least a $100-billion-a-year problem, with patients getting sicker, showing up in the ER, or getting an operation that might have been avoided if they'd only taken their meds according to doctor's orders. Of all avoidable US healthcare costs, non-adherence is by far the largest, reports IMS Health (see chart).

Avoidable costs of more than $200 billion are incurred each year in the US healthcare system, with non-adherence accounting for the largest share.

Depending on therapeutic area, patient characteristics, insurance coverage, and other factors, estimated non-adherence rates among patients range from 25% to 50% in the US, where nearly half of all adults have at least one chronic disease, according to Centers for Disease Control (CDC). An estimated 10% of hospitalizations in older adults may be attributable to skipping doses, or failing to pick up drug refills.

Everyone knows the statistics but the problem remains despite multichannel disease awareness efforts, new mobile apps, digital tools for tracking health behavior and insurance plan or pharmacy incentives. Efforts to make medicine participatory—instead of rigidly paternalistic—haven't had an enormous impact on non-adherence to date. That's because the choice to take a pill or an injection, in the outpatient setting, is an utterly personal decision—it's based on a panoply of variables, from cost of therapy and the potential for side effects (and how they conflict with day-to-day obligations), to physician trust and the level of comprehension related to risks associated with non-adherence.

It also has to do with plain old forgetfulness, inconvenience, and differing individual priorities. For many patients, collaboration in the context of healthcare decision-making sounds like more work and more effort at a time when jobs and family already compete for any spare time left during the day or night. And yet, "most of what determines [health] outcomes happens outside of the doctor's office," said Farzad Mostashari, a visiting fellow at the Brookings Institution and former National Coordinator for Health Information Technology at HHS, during the SAS Health Analytics Executive Conference in North Carolina last month. What is Mostashari's prescription? "Reduce friction and increase services to promote loyalty." If being adherent to a medication becomes easier than not being adherent, the statistics may finally take a turn.

Greasing the wheels

During a roundtable discussion at the mHealth Summit last December, Vera Rulon, director of external medical communications at Pfizer, recalls sitting next to a diabetes patient who said she "didn't want to be bothered" with a medication regimen, to the extent possible. This patient "wanted something that monitors blood sugar, gives you insulin when you need it or at least alerts you when you need to do something, in a seamless and transparent way," says Rulon. Providing a seamless experience means understanding more than just the nature of a given disease, and a drug's product attributes. It also requires an understanding of the patient, and his or her real-world environment.

"For this particular medication, you do need to look at these factors, and this is what may have an impact on a person's response," for example, says Rulon. "Physicians need to be sensitive to a patient's perspective...building a rapport and trust, and sharing in the decision-making process helps get buy-in for patients to do what they need to do to help themselves."

In addition to actual products that make sustained adherence to therapy an easier pill to swallow are programs that make prescription drugs easier to get. Payers are often seen as the primary barrier to quick and convenient drug access, since a growing number of prescriptions are written for expensive specialty products that require prior authorization, step therapy, or higher co-pays or coinsurance to obtain. Patients taking biologics for chronic disease are often forced to play the same pharmacy counter game of phone tag with insurance companies and physicians every few months, to keep the refills coming.

But insurance providers are partnering with pharmacy benefits managers (PBMs) and even health information companies like WebMD to provide a more convenient way for patients to request and fill prescriptions. Insurers like United Health and BlueCross Blue Shield are experimenting with premium discounts in employer health plans for those patients who can document certain healthy activities, including medication adherence. Pharmacies, too, are launching new service offerings to promote better adherence rates and to build loyalty with patients.

Kaiser Permanente's integrated model puts it in a unique position to combine insights across the payer and pharmacy verticals. Terhilda Garrido, VP of health IT transformation and analytics at Kaiser, says patients can digitally access their own personal health records without having to enter any data themselves, and can also request refills, and even ask for mail order and pay with a credit card. Garrido says one of Kaiser's basic models is to "make the right thing easy to do," which in this case means getting prescription refills to patients with minimal effort. Like an Amazon.com purchase, Kaiser's patients can sign on and click to get a product order—in this case a medication refill—delivered by mail. "I've actually used it myself," says Garrido. "I've studied this stuff, but when you actually use [a refill delivery program], you think, 'Wow, this is pretty great.'"

Since online refill requests for prescription mail order are routed through one of Kaiser's fulfillment houses (which is "much more automated than the local facility at the medical center or clinic"), it's a lower cost-per-script filling rate, says Garrido. "So, we're thrilled about some of the advantages that being on the Internet is giving to our patients."

Kaiser invested $4 million in electronic health record (EHR) technology 10 years ago, a decision that "catalyzed our use of data," says Garrido. Now, the organization leverages its 10 petabytes of EHR data—and its four thousand data analysts—to push risk claims down and close gaps in care, including non-adherence. One program, called the Outpatient Medication Safety Net, uses an "adherence ratio" to predict when a patient will run out of medicine. This information—and whether a script was filled on time—is then passed to the physician through the patient's EHR. "Then the physician can say, 'I notice that you didn't pick up your statin. Let's talk about that, and why it's important and why I prescribed it, and what [barrier] might be getting in the way,'" says Garrido. "We're presenting that information to physicians to enable a conversation that in fact does increase adherence rates."

Transparency trigger

Of the 9.3 million patients covered by Kaiser, almost half—4.4 million, says Garrido—are active users who log in to their personal health records to view lab results, refill prescriptions, or otherwise participate in their own treatment and care. A pilot program in the northwest is going one step further by giving patients access to their doctor's progress notes from past appointments within the EHR.

The "progress notes" pilot program at Kaiser is modeled on the OpenNotes research project spearheaded by Tom Delbanco, professor of general medicine and primary care at Harvard and Jan Walker, a member of the research faculty at Harvard and Beth Israel Deaconess.

In an October 2012 Annals of Internal Medicine article, Delbanco, Walker and colleagues published research (funded by The Robert Wood Johnson Foundation and other charitable organizations) suggesting that physician notes, taken during an appointment, can have a substantial impact on behavior and adherence when the notes are freely shared with patients (see sidebar). The authors conclude "open notes seem worthy of widespread adoption," since "patients accessed visit notes frequently, [and] a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue." Sixty to 78% of participating patients reported an increased adherence to their medications. On the physician side, "doctors experience[ed] no more than a modest effect on their work lives," the authors wrote.

OpenNotes: Bending the Adherence Curve

Kaiser's EHR provider is Epic, and Garrido says it's not so easy to customize functionality in the EHR, and corresponding personal health record. But Kaiser figured out a way. "We've created these smart phrases that essentially copy the physician's progress note into what is called the "after visit summary" in Epic, says Garrido. In addition to printed information given after a visit—current meds discussed, patient instructions, other physician comments, etc.—that information is also archived within the patient's personal health record and accessible at any time. The ability to refer back to exactly what a physician said, days or weeks after an appointment, is a simple but effective tool in driving healthy behavior, Garrido says.

Plus, the notes appear in the health record without any additional typing or effort from physicians; adding another data entry requirement to a patient visit is a sure way to kill any new program, notes Garrido. Patients in the Kaiser EHR system still have to log in through a rigorous authentication system for access—which can be a barrier for some patients—but Garrido is hopeful that Epic will be able to create a button or some easy way for patients to simply mark or click for speedy access to progress notes from recent visits with physicians.

Asked about biometric data as a potential component of a patient's health record, Garrido emphasized the importance of patient reported outcomes, and the integration of a patient's perspective and experience into any treatment plan. Are patients willing to open up their biometric sensor data to health insurers? "Some patients want to do it, but it's really up to the physicians to decide why they want this data," says Garrido. "We're relying on clinicians, currently, to encourage sharing of [biometric] data."

On the flip side, not every doctor is comfortable sharing his dispassionate assessment and clinical notes with patients; it challenges the traditional notion of physician/patient hegemony by creating a medium for a patient's critique of a physician's choices. But most of the time, it probably just leads to healthy dialogue. Delbanco's OpenNotes research provides data suggesting that many apprehensions about sharing information fade with actual experience.

Rulon says Pfizer is looking at "testing out Blue Button"—a digital tool used in some CMS health plans that lets patients easily download their EHRs and other personal health data —"in clinical trials, so patients could actually access the information from their clinical trial participation...which would become part of their personal health record." The benefit, says Rulon, is that patients could more easily "see whether that medication is something that works for them, or not."

Pharmacy factor

Plenty of research has been done to prove that high adherence rates improve health outcomes and reduce costs to the system, and pharmacies understand that better adherence also means higher quarterly returns. The largest chain pharmacies have all rolled out digital services for patients (e.g., e-refills) and physicians (e.g., e-prescribing), and in May, the National Association of Chain Drug Stores (NACDS) Foundation awarded three research grants totaling $1.8 million to study "the impact of pharmacist-collaboration in helping patients manage their medications and avoid readmissions following discharge from the hospital."

Hospital readmissions are expensive, and Section 3025 of the Affordable Care Act requires CMS to reduce payments and, therefore, penalize some hospitals when patients are readmitted within 30 days of a discharge; the provision went into effect in October 2012. Historically, hospitals haven't done a good job supporting patients after they're discharged—there isn't a clear financial incentive attached to counseling patients about healthy routines and medication adherence outside hospital walls. Hospitals make money when patients walk in, not out.

In an effort to fill this gap, for patients and for hospitals worried about readmission rates, Walgreens launched "WellTransitions," a program aimed at patients transitioning out of the hospital to "make sure the patient knows what they're supposed to be doing when they go home," says Kristi Rudkin, senior product development at Walgreens. Medication regimens and schedules often get changed during a hospital stay, so WellTransitions helps patients get comfortable with a new medication routine. "I think patients generally want to do what they're supposed to do, but sometimes things get in the way," says Rudkin.

Walgreens pharmacists assigned to the WellTransitions program—which requires a "small upfront fee to the hospital"—provide medication alignment and bedside prescription delivery; patient counseling and clinical follow-up with physicians; reinforcement contact with patients at nine days and 25 days after discharge; and an monthly joint outcomes report to assess the program's effectiveness in terms of cost and readmission reductions. At the 2014 American Pharmacists Association conference last April, Walgreens unveiled data showing that patients who participated in the WellTransitions program were 46% less likely to experience an unplanned hospital readmission within 30 days of discharge.

In addition to online prescription management tools like opt-in refill reminders and therapy consultations, Walgreens, like Kaiser, is analyzing its own data for targeted interventions. "Our overall technology strategy is to leverage the systems we have and build new systems that allow us to identify the patients that need an interaction with a pharmacist, or need a certain level of service to remain adherent," says Rudkin.

As an example, Rudkin says Walgreens identifies patients filling a new prescription for the first time, and passes that information to the pharmacist, to ensure the patient gets adequate instruction. "When that patient comes back for the first refill [of a new prescription], we alert our system to tell the pharmacist right on the screen whether that patient is on time to refill, or late," says Rudkin. "The pharmacist doesn't have to do any calculations, and that enables a different conversation." Anticipating non-adherent behavior, and intervening before a refill is missed, is a powerful, data-enabled service. But Rudkin says there's work to be done. "Predictive modeling is interesting in and of itself—it's a very important component—but the other side of that is, what do we do with that information, and how do we use it?" says Rudkin. "How do we fit that into the pharmacy workflow to make sure the patients that are struggling can be helped?"

One historical problem with refilling prescriptions—and a leading cause of the periodic pharmacy haggle so many patients have experienced—has to do with prescription alignment, or being able to get every prescription filled at the same time. Rudkin says Medicare has made "huge strides" by implementing override tools to make prescription pick-up more efficient for patients. She also hopes that more insurers will embrace longer refill periods in the retail setting, like a three-month, 90-day supply, for example, which cuts down on trips to the pharmacy, and related non-adherence.

Asked for an example of how pharma might support the pharmacy experience for patients, and facilitate better adherence through Walgreens, Rudkin called pharma's device training programs "a unique service" for patients. By delivering training and instructions to the pharmacist at the time a prescription is dispensed, these programs "help ensure that the pharmacist has a consultation with the patient prior to the sale of the prescription," says Rudkin. "In some cases, the doctor's office has already covered [device training] with patients, but even some of those patients will say, 'Show me again.' Most patients starting a new medication decide in the first three months whether they're going to continue that medication or not."

Convenience is king

Everyone has a vested interest in prescription adherence; for pharma, pharmacy, providers and payers, the interest is financial. For patients, it's personal: the return on adherence is paid in the currency of health and life, which is harder to represent on a spreadsheet (Quantified Health acolytes notwithstanding). The science of adherence seems to have pivoted in recent years away from a B.F. Skinner-flavored behaviorist approach to one focused more on behavioral economics, with the emphasis placed on money as the primary mover.

It's true that out-of-pocket costs and copays do continue to prevent patients from picking up their prescriptions. In fact, some signs point to difficulties with financial assistance programs in the health exchanges. It's an important one, but cost is only one barrier. Innovative technological approaches using narrative storytelling and gameplay— such as CyberDoctor's recently released PatientPartner app—are generating impressive data. PatientPartner asks patients to live with a disease vicariously by choosing a fictional diabetic (in this case), and making health decisions for him or her through a series of prompted "scenarios," which resemble all too real-world situations. Bad choices lead to poor health outcomes in the story, which ostensibly helps to model healthy living for actual patients by hammering home the risks of non-adherence.

At the Health 2.0 conference last October, CyberDoctor revealed the results of a randomized clinical trial with 100 non-adherent diabetes patients in Pennsylvania's PinnacleHealth System. According to CyberDoctor CEO and founder Akhila Satish, using the PatientPartner app increased medication adherence by 37%—from 58% to 95 %—or the equivalent of three additional days of drug adherence per week. Patients who read through scenarios on the app for 12 minutes during the trial brought HbA1c levels down by a full percentage point – from 10.7% to 9.7%, according to data presented by the company.

The adherence problem won't be solved by a single financial incentive, mobile app, data application, educational program, or transparency initiative. Instead, stakeholder groups across the healthcare delivery system must use all of these tools and more, to "collaborate out to the patient" and move beyond the traditional borders and segments of patient care. If organizations can't work together to push adherence rates up—when so many incentives are aligned—what hope is there for success in fixing other problems where incentives are woefully misaligned, like fee-for-service? Patients are ultimately responsible for their own health, but no one wants to hang out in the pharmacy any longer than necessary. When it comes to practicing healthy behavior, convenience is king.

Ben Comer is Pharm Exec's Senior Editor. He can be reached at bcomer@advanstar.com.