Top Barriers to Patient Persistence

Why don’t patients persist in taking their medication as prescribed?

This is the nearly $300 billion question about wasted spending the entire healthcare system has yet to solve. Moreover, Capgemini estimates that medication non-adherence accounts for approximately $637 billion in revenue opportunity losses for U.S. pharmaceutical manufacturers. The root causes: lack of initial alignment between provider and patient and inadequate follow up with patients once the prescription is written.

Time pressure and competing priorities lead to lack of medication alignment

The lack of initial alignment regarding prescribed therapies has many causes. What potentially disrupts the first fill and later, the first refill?

It’s a matter of time and trust in the precious minutes or seconds the physician shares with the patient.

Physician/patient interaction time is increasingly tightly constrained, with some surveys suggesting that physicians only spent 27% of their total time on direct clinical face time with patients. This time is inclusive of symptom evaluation, diagnosis, listening to the patient, and more.

Frequently, less than one minute spent within those visits is given to the “what and why” about prescribed medication therapies, including side effects. Failure to adequately explain what the medication is and why it is important is a massive barrier to compliance. However, time pressures are very real. Frequently patients don’t want to take any more of the doctor’s time than what they perceive as needed. Or perhaps they want to complete the visit as quickly as possible after spending a lot of time in the waiting room. Lack of time with the provider can also tempt patients to consult unreliable outside resources like the dreaded Dr. Google.

Often, even if patients know why medications and compliance are important, they still don’t know what to expect from therapy, particularly in terms of side effects and drug-drug interactions.

There’s also the question of competing priorities for patients.

Doctors are the experts in intervention and therapies. Patients are experts in their lives and their priorities: their lifestyle, their finances, and emotional factors that inhibit compliance, including depression, perceived stigma and socio-economic challenges, just to name a few. Questions like “How much is my co-pay, and will I have to give up something else to afford this medication?”, or ”How will this medication make me feel, and is taking this medicine worth my feeling bad?”, or “Will taking this medication serve as a daily reminder that I’m sick?” are examples of potentially competing priorities patients may face. If patients don’t receive adequate information about the importance of a newly prescribed therapy, it’s possible the therapy doesn’t come out on the top of the priority list.

Failure to personalize, and persist in, follow up with patients

Our colleagues for a large diabetes provider told us that they schedule patients for four visits per year. The average actual number of visits completed: 2.4. The picture is similar for HIV patients. In the US, it is estimated that only 75% of HIV-diagnosed patients are linked to care, and only 66% of those linked to care are successfully retained in medical care. Various U.S. medical sources, including the Health Resources and Services Administration and the Institute of Medicine, define "retention in care" as at least two appropriately spaced visits within one year with an HIV medical provider.

Technology, including patient/provider portals, text messaging, and email (especially if login is required), only works for certain populations. Based on our experience working with thousands of patients nationwide, we know that telephonic patient outreach is mandatory for certain patient populations, for example the elderly and those who require consistent, ongoing support in order to remain adherent. This outreach is time-consuming but effective. It’s also likely to be overlooked in the rush to employ newer technology platforms for engaging patients.

The burden of positively impacting a patient’s health cannot be placed entirely on physicians and their staff. Patients must be both interested and empowered to positively affect their health.  A trustworthy source is needed to provide patient follow-up to demonstrate care and establish trusting relationships. Patient follow-up is needed on as many ends as possible to demonstrate care and establish trusting relationships, activity that requires a methodical approach over time.

Solutions-What can the brand team do about it?

Improve Initial Alignment

An honest assessment of the real patient journey to understand what’s working and where gaps persist is the first step brand teams should undertake to improve alignment. Ensure that the effort is cross-functional and includes clinicians, healthcare economics team members and representatives from both sales and marketing. For example, in a hub model a manufacturer’s representative might know that a prior authorization has not been approved or that a refill has not been picked up. This representative may then go back to the provider to let her know. In this scenario, however, who goes back to the patient for follow up?

Our advice: if you’ve done this assessment and still believe you have filled in all of the gaps, start over.

Optimize Follow-Up Initiatives

Knowing that half of all new prescriptions don’t get filled, it’s imperative that intensive patient follow up to address concerns, confirm the accuracy of information they have on hand, and reinforce the value of their therapy and compliance take place before patients go to the pharmacy.

An assessment of patient needs will generate scores of opportunities for intervention, but the following are high value solutions brand teams can influence for the benefit of patients:

• Patients need constant, regular reminders with good information in the form or format that works best for them: text, phone, email, web, or in person.

• Person-to-person support is the least efficient but most effective. Many manufacturers will not know about prescriptions written or first fills[JC1] . The physician won’t know either. The only people who really know are the patients. If you don’t communicate with patients, it is unlikely you will impact persistence.

• The first refill represents pharma’s top opportunity to influence behavior. This will require time, resources, a new approach to patient engagement, and assumes the manufacturer and brand team actually have enough contact information to reach patients directly.
  
  Ultimately, a sliding scale for follow up based on patient needs and preferences is optimal. Patient enrollment program investment is increasing, but what are you going to do with it? Start with intensive engagement efforts- person to person-then scale back as needed. If text reminders are enough, great. If not, persist in your own efforts to reach them in a “whatever it takes to improve patient lives and outcomes” mindset.

• A multi-channel (HCP/DTC), multi-protocol paradigm. While “population health” is a hot term, actual patient health happens one individual at a time. Texting may work for some, but a phone call may be the best fit for others. Certain patients need a text prior to a phone call to trust the intent of the unknown number. And still other patients want to use their new provider portal. A multi-channel, multi-protocol approach drives population health by recognizing and delivering on individual needs. If you don’t have it, you need it. Acknowledge one size does not fit all.

If persistence is the gold standard by which brand teams measure success investing the right amount of time in the right type of resources is critical. In part 4 of this 4-part series, we will discuss tactics brand teams and partners should follow to improve medication persistence.

Vickie Andros, PharmD, is Director of Clinical Services, and Jake Caines is Senior Director of Commercial Strategy and Performance, both at Curant Health.