By Kim Huynh and Esther Ketelaars, health and life sciences experts, PA Consulting.
Studies unanimously show the negative effects medication non-adherence has on clinical outcomes and healthcare costs. Adherence is critical to ensure that medications work properly and important for pharmaceutical companies because it helps keep their drugs covered under health plans. Healthcare insurers want to ensure their covered drugs are treating their members effectively and are seeking to prevent more costly health care.
So, while traditionally medical adherence solutions have been paid for and promoted by pharma and payors, a new player has a chance to enter the scene and challenge the status quo. Now is the time for providers to proactively address medication adherence as they start to bear more financial risk through value-based care models.
How can providers play a larger role?
Provider organizations who focus on medication nonadherence have a great opportunity to improve patient outcomes and support their value-based care models. According to the Center for Disease Control medication nonadherence results in 10% of hospitalizations and 125,000 preventable deaths in the U.S. each year. Likewise, low medication adherence leads to treatment failures between 30% and 50% of the time.1 These negative impacts become even more relevant to providers as patient outcomes continue to be more closely tied to reimbursement and payment incentives.
Pharmaceutical companies, payors, some providers, other consumer-focused companies in the healthcare value chain, and even governments have tried to address nonadherence. With the recent growth of digital health solutions especially, many have focused on leveraging novel technologies. However, there are a myriad of reasons for patients not compliant with their medication and adopting a single tool or technology has rarely been effective in reducing nonadherence.
A one-size-fits-all approach will often only address a single issue for a limited number of patients. With their direct access to patients, providers have a better chance of addressing the complex mix of reasons for nonadherence and design medication adherence programs customized to each patient. Personalized intervention plans invite a direct solution to each patient’s reasons for nonadherence with the appropriate tools that address the underlying cause for that individual.
Developing such a program requires factoring in root causes and reasons for nonadherence, using predictive analytics to identify high-risk patients, and gathering a diverse set of interventions to address those root causes. The position and shared decision-making power between providers and consumers indicate that providers can address medication adherence for more patients, improve patient outcomes, and reinforce value-based care.
Designing a patient-centered medication adherence program
Many of the tried and tested programs have been designed based on an assumption of the underlying reason for nonadherence. However, for these programs to be truly effective provider organizations need to understand and diagnose the patient’s reasons for nonadherence and tailor their intervention with the right tools.
Understand the reasons for medication nonadherence
Exploring the factors contributing to nonadherence allows organizations to understand the inherent complexity of nonadherence. Most interventions fail to produce the desired results because they don’t consider the many contributing factors. The reasons for nonadherence go beyond simple forgetfulness. Only 30% of patients cite forgetfulness as the cause of their nonadherence.
This number may include those who are unconsciously motivated to forget due to low belief in the medication’s effectiveness. The remaining reasons can be attributed to other priorities (16%), deciding to omit a dose (11%), lack of information (9%), and emotional reasons (7%). One quarter (27%) abstained from providing a reason, which compounds the number reasons for nonadherence.2 Beliefs and experiences are at the core of behavioral decisions.
Patients can become non-compliant because of negative associations with their medication or disbelief in the effectiveness of the medication. Moreover, affordability of the medication can play a crucial role in continued adherence to medication.
Use predictive analytics by leveraging your organization’s dataset
Knowing your population is key to best serving each patient, and understanding a patient requires using a large dataset to identify those with high-risk factors for nonadherence. We know 80%-90% of healthcare occurs outside of acute care settings and that the social determinants of health can have a significant influence adherence.
Data on socioeconomics, types of illnesses, medication regiment and health insurance coverage are examples of the many contributing factors. These data elements are accessible from a provider organization’s electronic health records and patient questionnaires. The combination of these data elements can generate insights when predictive analytics is applied.
The output is the identification of patients at high risk of being nonadherent and the likely reasons for nonadherence. For example, predictive analytics may show that patients who have an income between $20,000-$30,000 annually, live in a rural area, and have a medical condition that requires two medications may be at high risk for nonadherence.
The cause identified could be high medication costs and low accessibility to a nearby pharmacy. Access to patient profiles allows providers to determine whether interventions are needed, and which solutions would be most appropriate.
Equip your organization with a diverse set of solutions
Our experience and research have found that there are several types of interventions to improve adherence. These approaches target different points of the patient journey. Behavioral and educational approaches can address potential beliefs that prevent patients from taking their medication. Technology can solve for a patient’s forgetfulness.
Recent research at a tertiary care hospital showed that a mobile reminder alert was more effective than a reminder card system for medication adherence in asthma patients. Each tool can be impactful in their focus areas and for select patients, but no single solution can make a wide impact on its own.
Organizations should choose solutions to include in their toolbox that addresses more than one cause of nonadherence. Most interventions focus on a specific goal, such as medication education, financial support, driving behavior change in patients, providing integrating care across healthcare providers and lastly implementing technological solutions.
Recently, technology has been the most discussed intervention. Technology can help patients address forgetfulness/behavior monitoring via mobile apps that send reminder notifications or smart bottles that dispense pills and alert patients. There’s also a gamification approach that rewards patients. For example, Wellth works offers financial incentives through third parties to encourage patients to adhere to their medication regiment.
Lastly, there are several mobile apps that quickly connect patients, providers and pharmacists for timely refills. Yet with all the options available, it is important to remember that technology is a tool and not the silver bullet. Organizations should assess where within the patient journey these tools apply and whether they address the root cause of nonadherence or offer a monitoring mechanism.
Personalize plans for each patient
With a toolbox of effective interventions and understanding of a patient profile, organizations can then assign the right interventions to patients at high risk of nonadherence based on medical and socioeconomical data. Customizing interventions can lead to greater success and ensure patients receive the right type and amount of support. The diagram below, fondly known as the Swiss Cheese model, shows the multiple layers of interventions. Notice how one intervention may address a patient’s need if the first one doesn’t and how one or multiple interventions might be needed for a patient to become adherent to their medication.
Taking the lead in medication adherence
A one-size-fits-all approach to medication nonadherence has failed to produce results thus far. By personalizing healthcare through high engagement and innovative technology, higher medication adherence can be achieved. While it requires an investment of resources and time from the organization developing a comprehensive adherence program with the capability to understand patient’s needs and the appropriate set of interventions will improve patient outcomes. As US healthcare continues to move to a value-based care model, addressing medication adherence will also improve the bottom line.
- Centers for Disease Control and Prevention. (2013). Medication Adherence. CDC Noon Conference: March 27, 2013. http://www.cdc.gov/primarycare/materials/medication/ docs/medication-adherence-01ccd.pdf
- Bosworth, H. (2012). The Public Health Dilemma. In Enhancing Medication Adherence. Springer.