BY RACHEL Z. ARNDT | MAY 26, 2018
The directions are usually
pretty basic: Take 1 tablet once a day with water.
Simple, right?
For eons, providers, payers
and pharmacists have resorted to good old-fashioned trust and assumed that the
patient was following those simple instructions.
After all, it's hard to
keep a constant eye on patients when they are at home. But trust alone doesn't
always translate to a patient taking the medication, or taking it correctly.
Medication nonadherence (or noncompliance) is a big problem. It cuts into quality and outcomes and raises costs. When patients don't take their medications as prescribed, it leads to about 10% of hospitalizations and 125,000 preventable deaths annually in the U.S. According to one estimate, it also leads to as much as $300 billion per year in healthcare costs from complications and associated hospitalizations.
Patients with "low" or "intermediate" medication adherence were more than twice as likely as those with "high" adherence to be readmitted to the hospital, according to a 2017 study.
But readmission penalties don't take into account medication adherence, which some argue is beyond hospitals' control.
Even though they often know what they should be doing, patients still struggle to take medications as prescribed. They might not be able to afford their medications; almost 8% of U.S. adults tried to save money by not taking their medications as directed, according to the 2013 National Health Interview Survey.
They also might not understand how to take them correctly. Or they might not feel like the drugs are doing anything.
But the rise of new technologies gives the industry a potentially powerful way to improve medication adherence. Providers and pharmacists can now watch patients from afar and intervene when they aren't following directions.
"What's in it for providers and payers is, when people adhere to their drug prescriptions, they generally fare better from an outcome perspective," said Christer Johnson, EY's health analytics advisory services leader for the healthcare sector in the Americas. "There's a dollar benefit to that, as well."
In a 2015 study, researchers showed that for every 1% increase in prescription drug use, nondrug Medicaid costs decreased 0.167% for adults who aren't blind or disabled.
Getting patients to take medications correctly isn't entirely patriarchal—despite the harsh term "noncompliance"—or financial. It also has to do with ever-trendy patient engagement—getting patients themselves to take the lead in maintaining their own health.
"Greater engagement is going to drive much better adherence," Johnson said.
Solutions include the physical—"smart" pill bottle caps—and the digital—apps. Some are passive, letting patients do the work of recording that they've taken a dose, and some are active, tracking patients as they take their pills and displaying the results in pharmacy management systems and in separate software.
"They're trying to help a person stay on a therapy to reduce medical costs by improving their overall condition," said Brian Kalis, managing director of digital health and innovation for Accenture's health business.
Medication nonadherence (or noncompliance) is a big problem. It cuts into quality and outcomes and raises costs. When patients don't take their medications as prescribed, it leads to about 10% of hospitalizations and 125,000 preventable deaths annually in the U.S. According to one estimate, it also leads to as much as $300 billion per year in healthcare costs from complications and associated hospitalizations.
Patients with "low" or "intermediate" medication adherence were more than twice as likely as those with "high" adherence to be readmitted to the hospital, according to a 2017 study.
But readmission penalties don't take into account medication adherence, which some argue is beyond hospitals' control.
Even though they often know what they should be doing, patients still struggle to take medications as prescribed. They might not be able to afford their medications; almost 8% of U.S. adults tried to save money by not taking their medications as directed, according to the 2013 National Health Interview Survey.
They also might not understand how to take them correctly. Or they might not feel like the drugs are doing anything.
But the rise of new technologies gives the industry a potentially powerful way to improve medication adherence. Providers and pharmacists can now watch patients from afar and intervene when they aren't following directions.
"What's in it for providers and payers is, when people adhere to their drug prescriptions, they generally fare better from an outcome perspective," said Christer Johnson, EY's health analytics advisory services leader for the healthcare sector in the Americas. "There's a dollar benefit to that, as well."
In a 2015 study, researchers showed that for every 1% increase in prescription drug use, nondrug Medicaid costs decreased 0.167% for adults who aren't blind or disabled.
Getting patients to take medications correctly isn't entirely patriarchal—despite the harsh term "noncompliance"—or financial. It also has to do with ever-trendy patient engagement—getting patients themselves to take the lead in maintaining their own health.
"Greater engagement is going to drive much better adherence," Johnson said.
Solutions include the physical—"smart" pill bottle caps—and the digital—apps. Some are passive, letting patients do the work of recording that they've taken a dose, and some are active, tracking patients as they take their pills and displaying the results in pharmacy management systems and in separate software.
"They're trying to help a person stay on a therapy to reduce medical costs by improving their overall condition," said Brian Kalis, managing director of digital health and innovation for Accenture's health business.
Why
"People can be
predictably and systematically irrational," said Dr. George Savage, chief
medical officer of Proteus Digital Health, which makes sensors for trackable
pills. "Even though I know this medicine is good for me and I should be
taking it, I may not. People want to get well, but nevertheless, they fail to
do the right thing."
The solution, many say, is for the healthcare system to proactively intervene.
But healthcare has long lagged behind other industries in engaging its users, especially in any kind of automated way. "For healthcare, this kind of proactive outreach is still kind of new," Johnson said. "But for industries like telecommunications, banking and retail, they've been driving outreach to increase sales for years."
The developers of medication adherence tools are trying to change that. They know that patients who take their medications correctly tend to be healthier.
For example, a study of people with Type 2 diabetes showed that those who adhered to glucose-lowering agents were hospitalized less often and were less likely to have acute complications.
They also know that there's a business case for better medication adherence. And they know that newfangled technologies, like machine learning, can help them be more exact in how they engage patients.
The solution, many say, is for the healthcare system to proactively intervene.
But healthcare has long lagged behind other industries in engaging its users, especially in any kind of automated way. "For healthcare, this kind of proactive outreach is still kind of new," Johnson said. "But for industries like telecommunications, banking and retail, they've been driving outreach to increase sales for years."
The developers of medication adherence tools are trying to change that. They know that patients who take their medications correctly tend to be healthier.
For example, a study of people with Type 2 diabetes showed that those who adhered to glucose-lowering agents were hospitalized less often and were less likely to have acute complications.
They also know that there's a business case for better medication adherence. And they know that newfangled technologies, like machine learning, can help them be more exact in how they engage patients.
"We've never been held
accountable for people's adherence, and now we are," said Dr. Kamal
Jethwani, senior director of connected health innovation at Partners
HealthCare, which is piloting a medication-dispensing device and platform made
by Philips. "It's a culture shift."
Despite the obvious benefits, it's been a slow shift. Though providers do sometimes directly give their patients tools for medication adherence, more often it's payers and drugmakers that actually pursue—and pay for—these tools.
For payers, the investment in these tools makes sense: If patients take their medication consistently, they'll likely be healthier, which will reduce costs. "For payers, it's both healthier patients and being able to trust that the drug is doing what they're paying for," said Herman Sanchez, a partner at consulting firm Trinity Partners.
Patients, too, will benefit—both quantitatively and qualitatively. "If we can make it easier for people with chronic conditions to properly take their medicine, we'll see the dividends not only in the additional years people live but also in the quality of life," said Caitlin Carroll, director of public affairs at the Pharmaceutical Research and Manufacturers of America. "If you can improve adherence, that's a week or a month that people are able to go to work, and the savings from that, between economic growth and reduced federal disability, are significant."
Despite the obvious benefits, it's been a slow shift. Though providers do sometimes directly give their patients tools for medication adherence, more often it's payers and drugmakers that actually pursue—and pay for—these tools.
For payers, the investment in these tools makes sense: If patients take their medication consistently, they'll likely be healthier, which will reduce costs. "For payers, it's both healthier patients and being able to trust that the drug is doing what they're paying for," said Herman Sanchez, a partner at consulting firm Trinity Partners.
Patients, too, will benefit—both quantitatively and qualitatively. "If we can make it easier for people with chronic conditions to properly take their medicine, we'll see the dividends not only in the additional years people live but also in the quality of life," said Caitlin Carroll, director of public affairs at the Pharmaceutical Research and Manufacturers of America. "If you can improve adherence, that's a week or a month that people are able to go to work, and the savings from that, between economic growth and reduced federal disability, are significant."
What
Medication adherence tools
are becoming more sophisticated and interactive, growing beyond simple text
messages and app reminders.
"An app alone is not really going to cut it anymore," said Greg Caressi, senior vice president of transformational health at Frost & Sullivan.
One tool is a smart pill bottle cap, like the one made by Pillsy. The caps come in different sizes that fit the standard bottles from Walgreens, CVS Pharmacy, and other major drugstores.
"We're trying to remove any friction to the desired behavior," said Jeff LeBrun, CEO and co-founder of Pillsy. "A lot of medication adherence solutions make it more difficult, like requiring a user to pull up an app and push a bunch of buttons." Even smart pill boxes, he said, require effort, since a patient must transfer the pills.
The only thing the pill-taker has to do is the initial setup—and sometimes even that's unnecessary, since some pharmacies handle it. The cap registers when it's removed and logs the event in an app.
Meanwhile, on the other end, specialty pharmacists and care coordinators can watch adherence in real time, texting patients if there's a problem.
Other similar tools are condition-specific, like Adherium's sensor, which snaps onto inhalers for people with asthma and chronic obstructive pulmonary disease and gives providers feedback on their patients. In a study of children, adherence to preventive medication went up by 180% when the kids used Adherium's sensor and monitoring system.
The company has a partnership with AstraZeneca to get its tool to patients, and it recently received clearance from the Food and Drug Administration to sell the tool directly to consumers.
Some pharmaceutical companies are working with third parties on rewards programs to cajole patients into more consistently taking their pills—and getting them refilled. Novo Nordisk, for instance, teamed with Sempre Health on engagement for diabetes medication adherence. Sempre also partners with health plans, sometimes getting patients lower co-pays for filling prescriptions on time.
Pharmacies also want timely prescription refills. Drawing on software made by McKesson Corp. and others, they can text patients reminders and provide educational materials. But "ultimately it's up to the client," said Heather Cusick, McKesson's director of product management for clinical services.
Other industry players are going a step further and pursuing much more exact—and bodily—surveillance. The FDA granted its first approval for a "digital" pill in November 2017. The pill, Abilify MyCite, made by Otsuka Pharmaceutical, has a tiny embedded sensor that tracks ingestion and beams a signal to a wearable patch and eventually to a cloud-based health record to track adherence. Patients decide who receives their adherence information.
"Rather than innovation in medicine always being defined as a brand-new drug, you can define it as getting more value for more people from drugs that already exist," Savage said.
Proteus has been working with providers to get the sensor-enabled pills to patients. The company is also in early discussions with payers for value-based arrangements, with the hope that it'll have one by the end of the year.
"The way to make money is to deliver something that's objectively valuable for the patient," Savage said.
"An app alone is not really going to cut it anymore," said Greg Caressi, senior vice president of transformational health at Frost & Sullivan.
One tool is a smart pill bottle cap, like the one made by Pillsy. The caps come in different sizes that fit the standard bottles from Walgreens, CVS Pharmacy, and other major drugstores.
"We're trying to remove any friction to the desired behavior," said Jeff LeBrun, CEO and co-founder of Pillsy. "A lot of medication adherence solutions make it more difficult, like requiring a user to pull up an app and push a bunch of buttons." Even smart pill boxes, he said, require effort, since a patient must transfer the pills.
The only thing the pill-taker has to do is the initial setup—and sometimes even that's unnecessary, since some pharmacies handle it. The cap registers when it's removed and logs the event in an app.
Meanwhile, on the other end, specialty pharmacists and care coordinators can watch adherence in real time, texting patients if there's a problem.
Other similar tools are condition-specific, like Adherium's sensor, which snaps onto inhalers for people with asthma and chronic obstructive pulmonary disease and gives providers feedback on their patients. In a study of children, adherence to preventive medication went up by 180% when the kids used Adherium's sensor and monitoring system.
The company has a partnership with AstraZeneca to get its tool to patients, and it recently received clearance from the Food and Drug Administration to sell the tool directly to consumers.
Some pharmaceutical companies are working with third parties on rewards programs to cajole patients into more consistently taking their pills—and getting them refilled. Novo Nordisk, for instance, teamed with Sempre Health on engagement for diabetes medication adherence. Sempre also partners with health plans, sometimes getting patients lower co-pays for filling prescriptions on time.
Pharmacies also want timely prescription refills. Drawing on software made by McKesson Corp. and others, they can text patients reminders and provide educational materials. But "ultimately it's up to the client," said Heather Cusick, McKesson's director of product management for clinical services.
Other industry players are going a step further and pursuing much more exact—and bodily—surveillance. The FDA granted its first approval for a "digital" pill in November 2017. The pill, Abilify MyCite, made by Otsuka Pharmaceutical, has a tiny embedded sensor that tracks ingestion and beams a signal to a wearable patch and eventually to a cloud-based health record to track adherence. Patients decide who receives their adherence information.
"Rather than innovation in medicine always being defined as a brand-new drug, you can define it as getting more value for more people from drugs that already exist," Savage said.
Proteus has been working with providers to get the sensor-enabled pills to patients. The company is also in early discussions with payers for value-based arrangements, with the hope that it'll have one by the end of the year.
"The way to make money is to deliver something that's objectively valuable for the patient," Savage said.
How
Technology alone won't solve the complicated adherence puzzle, and
that's partly because it doesn't work in isolation. The Proteus sensor, just
like the Pillsy cap, depends on human interventions, both on the patient side
and on the platform side. Importantly, all these tools require behavior change.
In fact, they require two levels of behavior change: One level is taking the medication correctly and another is using the adherence tools correctly. This takes work, as patients must connect to some device, log into some app or respond to some text message.
"When the solutions are designed to work with natural human behavior, that's when you start to see outcomes," Kalis said.
Besides reducing the friction involved in using these tools, to get patients interested in the first place, providers might better explain what their medications are for—and that those medications are likely the right ones to be taking.
"The idea is that adherence is generally higher if a drug works and a patient notices an impact," Johnson said. "If there's a lack of certainty around which drug might be best, having that communication early on—that the patient might need to try a few things—is very important."
Providers, payers and others might also make patients feel like what they're doing is important. It has very little to do with being watched, Savage said, and more to do with knowing what you're doing matters.
"People understand they need to take their medications," LeBrun said. "They just never get in the habit."
Habit is key. More and more app developers and others understand that the best route to healthier patients and lower costs might not be paternalism but, rather, encouragement and ultimately granting control to the patient, not to the person telling the patient to take the pills. They understand that the end goal isn't getting medications to sit in the foreground but instead making them so habitual that they can fade into the background.
"From the patient's point of view, it's really not even about managing their condition," Caressi said. "It's certainly not about reminding them to take their meds. It's how can they live their life while they have this condition."
In fact, they require two levels of behavior change: One level is taking the medication correctly and another is using the adherence tools correctly. This takes work, as patients must connect to some device, log into some app or respond to some text message.
"When the solutions are designed to work with natural human behavior, that's when you start to see outcomes," Kalis said.
Besides reducing the friction involved in using these tools, to get patients interested in the first place, providers might better explain what their medications are for—and that those medications are likely the right ones to be taking.
"The idea is that adherence is generally higher if a drug works and a patient notices an impact," Johnson said. "If there's a lack of certainty around which drug might be best, having that communication early on—that the patient might need to try a few things—is very important."
Providers, payers and others might also make patients feel like what they're doing is important. It has very little to do with being watched, Savage said, and more to do with knowing what you're doing matters.
"People understand they need to take their medications," LeBrun said. "They just never get in the habit."
Habit is key. More and more app developers and others understand that the best route to healthier patients and lower costs might not be paternalism but, rather, encouragement and ultimately granting control to the patient, not to the person telling the patient to take the pills. They understand that the end goal isn't getting medications to sit in the foreground but instead making them so habitual that they can fade into the background.
"From the patient's point of view, it's really not even about managing their condition," Caressi said. "It's certainly not about reminding them to take their meds. It's how can they live their life while they have this condition."
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