Key ways healthcare executives can improve therapy compliance.
Although estimates of the cost of medication nonadherence differ, everyone agrees it's too high. A 2014 study in Risk Management and Healthcare Policy cited a number between $100 and $300 billion, while a late 2018 analysis in the Annals of Pharmacology posited more than $528 billion.
Here are six things healthcare executives should know about improving medication adherence.
1. Align incentives
“One of our taglines at the American Pharmacists Association (APhA) Foundation is ‘Align the Incentives. Improve the Outcomes. Control the Costs,’” says Benjamin M. Bluml, RPh, and the Foundation’s senior vice president of research and innovation.
“If we properly invest in and align the incentives for patients, providers, and payers, we consistently observe significant improvements in care delivery, quality of care, and reductions in the total cost for care over time,” he says.
“This means collaborating in a team-based care effort-that includes a pharmacist-to change and improve the way care is delivered,” says Bluml. “After all, the primary treatment modality for chronic disease is medication, so if we don’t get medication right and help people understand its value we're never going to ‘get there.’”
The Foundation has realized excellent success with patient-centered, team-based care initiatives to improve adherence, Bluml says, specifically citing cardiovascular disease, depression and diabetes. For example, patients made 30-minute appointments with pharmacists on a quarterly basis to review finger-stick blood glucose readings and discuss cholesterol, diet, and exercise goals.
“This gives patients a focus for their role, then an incentive to follow up with their provider,” he says. “Here’s an idea for payers: Tell patients if they keep regularly-scheduled visits with their pharmacist for diabetes-related care they'll get a free BG monitor and test strips to stay on track, and you can even take care of the copayment. You’ll spend your per-member dollars differently, but save $1,000-plus per person per year when they're not in the ER or hospital as much, eliminating huge costs. The member becomes a more engaged, informed decision maker.”
2. Not just 'one and done'
“Payers already know they're paying for medications and that there will continue to be more highly specialized therapies,” says Deborah Hauser, RPh, MHA, and network director of pharmacy for Einstein Medical Center in Philadelphia.
She seconds strategic use of medication management therapy programs that incorporate pharmacist “touch points” with patients during the course of therapy and result in engagement.
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"This is not about just filling a prescription and walking away,” Hauser says. “If a patient doesn’t take their medication, a pharmacist can also assess whether there's a lack of motivation, a socioeconomic reason, intolerable side effects, or the inability to follow proper instructions.”
When they wonder out loud if their medication is “doing anything,” the pharmacist can explain the medication is not for symptomatic control, but to treat underlying disease, she says. “Especially with costly therapies, when a health plan has standards that apply to their use, there must be accountability. Is the medication being used as intended?”
At Einstein's specialty pharmacy, pharmacists call members to ask, “How many have you taken?” or “Do you have any left over?” and then re-educate and reinforce how important the medication is to overall health status.
“There are a lot of stakeholders here, so who's going to do the work?” says Hauser. “A pharmacist is the best stakeholder to assess and engage the patient about the importance of medication adherence.”
3. Realize one-size-fits-all isn’t long term
At the clinical services and analytics company RxAnte, Kerri Petrin, MPH, and vice president of client services, knows that effecting behavior change in members remains a major challenge.
“We’re first approached by clients because they notice that a static approach to adherence outreach has resulted in flattening population-level adherence rates,” says Petrin. “We see a tremendous value materialize when we’re able to help our clients adopt an evidence-driven, member-centric approach that identifies the best method and time to engage a member-based upon their predicted risk of nonadherence, past receptivity to interventions, and the most effective time to intervene.”
When plans use these concepts to drive intervention strategy, Petrin says, two critical markers of a successful adherence program emerge. “There are steadily improving adherence rates while remaining within the health plan’s target intervention budget. The result is that plans are better able to plan for future member needs and can effectively quantify what it takes to achieve their adherence goals each year.”
4. Dial into digital connectivity
Many health plans have been using phone calls, mailings, and emails to encourage patient adherence. “Now they're looking for innovative ways to meet patients when they want and where they want, and that's where smartphones come in,” says Kyle Amelung, PharmD, director of clinical solutions for Express Scripts.
Since nearly 80% of adults in the United States own one and check them nearly 80 times a day-and they’re different ages, have different demographics and incomes, and live in both rural and urban areas, Amelung says. He cites apps as a way to “affect and send a message in real time, receive data back and act on it right away.”
It is, in a word, “convenient.” Conditions really can be managed with digital connectivity and yield improved outcomes for patients and lower costs for health plans.
“A smartphone is not the overall solution but it can certainly be the means to a solution,” he says. “You must have uptake and believability from patients, providers, and payers. And you must remember that none of this will move the dial unless you tie in a human element. Our job is to create that therapeutic formulary for smart devices.”
5. Know this is personal
Don't forget the member probably sees their pharmacist probably once a month, while seeing the physician one to two times a year, says Amelung.
However, when reaching out to a member about medical adherence, remember their health is a personal and intimate topic, says Lindsay Conway, managing director at the Advisory Board. “Maybe they don’t feel well and don't want to confide in someone with whom they don’t have an existing relationship. You must earn the right to have what may be an intimate conversation and to earn their trust.”
Related article: Top 3 roadblocks to medication adherence and how to avoid them
Having a professional sit down for face-to-face time with a patient costs money, Amelung says.
“We see those kinds of programs most often with the sickest and most complex patients who stand to benefit most from medication. It can be difficult to determine what makes a financially sustainable model,” he says.
6. Train and coordinate
Whatever the model, the professional doing interface needs skills and training, says Conway. Most important and most challenging is “coordination, coordination, and coordination.”
“When it’s missing, patients sometimes have to jump over hurdles with automated systems or phone messages,” she says. “We’re seeing more hospitals, health systems and physician groups operate their own pharmacies to solve coordination challenges and offer better care and continuity,” she says.
“If you’re a provider managing a complex population, some patients may be getting medication management from their health plans, others from pharma companies, and each program is a little different,” Conway adds. “So, it’s a challenge to keep track of which patients are getting support; what kind of support; and when you need to step in and provide support.”
Experts agree that with coordination, innovation, support, and education, medication adherence goals can benefit both payer and provider.
Stephanie Stephens, MA, is a journalist, producer, and host in Orange County, California.