“For the past 20 to 25 years, the data has fairly consistently shown that, overall, of people who have been prescribed long-term medications, about half of those patients are not going to take them as prescribed,” says Todd Ruppar, Ph.D., a professor in the College of Nursing at Rush University in Chicago.
When Yossi Bahagon, M.D., meets with healthcare firms to pitch his company’s treatment-adherence solution, he doesn’t spend much time detailing the problem his company is trying to solve.
“In our slide deck, we don’t have a slide saying, ‘Oh, 50% of patients are not adherent,’ ” says Bahagon, co-founder and chairman of the digital health firm Sweetch, an Israeli company. “They know that better than we do.”
Nor does the academic community require a lesson on the problem.
“For the past 20 to 25 years, the data (have) fairly consistently shown that, overall, of people who have been prescribed long-term medications, about half of those patients are not going to take them as prescribed,” says Todd Ruppar, Ph.D., a professor in the College of Nursing at Rush University in Chicago.
Half is not a good proportion when it come to medication adherence. Ruppar says the trend is headed in the wrong direction. “It’s not getting better,” says Ruppar.
Modern medicine has brought about a host of treatments that can contain — and sometimes cure — harmful medical conditions, many of them killers were it not for the treatments standing in their way. But as many experts and clinicians have pointed out, all those awe-inspiring scientific advances are just jogging in place if people do not take the medications. It is threadbare but true: A medication can only work if the patient actually takes it and, depending on the drug and the condition, takes it as prescribed. Decades of data have made it clear that a large proportion of patients will fail to do so.
Related: SCAN Tackles Major Disparities in Adherence
Now a swarm of new companies like Sweetch say new technology can put a dent in the adherence problem, not so much because of the technology but because the software they are selling is sophisticated enough to take a tailored approach to patient management.
Beyond the labels
Historically, patient adherence has been assessed using a rather blunt measurement. Since the 1970s, the figure of 80% has typically been used as the dividing line between adherence and nonadherence, Ruppar explains. The problem, Ruppar says, is that the 80% figure is rather unscientific.
“Eighty percent may be enough for some conditions, but it’s definitely not for others,” he says. “For antiretrovirals for HIV, or for immunosuppressives for people who have had organ transplants, you need to be at, like, 99 (%) to 100%.”
The fact that half of patients with chronic diseases do not reach 80% adherence affects healthcare costs. Low adherence leads to lower rates of disease control and invites a host of comorbid health problems. Adherence also has a financial dimension for pharmaceutical companies. The more reliably patients take medications as prescribed, the larger companies’ sales will be.
But in the larger healthcare picture, lack of adherence can start a downward spiral, says Scott Taylor, CEO and co-founder of Perx Health in Sydney, Australia, another patient engagement firm. If not taking a medication leads to the worsening of a condition or the occurrence of related conditions, other medications may need to be added. The more complicated a regimen becomes, the more difficult it is to follow and the greater the chance of nonadherence increase. “It becomes a bit of a compounding issue over time,” says Taylor. For patients with chronic conditions — especially multiple chronic conditions — nonadherence translates into tens of thousands of dollars in avoidable healthcare costs each year, Taylor says.
One reason adherence is such a thorny problem for patients and providers is that its origins tend to be a messy combination of factors. Lack of adherence can be both unintentional and intentional, Ruppar notes. Some people forget to take their medications. Others are affected by the many twists and turns of the social determinants of health: the pharmacy is miles away, child care cannot be arranged, out-of-pocket costs compete with other expenses.
Sharon Jhawar, Pharm.D., MBA, the chief pharmacy officer at SCAN Health Plan, a Southern California-based Medicare Advantage insurer, says cost can be a factor even when prescriptions are made available for free. She notes that some high-cost medications are available to SCAN members without a copay, but only if they get their prescriptions from pharmacies in SCAN’s preferred network or through mail-order pharmacies. But some members don’t realize that there is a preferred network and wind up paying high out-of-pocket costs. As her health plan began working to boost medication adherence, it began reaching out to individual members to ensure they knew about the availability of lower-cost drugs and where to get them, says Jhawar. “By simply switching to the pharmacy that’s just on the next corner, that could be an opportunity (to save money),” she says.
Ruppar says some patients are deliberately nonadherent. “People may be suspicious of pharma,” he says, “or they may not understand how the medication works and that they need to take it every day, even when they feel OK.”
Low-tech and high-tech solutions
Given the complex and varied drivers of the adherence problem, a wide range of solutions have been developed. They range from the personal to impersonal, from low-tech to high-tech options. Ruppar speaks up for the low-tech measures. “The cheapest, most effective thing for remembering to take medications is generally that seven-day pillbox,” he says. It’s a visible, tangible reminder to take your medication and also an easy way to know if you’ve already taken it. Ruppar says some younger patients recoil at the idea, which they associate with older adults, but he says it works for any age.
Jhawar says her health plan has emphasized communication. In addition to phone calls from the health plan, she says providers and pharmacists also need to rethink when and how they communicate medication information to patients. She notes that in a typical doctor’s visit, the first person a patient interacts with in the examination room is the nurse: “You tend to converse a lot more and share a lot more and ask a lot more questions.” Next comes the physician, but Jhawar says some patients do not feel as comfortable asking questions of the physician. If they don’t have that comfort level, their questions may go unanswered because the patient may not have another chance to speak to the nurse.
Adding a follow-up conversation with a nurse or other provider can give patients a better chance to raise questions, Jhawar says. Those conversations can also take place with a pharmacist, whether that is the retail pharmacist dispensing the medication or a health plan pharmacist checking up on a patient. The key, she says, is making sure each link in the chain sees their role as critical to achieving patient adherence. “What we have found with medication adherence is it takes this village,” she says. “...It takes continual reinforcement that helps to drive the right healthcare behavior.”
Building on wins
That reinforcement does not necessarily have to come from a human. At least, that is the premise under which a wave of new startups are operating. Sweetch, Perx, and other competitors are using artificial intelligence (AI) to boost patients’ treatment adherence by tailoring approaches to each patient. Bahagon says Sweetch might use a mix of behavioral, location, and schedule information to prompt a patient to sneak in a quick walking workout between meetings. The app could deliver a notification saying something like, “It’s 45 minutes before the next meeting. It’s raining outside. So grab your umbrella and go pick up a coffee from the nearest Starbucks at this address.” If that patient acts in response to such a prompt, they will likely receive similar ones in the future. If they do not, Bahagon says, the software will recalibrate and try a different approach. “If you ignored it in the past, sending it to you again not only won’t create a trigger to action, it will frustrate you,” he says.
By using this type of AI-enabled “precision engagement,” Sweetch says 70% of its notifications are acted upon. Moreover, 6 in 10 users who start using Sweetch are still using it a year later, several times higher than the industry average for mobile health apps, which Bahagon says ranges from 10% to 15%.
“From our perspective, we prefer to achieve gentle, gradual, sustainable responses over the long term,” Bahagon says.
Taylor, who studied behavioral economics before starting Perx Health, says one important aspect of his company’s approach is building upon “wins.” “If we’ve got someone engaged to take their medication, and they need to complete their physical therapy at some point that day, the best time to do that is when they’re already engaged,” he says.
One of Perx’s techniques is offering incentives, such as gift cards, to boost adherence, but he notes that 20% to 30% of users who earn such rewards never claim them. Those patients may be more motivated by different kinds of incentives, such as maintaining a long adherence streak or contributing to a community goal. The key, he says, is to have the right mix of incentives and prompts to drive an individual patient’s behavior.
The strategy seems to be working. Perx says 90% of its notifications are acted upon. One client, the health insurer QBE, found the healthcare costs of members who used Perx were about $6,000 less per year than for patients not using the tool, Taylor said. However, results like that should be taken with a grain of salt because people who elect to use health-related apps may also be more inclined to adopt cost-saving behaviors.
The middle way
Neither Bahagon nor Taylor sees their software as a panacea. Even if the software can incorporate feedback and deliver personalized approaches, sometimes those approaches work best in partnership with human interaction. Bahagon and Taylor say that informing providers about which patients they need to check up on is one use of the information generated by apps. Rather than simply noting that a patient did or did not refill his medication, a physician whose patient uses one of these tools might be able to notice trends, such as the fact that a patient might forget most often to take a medication when he is at work.
Ruppar says one hurdle to improving adherence is that many of the interventions that produce positive results in clinical trials flop when they are outside of that controlled context because they are too time consuming or difficult to use. That’s why companies like Perx and Sweetch are pricing their products in the midrange — less expensive than relying entirely on humans making phone calls and personal visits but more expensive than pillboxes or many wellness apps.
Will that middle course be the way to go? It’s too soon to say. But what is clear is that medication adherence is a costly problem and solutions to costly problems are almost never free. Bahagon says the current era of precision medicine is built on the premise that high-priced drugs can provide value despite the staggering costs. That will not happen, though, without improved patient adherence. “The most sophisticated medication that the pharma company invested $5 billion in, or the most sophisticated medical device … no matter how much technology and effort we put into it, if the patient doesn’t do the final last-mile action, it won’t work,” he says.