Making Adherence Stick
Real-world persistence varies with every medication, formulation, disease, and person . How are companies managing to boost patient adherence? PM360 asked several experts to share their insights on the most successful tactics in use in the field today.

Rob D’Urso, MBA
Director of Marketing
Promius Pharma
Bridgewater, NJ
rdurso@promiuspharma.com
Companies are taking a variety of approaches to increase patient adherence and persistence with an end goal of delivering the proper medicine, in the proper dosing regimen, to effectively treat or manage patients’ conditions. These tactics range from printed patient education material provided at the physician’s office to interactive patient reminders and incentives (rebates). Below is a list of some tactics used by various companies:

• Rebate programs for refilled prescriptions
• Email or mail reminders for prescription refills
• Sponsorship of support groups and disease state management programs
• Use of the Internet to send dosing reminders to cellphones or email accounts
• Development of patient education material for in-office consultation with healthcare providers

The use of technology has changed the landscape of patient adherence programs. We have the ability to reach patients at the point of purchase with instant rebates and product messaging to increase initial fill rates and better understanding of how to best use the medication. Refill rates can be increased with the use of email and mail reminder programs to help patients continue to purchase required medications. A company must utilize a variety of tactics to reach its patient population to increase adherence. Too often marketers select one program as their patient adherence program and have unrealistic expectations for performance. We never use one tactic or media to reach our physician customers, and patient communication cannot be viewed any differently.

Within the dermatology specialty, I have found a combination of patient education materials and a good instant rebate program can be quite successful in increasing patient adherence and persistence. The patient education material, focused on medication usage and what a patient can expect throughout treatment, helps to provide cause-and-effect examples of remaining persistent with medication. The instant rebate program provides a financial incentive to utilize a branded product in the proper dosing frequency. We will continue to look for the ideal program for patient adherence, since all conditions are unique and have specific patient adherence challenges.

Ann Friedman Ryan
SVP, Director of CRM & Interactive
EvoLogue, part of CommonHealth
Parsippany, NJ
afriedmanryan@commonhealth.com
Marketers are continually looking for the “next thing” or an innovative way to do it better. The reality
is, there are very few new, clearly beneficial tactics to employ, so our primary focus has been not on finding that next new thing, but on evolving how we both use and execute existing, proven tactics.
One of the most measurably impactful approaches is for marketers to place less emphasis on adherence and persistency and instead redirect the focus of the discussion to medication initiation. Patients do not differentiate between types of communications—to a patient, they all are brand messages. And despite the fact adherence and persistency are commonly thought of as behavioral problems, in reality they are really problems of motivation. Thus, providing tools to assist patients in accurately self-identifying and presenting their condition or situation to their physician is the first critical step in the process.

For a patient to be able to both understand and share this information in a manner that clearly conveys its impact on their quality of life essentially affords both patient and physician the ability to begin from the same base. This foundational understanding provides a context to talk about managing treatment success at the point of first interaction of the brand, the patient, and the physician.The prescription starter kit is a vital strategic opportunity for marketers to facilitate and model success for a patient. Starter kits are not new and have long been part of the medication initiation process. They are used to deliver product samples as well as dosage information. But by using this traditional medium to address the motivational problems challenging patient compliance, we have the opportunity to encourage a patient’s personal efficacy—to turn on their sense of personal accountability. Knowledge alone does not drive behavior change. This approach, deeply rooted in understanding what inherently motivates the individual, marries the action of the patient with the action of the medication to drive nonclinical differentiation and go beyond the benefit of what the medication alone provides.

Kenneth Freirich, MBA
Executive Vice President
Health Monitor Network
Paramus, NJ
freirichk@healthmonitor.com
The strategy to motivate patients to adhere to their treatment plan is to reinforce the importance of compliance through a trusted source at key decision moments. Personal physicians are still the number-one authority to whom condition sufferers will listen when it comes to managing their health.

Successful companies have leveraged programs built around patient education materials distributed by physicians both in-office and to patients’ homes. These educational materials are catalysts for discussion between patients and their doctors. A great case study that comes to mind is a patient education guide on acid reflux that was distributed in doctors’ waiting rooms. The guide included a branded ad and BRC from a pharmaceutical company. An independent market research firm conducted an adherence impact study on the program at month seven. Among the study’s key findings:
1) Patients and physicians engaged in conversations about managing their condition and treatment based on the guide’s contents.
2) Physicians handed out guides to patients to read at home.
3) NRx and TRx increased through the duration of the program.

Extending communication between the doctor and patient beyond the office visit also is critical to an effective adherence program. Recently, we launched a health magazine sent to patients’ homes compliments of their doctors. According to a market research study of 40,000 readers, 77% of patients are more compliant with their treatment because they received the communication and information from their physicians as opposed to other sources they found less trustworthy. A number of brands have successfully leveraged this channel and by supplying information through their doctors have motivated patients to adherence and persistency.

Joe Shields, MBA
Product Director
ENBREL Consumer
Wyeth BioPharma
Collegeville, PA
shieljp2@wyeth.com
If we continue to approach patient adherence through traditional promotional tactics, we’ll continue to be disappointed with the results. And how effective is a mobile phone reminder to a person who remembers to take his or her medicine, but isn’t sure if it’s working?

Here are some common characteristics of successful adherence programs:

Systematic We have systematic ways to drive traffic to a Website, generate leads, and convert prospects to patients. Adherence requires the same mindset and discipline, managing your investment in a portfolio of tactics and optimizing through consistent measurement. Programs must also be designed with an understanding of how the healthcare system actually works—referrals, co-pays, co-insurance, retail pharmacy reversals, specialty pharmacy interventions, and other important levers affecting HCP and patient behavior.

Insightful Programs must be grounded in HCP and patient research on barriers and motivators to adherence. Design solutions to overcome the specific barriers for your treatment (such as cost, administration, forgetfulness, side effects) and enable the motivators (such as tracking progress, reengaging in favorite activities, future wellness, family). Not all patients will respond to a single tactic if it does not address their particular issue. Co-pay and refill data can also provide insights about behavior and help to trigger communications at the point when they are most relevant to a particular patient.

Multi-channel Being systematic also requires an adherence “media plan” to ensure that you are reaching patients where they live, work, and play. Are you covering the most important channels, knowing that not every patient will sign up for a pharma company’s relationship marketing (support) program? Are the retail and specialty pharmacy channels optimized? Does your product Website support existing patients?

Scalable Every program requires effort and investment, so one needs to ensure that key elements of the program can scale nationally, using large networks of retail pharmacies, for example.

Joe Meadows
Vice President, Marketing & Creative Services
Catalina Health Resource
Blue Bell, PA, and St. Petersburg, FL
joseph.meadows@catalinamarketing.com
I find that those who are most successful at improving adherence are doing three things well:

First, they design their adherence programs to educate the patient early and often. Many patients find it difficult to introduce a new medication into their daily routine, and few patients welcome the thought of taking a medication for what may be many years. There’s a natural resistance to this idea at some “gut” level, even if we know the medication is needed. Smart companies accept this fact and focus on delivering messages that reinforce the physician’s reasons for prescribing the product, often with multiple messages and through multiple channels over the first few months of therapy.

Next, these companies are honest and frank with the patient, and use understandable language to communicate risks and safety information. They don’t try to hide problems that can occur, and they spend time trying to get their “balance” right. Successful companies make a real effort to do more than just “check the box” by loading the patient down with information that may meet the letter of the law, but which is difficult for any person without medical training to understand.

Finally, companies that successfully promote adherence realize that they’re asking the patient to stick with something for a long time, and they do the same for the patient. They don’t just communicate early and often—they stay with the patient for many months or even years into the future. Our research shows that adherence programs generally continue to have a positive effect—in terms of both patient behavior and return on investment—for months or even years after the patient starts on therapy. We have also found that patients can begin to exhibit poor adherence only months or weeks after a program is stopped, even if they have been on therapy for an extended period of time.

Cheryl Ann Borne
Consulting Project Manager
e-Marketing and Relationship Marketing
Novo Nordisk
Princeton, NJ
cybo@novonordisk.com
Socioeconomics have long been a contributing factor to adherence for patients with chronic illnesses. Although nowadays prescription cost is off-putting to people across a widening range of socioeconomic levels as increasingly more people cannot afford to fill their

prescriptions. Both the recession and the rising costs of healthcare premiums, which have outpaced inflation for the last decade, are culprits. These causative factors have converged and created the perfect time to improve adherence through cost savings via medication rebate coupons. Particularly with the economy in recession, there has been a spike in coupon redemptions across all markets. This last year there was 10% growth—the first jump in redemptions since the early 1990s.
A powerful financial incentive strategy to get patients on therapy would be to combine a medication rebate strategy with your sampling strategy. For example, a coupon can be handed from the HCP to the patient along with the Rx sample and prescription at point of care. The coupon provides an instant rebate to the patient at the pharmacy, reducing out-of-pocket expense and offsetting unfavorable tier positioning. Oftentimes the brand prescription drug co-pay ends up being cheaper than the generic drug co-pay.

Coupons come in a variety of formats, with options ranging from vouchers, pharmacy checks, and multi-use debit cards, as examples. A multi-channel approach might include tactics such as the coupon tipped or bound into targeted consumer magazines, a downloadable and printable coupon from the brand Website, and in-office rack cards. Opt-in capabilities would enable follow-on direct mail and email coupon promotions to existing patients targeted during critical drop-off points so as to maintain the patients on therapy.

Likewise, a brand faced with generic entry can level the cost playing field with a co-pay reduction program. A co-pay card can provide instant reduction of a patient’s co-pay and continuing benefit for each prescription filled for 12 months. The typical response from patients once a drug goes generic is: “If money were no object, then, of course, I’d continue to use your product.” Therefore, if the cost playing field is leveled, then the cost objection goes away.

Carleen Kelly
President
Surge Worldwide
Healthcare Communications
New York, NY
carleen_kelly@surgehealthcare.com
While cost may figure prominently in the abandonment rate for prescriptions—currently 7%, according to Wolters Kluwer—nonadherence costs more in terms of lives and burden on healthcare. According to the National Council on Patient Information and Education, poor adherence translates to an annual estimated loss of $177 billion for direct and indirect health costs. Companies devote approximately 3% of budgets to retention; there is much more they can be doing. Because it’s always easier to address issues before they become overwhelming, up-front adherence programs targeted to HCPs can focus on how to interact with patients at the point of prescribing. Patients who understand—and accept—the need for medication will more likely be adherent.

Getting directly to patients—in the form they prefer—will also enhance success. Interactive programs offer a wealth of options, ranging from simple to complex, that can be implemented in a variety of ways. Automated reminders via computer or text message, with a follow-up component, can provide a daily “nudge.” Programs that include support on social networking sites or from a personalized health coach may also help keep patients on track. A good interactive component can enhance a support system or serve as the primary support for people without other resources.

Many companies already work directly to give patients a “boost” with CRM Websites that provide rebate or coupon incentives over time to enhance loyalty and retention. Additionally, companies may work through pharmacies, sponsoring a rebate card program or point-of-purchase co-pay mitigation program.

So forward-thinking companies can provide adherence programs, addressing a variety of issues, that are targeted to patients, to their families or caregivers, or to the HCPs who take care of them. The key to success is that the programs must resonate with the target in order to get results.

Dan Rubin
President
inVentiv Patient Outcomes
Burlington, MA
drubin@inventivhealth.com
Medication nonadherence is a complex issue that stretches far beyond patients who simply forget to take their medicine to encompass a broad range of social, economic, behavioral, and psychological factors. Traditionally, the pharmaceutical industry has taken a fragmented approach to tackling this complex issue. In large companies with broad portfolios, there are often dozens of separate, unconnected patient adherence tactics and education programs. Enacted at the brand manager level, these patient initiatives are frequently derailed or canceled entirely when budgets are cut or brand managers change roles. Further, physicians, pharmacists, caregivers, nurses, and payers (stakeholders in patient care) are often left out of adherence initiatives despite their importance in helping patients remain adherent.

Given the complex nature of medication nonadherence, a comprehensive, centralized corporate strategy that incorporates multiple stakeholders and multiple tactics is needed. Companies making the most progress in improving patient outcomes are those that have shifted to a broader, more strategic adherence model that incorporates multiple tactics aimed at the various stakeholders and the myriad of factors behind nonadherence. For example, a comprehensive program across stakeholders may include:

• Reaching patients at home at critical points in therapy with highly effective, pharmacy-based refill reminder and medication education programs. Highly targeted co-pay relief can be combined with these programs for patients for whom cost is a driver for nonadherence.
• Educating physicians about the incidence and impact of nonadherence within their geographic area through programs utilizing zip code-based persistence data in an effort to persuade them to participate in the adherence dialogue.
• Engaging managed care through the use of incentives to improve adherence to therapy, for instance, the Merck/Cigna deal for Januvia. Under the deal, Cigna receives discounts if patients effectively control their diabetes.
• Providing support to patients, families, and caregivers through Websites and social media initiatives.

While these programs are effective on their own, when orchestrated together as part of a broader program with consistent messaging, companies can measurably improve the number of patients who stay on therapy.

Leslie Rabin
Director of Account Planning
AbelsonTaylor
Chicago, IL
lrabin@abelsontaylor.com
We have sharpened our focus on helping clients to develop programs that are based on a deep understanding of patients and where their greatest challenges lie. On the surface, adherence and persistence issues tend to be similar across many disease states—cost, side effects, forgetfulness, for example. As a result, many cookie-cutter programs are developed around these areas. Yet standard tactics like email reminders are not always enough to spur action. We recognize that at its core, adherence requires efforts that encourage behavior modification, and we design our programs with this goal in mind.

Armed with an understanding of patient attitudes, behaviors, and how the disease and treatment impacts their lives, we are able to develop better, more effective programs. These insights benefit program development across many fronts. We can better customize messaging by who the patients are attitudinally and emotionally. It allows us to communicate with them at critical times and touchpoints in their environment, when and where they will be most receptive to our message. It guides us in developing comprehensive support programs that help patients throughout the entire process, with anything from administrative tasks to answering questions to providing understanding and support.

Some of the programs we have worked on recently are staged in approach, to account for the varying degrees of knowledge, emotions, and behaviors that patients can evolve through as they progress from diagnosis to living with the disease. Some include messages that are delivered in more obtrusive ways, like texts or downloadable programs that can be made to sync with Outlook calendars. We are overlaying patient segmentation information onto CRM programs for more customized approaches. With more complicated disease states, we have 360-degree programs that offer patient support throughout the process. They include online and phone support services, on-staff nurses, reminders, and online programs to help patients track progress.

Stanley Wulf, MD
Vice President
Chief Medical Officer
InfoMedics
Reading, MA
swulf@infomedics.com
Many pharmaceutical companies are exploring or implementing new techniques to address adherence. Nursing hotlines are being expanded to accommodate adherence programs and new technologies have been developed and are under examination. Recent product developments include combo packaging for multi-course regimens, E-pill prescription reminders to keep patients on track, and telephone reminder systems. However, these solutions may not be adaptable and scalable to all medication regimens and treatment challenges. A successful adherence campaign must accommodate each patient’s particular barrier to each medication and be capable of addressing (and to some degree, anticipating) common medication challenges.

The most successful adherence campaigns incorporate patient feedback programs, in order to work with patients to identify and overcome barriers that may arise. By continually checking motivation and confidence levels as well as understanding about the medication, potential barriers can be identified and circumvented. At specific times throughout treatment, such programs must offer plain language and useful support mechanisms to help patients achieve adherence and get over the hurdles they encounter. It is equally important to let patients know how successful they have been and to “graduate” them from the program once more reliable adherent behavior has been achieved.

In addition to educating patients, it is imperative to keep the physician informed. Very few adherence programs today fully address this critical need, dealing exclusively with the patient despite the physician’s demonstrable influence on patient behavior. Physicians for the most part are appreciative of the receipt of net new information about their patients and are usually happy to incorporate interim reports into each patient’s medical record. The content of the patient feedback reports can radically accelerate physician understanding of the product and thereby increase confidence in subsequent prescribing and support. For example, a recent program that we implemented increased patient adherence, measured in refilled prescriptions, between 17% and 26% and generated new sales of $5.5 million as physicians’ confidence in the brand increased.

Alyson Connor, MS
VP, Strategic and Behavioral Services
MicroMass Communications
Cary, NC
alyson.connor@micromass.com
Because adherence is a complicated behavior, simply providing information to patients is not sufficient to change their adherence behavior. In addition to taking medication as prescribed, for example, patients must also communicate effectively with their HCPs, maintain appropriate lifestyle changes, and track their health information accurately. What is more, many “real world” factors also influence patients, including the environment, relationships, culture, attitudes, and past experiences.

It shouldn’t be a surprise, then, that this complex issue isn’t solved by simply giving patients a drug discount coupon or sending them a refill reminder. To affect adherence, you need to speak to patients in the context of their own lives and to consider their needs—not just what you want to tell them about your brand.

The best approaches use behavioral science to understand patients from their perspective, by looking beyond demographics to identify the behavioral, emotional, and attitudinal drivers that will have a real impact. Knowing these drivers tells us which buttons we need to push to improve adherence. Viewing these issues from the perspective of each individual patient ensures that we make our communications relevant to their lives by speaking directly and personally to each individual’s needs and lifestyles.

For example, when we developed an adherence program for patients with kidney disease, behavioral research told us that most of these patients are externally motivated. To be adherent, they need someone with authority to help them make healthcare decisions. We also learned that renal dietitians have significant, ongoing relationships with these patients. Our solution was to deliver adherence support to patients through renal dietitians. That is, we provided tools and resources directly to renal dietitians, who were then able to motivate patients directly, offering a more personal point of contact. In understanding what drives these patients’ behaviors, we were able to impact their adherence more effectively.

Amy Smith
Clinical Account Director
HC&B Healthcare Communications
Austin, TX
amy.smith@hcbhealth.com
With the lightning-fast acceleration of drug development in the pharma industry today, we are seeing more effective and targeted drugs than ever before in our history. But counterintuitively, we are seeing trends toward decreased drug effectiveness in patients, despite how many finite and differentiated drugs are available for a single condition such as diabetes or hypertension. So what’s happening?

One of the biggest factors affecting decreased drug efficacy today has nothing to do with advances in pharmacokinetics and everything to do with patient adherence. It’s a big problem that impacts not only clinical outcomes but also cost of care for payers and sales for the manufacturers. Before drug and device marketers can develop solutions, they have to address the multitude of drivers behind patient noncompliance, such as a complicated dosing regimen, too many therapies, adverse effects, diminished symptoms, and financial barriers. Not all can be addressed easily, but some strategies can be effective. So what’s working?

Start with the Doc I’ve talked with many physicians acutely aware of adherence and persistence issues who admit that they’re not often top of mind during inter- actions with patients. Consider education and sales strategies that elevate the issue with the physician first and encourage a heightened sense of awareness among your MDs when prescribing your brand.

Bring Simplicity Front and Center Does your therapy offer convenience? Is it a once-daily dosing regimen? Make that a key message in your brand materials to remind prescribers that your therapy might be worth a second look if it can potentially affect compliance for the better over a more complex alternative.

Make the Call SMS (text) and phone (voice) messaging are effective tools for reminding patients to stay on track with their prescription regimen. Opt-in database programs allow marketers to offer this value-add tool to patients, encouraging a continued dialogue with them over time. This is especially valuable for enhancing the patient/brand relationship.

Aside from standard tactics such as patient education info, diary tools, and dose packaging, these considerations can be effective supplements to a well-rounded compliance program.