The late U.S. Surgeon General C. Everett Koop, MD, brilliantly encapsulated the urgency of the medication adherence challenge: “Drugs don’t work in patients that don’t take them.”
Unfortunately, we’re all too familiar with the disheartening statistics:
- 20% to 30% of new prescriptions are never filled at the pharmacy.1
- Medication is not taken as prescribed 50% of the time.1
- Nonadherence causes 30% to 50% of chronic disease treatment failures and 125,000 deaths per year in this country.1
These negative health effects are—and should be—the primary driver of adherence angst. But poor adherence affects drug makers, too. In 2015, nonadherence-related pharma-revenue shortfall totaled $250 billion in the U.S.2 The challenge to improve adherence is especially acute as manufacturers face a combination of shrinking pipelines, unprecedented pricing pressures, and new layers of managed access challenges.
It’s not as if there haven’t been efforts to improve the picture. The truth is, the push to bolster adherence has been a part of the biopharma conversation for decades. But the discourse has grown more urgent in the current millennium. For example, the World Health Organization raised the stakes significantly with the 2003 publication of its landmark report, Adherence to Long-Term Therapies: Evidence for Action.3 Indeed, in recent years we’ve seen a spike in new ideas designed to boost adherence, from smart bottle caps to lifestyle interventions to pharmacy medication synchronization and more.
Yet despite this flurry of activity, the problem persists. In fact, it’s become so serious that in his recent article summarizing 2017’s top pharmacy challenges, Dr. Robert Dudzinski put one item at the top of his list: Medication nonadherence.4 Here’s how he frames the challenge:
“What was once a problem relegated to pharmacy and inconspicuous to the rest of healthcare now has grown into a healthcare epidemic—one that providers, payers, pharma, and employers will inevitably address in order to improve outcomes and lower costs.”
Taking these data together, it’s no wonder that manufacturers are upping their game in the fight to improve adherence. In a recent survey, 63% of pharma brand teams were engaged in developing adherence initiatives.5
So what constitutes an effective adherence approach? Many experts have offered models identifying various dimensions of adherence/nonadherence. Each adds to the conversation and seeks to help “move the needle” on this intractable issue. Here are three that may offer value (a free full-text resource is available and cited for each):
The World Health Organization identifies five interacting dimensions in its report, Adherence to Long-Term Therapies: Evidence for Action3 (Figure 1-A). The five sets of factors are social/economic, therapy-related, patient-related, condition-related, and health system and health team.
Baroletti and Dell’Orfano6 offer a three-dimension model (Figure 1-B) highlighting socioeconomic, communication, and motivation factors.
Finally, Osterberg and Blaschke7 suggest a different three-dimension model (Figure 1-C) that focuses on the interactions among the patient and provider, provider and healthcare system, and healthcare system and patient.
While these models present comprehensive views of adherence issues, pharmaceutical brand teams may benefit from a model that offers a more direct focus on how to encourage consumers to start and stay on their medicines.
To that end, ConnectiveRx, together with industry experts, identified an alternative adherence model based on several key inputs, including a review of existing models, input from customers and adherence experts, and our own extensive experience in implementing adherence programs. The team identified three tenets that can help drive successful adherence programs:
- First, to be truly useful, a contemporary medication adherence model must account for the digitally engaged consumer of 2017.
- Second, for model-based guidance to be actionable, it must zero in on the key stakeholders involved in any individual prescription transaction: the prescriber, the pharmacy, and the consumer.
- Third, to be realistic, the new model should recognize that medication adherence is never a one-and-done exercise; instead, it’s an ongoing process that continues over time. This last thought is crucial: The consumer journey is not linear and segmented; rather, it is a continuous and ongoing process that involves important touchpoints and real-time decision making by the consumer. It is in these consumer decision points where a brand strategy misstep can result in the loss of hard-won new patient starts.
In the end, the team designed a new way of looking at adherence; one that accounts for today’s digitally engaged consumers, focuses on the key stakeholders, and redefines adherence as an ongoing non-linear process. “The Connective Medication Journey” (Figure 2) depicts a continuing migration that includes the intertwined processes of discovering and learning (on the left) and accessing and adhering (on the right). Throughout the process, the consumer is actively engaged in answering important questions like these:
Discover & Learn:
- How can I understand my condition?
- Can my regular doctor handle this? If not, where do I go for help?
- If I need medicine, how can I be sure I’m getting the right drug?
- What can I expect regarding outcomes, side effects, and interactions?
- How do I find the best pharmacy for me?
Access & Adhere
- How do I identify and engage with available financial support?
- How do I follow my therapy plan?
- How do I assess my overall experience vs. cost?
- How do I automate and manage my refills?
- How do I continue on therapy and monitor my own personal cost/benefit experience?
Brands that strategically consider these consumer questions will be more focused on the consumer mindset and thereby more likely to engage it successfully. This approach can help marketers as they build strategies related to consumer education, prescriber-consumer communication, access and cost barriers, etc.
But this new model goes even further, capturing the idea that the medication journey is connective in three key ways:
- The journey is internally connective. Each consumer’s medication-adherence journey is uniquely personal, continuously connected over time (from initial Rx to initial fill to multiple refills over months/years), and includes a multitude of connected decision points as the individual discovers, learns, accesses, and adheres to treatment.
- The journey is externally connective. To be successful throughout his or her personal medication-adherence journey, each consumer must connect with and learn from other well-informed stakeholders. Two of the most important external connections are with the prescriber and pharmacist. For example, the branded-product prescriber should be informed regarding efficacy, safety, access barriers, co-pay assistance, consumer education resources, etc., and should actively encourage adherence. Likewise, the pharmacy/pharmacist should be prepared to support consumers’ adherence-related needs.
- Finally, the consumer journey is digitally connective. Now more than ever, consumers stay connected and in charge of their healthcare via social media, public online resources, and consumer access portals. This new digital connectedness represents a unique opportunity for pharma brands to engage consumers. Of course, tangible channels are still important, but forward-thinking brand teams are beginning to focus their consumer-facing marketing on digital media including text, mobile, social media, etc.
Using this new model as a starting point, brands can begin to build a profile of consumers based on demographics, EHR history, pharmacy interaction, etc. With that profile in hand, brands can advance the medication journey by interacting with the prescriber, pharmacy, and consumer at multiple touchpoints.
Brands can take definitive steps to inform and motivate consumers and prescribers, educate pharmacists to help activate the consumer journey, support consumers with full-service co-pay programs, and engage consumers through omni-channel media (Figure 3). Ultimately, these contacts should be integrated in order to deliver the right communication to the right stakeholder via the right channel at the right time. A brand team that effectively engages key stakeholders in this manner can expect to see real progress toward better adherence.
1. http://www.fda.gov/Drugs/ResourcesForYou/SpecialFeatures/ucm485545.htm. Accessed January 19, 2017.
2. Toich L. “The Cost of Medication Adherence to Pharma.” Specialty Pharmacy Times. Published online December 30, 2016. http://www.specialtypharmacytimes.com/news/the-cost-of-medication-adherence-to-pharma. Accessed January 19, 2017.
3. World Health Organization. “Adherence to Long-Term Therapies: Evidence for Action. 2003.” http://apps.who.int/medicinedocs/pdf/s4883e/s4883e.pdf. Accessed January 20, 2017.
4. Dudzinski R. “Top 3 Pharmacy Challenges in 2017: Two-pronged Solution.” Managed Healthcare Executive. Published online January 19, 2017. http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/top-3-pharmacy-challenges-2017-two-pronged-solution. Accessed January 19, 2017.
5. Cutting Edge Information. “63% of Brand Teams are Involved in Patient Adherence Activities.” Published online December 29, 2016. http://www.marketwired.com/press-release/63-of-brand-teams-are-involved-in-patient-adherence-activities-2185640.htm. Accessed January 19, 2017.
6. Baroletti S, Dell’Orfano H. “Medication Adherence in Cardiovascular Disease.” Circulation. March 29, 2010, Volume 121, Issue 12. http://circ.ahajournals.org/content/121/12/1455. Accessed January 20, 2017.
7. Osterberg L, Blaschke T. “Adherence to Medication.” New England Journal of Medicine. 2005;353(5):487–497, http://www.ub.edu/farmaciaclinica/projectes/webquest/WQ1/docs/osterberg.pdf. Accessed January 20, 2017.