As healthcare payment systems increasingly emphasize outcomes, stakeholders— manufacturers, providers, pharmacies, and payers—will have to work together to understand the dynamics of patient adherence (and non-adherence) and address them creatively to engage the patient in successful treatment.

Some pharmaceutical companies still approach patient adherence very narrowly, primarily through targeted education and reminder programs. Despite efforts, these programs have failed to completely address the root causes of patient non-adherence.

Given this trend, it was exciting when a manufacturer of dermatology products decided on a comprehensive patient adherence strategy that superseded traditional approaches to the issue. The company wanted to look at the problem from a fresh perspective by identifying root causes and defining ways to address them holistically. Ultimately, the project fostered the development of a three-year adherence strategy roadmap. Key components were an enhanced involvement in the social media space and a patient opinion leader (POL) strategy. The project marked a new step for the company in the area of patient adherence, and more importantly, confirmed the prior insight that patient adherence is starting to be, and will increasingly become, a question of intelligent collaboration across healthcare stakeholders.

PATIENT ADHERENCE TODAY

The pharmaceutical industry is divided on how to address the larger problem of patient adherence. Some companies believe that patient adherence will be at the core of their business model in the future and are transforming current practices to reflect this belief. Others believe that patient adherence is too difficult for the industry to solve on its own. Companies such as Merck and GlaxoSmithKline are betting on the adherence model: recently, both Merck and GSK reviewed their specific adherence issues, uncovered root causes, and are now establishing enhanced capabilities to improve overall patient adherence. In 2011, Merck set up a center of excellence to focus exclusively on adherence.1 In the same year, GSK created a Patient Engagement Group to define standard patient adherence approaches across chronic diseases within its portfolio2.

Despite efforts by a few players, the industry as a whole lags in addressing the adherence issue. A recent patient-adherence report, Vision & Reality3, found that out of a group of 66 senior pharmaceutical executives, most felt adherence is an important problem, but that the industry is ill-equipped to solve the issue. According to the respondents, other stakeholders within the healthcare ecosystem—those with more direct contact with patients—need to take the lead on finding solutions.

At present, most pharmaceutical companies treat patient adherence as a responsibility of their marketing departments. Marketers see their job as communicating with patients within strict legal boundaries. Due to HIPAA and other regulations governing call centers, marketers fail to grasp how to address patient adherence beyond education and opt-in, direct-to-patient programs.

Despite this myopic view, traditional industry-led adherence programs have made significant progress in recent years. Once a patient has opted in to one of these programs, many options open up. They range from calls with nurse educators or nutritionists to text message reminders to take medication. Some programs also have incentive components varying from co-pay discount cards to loyalty games (in which patients can earn rewards for compliant behavior).

In addition, traditional patient adherence programs can now segment patients by expected behaviors. This allows the industry to deploy the tactics that are most effective for the specific segment. Some patient groups require only text message reminders; others benefit greatly from more expensive one-on-one consultations. There are many other options. Vitality (Cambridge, MA), for example, produces specialized pill containers that remind patients via SMS or phone call to take prescribed drugs. It can also inform HCPs of non-compliant behavior—although only, of course, after the patient has opted in to the service. Innovations such as this can raise adherence by up to 27% in the opt-in population, at a relatively moderate cost. Despite advances, these programs are limited by the fact that patients must agree to participate. By their nature, patients who choose to opt in are typically more engaged with their treatment and tend to be more adherent, regardless of additional programs.

NON-ADHERENCE IS NOT FORGETFULNESS

Leaders in this area understand that non-adherence is a not primarily caused by forgetfulness or a lack of understanding of the treatment. Most non-adherent patients decide to discontinue treatment. The dermatology project characterized different types of adherence hurdles. The target population of adolescents and young adults expressed clear need for independence and immediate gratification with their treatment. Their skin problems also affected them deeply, both socially and psychologically. Research and analysis uncovered five main reasons for non-adherence: 1) poor toleration of the product and its side effects; 2) perceived under-performance of the product; 3) complexity of the treatment regimen; 4) low perceived value of maintenance after symptoms first disappeared; and 5) cost. None of the top root causes involved patient forgetfulness or misunderstanding of the treatment protocol. Although the drivers of non-adherence vary by disease and product, one fact does not: adherence is a multi-faceted challenge that generally trumps purely educational, reminder-based approaches, driven by the pharmaceutical industry alone.

CHANGE IS ON THE HORIZON

Recent focus groups with hematologists indicated that they did not consider adherence as part of their responsibilities. Like many traditional physicians, they saw adherence as a non-medical issue stemming from patients’ lack of self-management. However, if these physicians were employed by an integrated delivery network with strong care quality guidelines, part of an Accountable Care Organization, or reimbursed by a pay-for-performance plan, their perspective would likely change dramatically. A health plan medical director recently told us in an interview that, as a result of U.S. healthcare reform, the responsibility for patient adherence is likely to shift to the provider. Patient outcomes are becoming the main driver for providers’ revenue, and thus in the near future providers will be incented to become actively involved in patient adherence.

SOCIAL MEDIA AND PATIENT OPINION LEADERS

In order to become a key stakeholder in the care delivery ecosystem, pharma must understand the needs, concerns, and motivations of community members. Social media is a key vehicle for reaching certain patient demographics, such as adolescents, to form communities to discuss health conditions. The dermatology company found that it could garner a wealth of information from social media. In online communities, adolescents tend to influence each other and to see their peers as more trusted sources of information than other traditional figures of authority—such as healthcare providers or parents. Getting to know the patients’ issues involved embracing their language and social media communities, and ultimately required us to engage with them directly.

Within social medial communities, patient opinion leaders emerge as trusted authorities. They are typically bloggers who have large followings in their disease-area online communities. Roche and Astra Zeneca were the first companies to initiate discussions with these online leaders. Given their importance, patient opinion leader engagement was a lynchpin in developing the dermatology company’s patient adherence strategy. This emphasis allowed marketers to better understand patients’ motivations, issues, and concerns in treatment of their disease.

A QUESTION OF COLLABORATION

Understanding drivers of poor adherence is merely the first step in solving the greater adherence problem. Innovators have realized that direct engagement with the broader healthcare community will drive behavioral changes. For example, GSK’s new Patient Engagement Group is aligned with the company’s Community Pharmacy, Care Management, and Advocacy teams. It is clear that GSK understands the need to leverage external partners to drive behavior changes in the marketplace. The company also recognizes that pharmacy chains are critical contributors to patient adherence. Research for Vision & Reality indicated that pharmacists were the only stakeholder who saw adherence as a key opportunity and also said they were ready to take the lead to drive change. Translating thought into action, McKesson recently set up its Pharmacy Outreach Network, uniting 2,500 independent community pharmacies and four pharmacy chains around patient adherence objectives. CVS Caremark followed through with its Pharmacy Advisor Initiative, combining insights from data mining of prescription benefit management records and face-to-face or phone counseling initiatives.

Payers are, of course, another important partner in solving the patient adherence problem. For example, Merck initiated a partnership with the health insurance company CIGNA, linking discounts on the diabetes treatments Januvia and Janumet to patient adherence and resulting outcomes.

Other pharma companies in asthma, COPD, oncology, and diabetes are partnering with providers. These companies use nurse educators to train physicians and office staff to help patients manage their disease. Adherence-enlightened marketers have also collaborated with integrated delivery networks to set up end-to-end disease treatment pathways. Regardless of the partner, the pharmaceutical industry must be open to collaborating to address patient adherence.

Despite the impending need, complete collaboration with other healthcare stakeholders is not an easy task. Pharma will have to move away from product-centric offerings and embrace a service-oriented approach. In the future, a rep call on a healthcare professional may look very different. It could include an update on the evolution of adherence in the physician’s own practice and the likely impact on health outcomes. A contract between a payer or an integrated delivery network and pharma might include commitments to deliver specific adherence services along the treatment pathway. Patient-adherence innovators have already started defining comprehensive service approaches and have begun to measure their impacts not only on adherence but also on health outcomes. It is only a matter of time before the entire industry incorporates patient adherence into its broader business strategy.

FIGURE 1:

FIGURE 2:

References
1. “New thinking in patient adherence”, FirstWord Dossier, February 2012.
2. Eye for Pharma, PACE event, October 24, 2011.
3. Vision & Reality: Patient Adherence, the next frontier in patient care, Capgemini Consulting, 2011.

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