Last month, I wrote about the fact that regardless of the condition for which a medication is prescribed, after three to four months, only about 40 to 50 percent of the people prescribed long-term medications are still taking them. Controlled testing has shown that direct marketing techniques can improve patient adherence with medications by 20 to 25 percent. So why aren’t these techniques used more often?
One of the biggest barriers to creating effective patient intervention programs is the speed with which they have to be implemented. Keep in mind that 20 to 30 percent of prescriptions are never filled, and 40 to 50 percent are not taken as prescribed, according to the National Council on Patient Information and Education. (Opens as a PDF) As a result, the closer to the point of prescribing that patient interventions begin, the more successful they will be. If the interventions don’t start until three months after a prescription is written, a significant portion of the patient population is already gone, and the patients who remain are those who are likely to remain persistent, anyway.
There are several reasons why people don’t take their medication as prescribed, but most important among them is the fact that people often do not understand why they are taking a particular medication or how long they’re supposed to take it.
Educating patients about how their medication works in simple language can go a long way to helping them realize how and why to take it. And while there are various stakeholders who can benefit from increased adherence, each has their own particular barriers to creating an effective program.
First, there are the pharmaceutical manufacturers. They’re constrained by the FDA regarding what they can say to the patient, not allowed to stray from the language in their approved labeling. Frequently, this constraint ends up with patients getting communications in language that they can’t understand. Additionally, brand managers may be reluctant to spend money from this year’s promotional budget to affect potential sales increases in future periods when they may have moved on to another assignment.
Pharmacies could potentially benefit from increased adherence; however, their margins on prescription drugs are too low to devote the resources necessary to deploy an effective patient education program. Their efforts are largely limited to refill reminders, which are not effective in increasing persistency. Forgetfulness affects compliance (taking medication as directed), but persistency (continuing to take medication over time) is driven more by the psychological factors I addressed last month.
Healthcare providers are constrained by the amount of time they have to spend with a patient and by the fact that the patients generally forget most of what they’re told during their 10 minutes with the provider before they even leave the office.
Those who have the most to gain are the insurers, the ones who pay the healthcare bills. Apart from the patients, these payers have the highest stakes in the game. Convincing a patient to take cholesterol and blood pressure medications is a lot cheaper that paying for the hospitalization costs associated with a cardiac event. And while the insurer, (for example, Aetna) may know that a patient was diagnosed with a particular condition, it’s the PBM, pharmacy benefits manager, (for example, Express Scripts) who knows if a medication was dispensed and when. These are important data points for creating effective patient interventions, because the sooner you get to the patients, the more patients you can affect. But the PBM can’t account for the 20 to 30 percent of prescriptions that are written and never filled.
The most effective interventions start with incenting patients at the time that their initial prescription is written: specifically, giving them a free initial supply of medication for providing their contact information. That data capture lays the groundwork for early intervention. From there, a data sharing partnership between the payers and the PBMs can provide the information to get the appropriate communications to patients at the right times. This type of partnership is a tall order, but as the New York Times reported in April — citing a study in the Annals of Internal Medicine:
“This lack of adherence, the Annals authors wrote, is estimated to cause approximately 125,000 deaths and at least 10 percent of hospitalizations, and to cost the American health care system between $100 billion and $289 billion a year.” (Opens as a PDF)
The various stakeholders need to come together to improve this situation.