MedCity Influencers, Patient Engagement

Medication adherence is dead. Long live medication adherence.

With all this blabbering about the shortcomings of the business of adherence, the point is not so much that adherence is not relevant, but that it is often a bloated, overused and misunderstood concept.

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Medication adherence is a fickle beast, yet it is not the ultimate determinant of positive health outcomes in patients. In many cases, non adherence may simply be a necessary part of the pathway of an individual’s health journey. What does that mean exactly?

Imagine a patient, let’s call him David. According to his health insurance, he has an 85 percent proportion of days covered (PDC) to his triple therapy that treats his Type 2 diabetes. This would be considered a remarkable score if we were to assume that he is taking metformin, pioglitazone, and exenatide as required. However, in contrast to his prescription claim records, the real world paints another picture, one that is marginally adherent to pioglitazone and exenatide medications and consistently adherent to metformin. David’s adherence and contribution to his plan’s star rating appear great because on each day, he is considered covered by at least one medication, all the while his health suffering.

Similarly, imagine Karen, a 55-year-old woman who has Type 2 diabetes and is working through a series of treatments with her physician to determine what the best option might be. During this time, her claims refill data might show us that she is non adherent to her treatment when in reality, she is adhering to another newly, doctor-prescribed treatment — a lifestyle intervention.

Karen and David reflect how today’s adherence metrics can only tell us so much. Depending on how we choose to cut the data, the score may come across as non adherence or adherence for the wrong reason.

On the other hand, there are many straightforward use-cases of individuals that simply forget to take their medications or just have poor health literacy, so therefore do not adhere. This, we would posit, constitutes the vast majority of the ‘adherence’ business focus.  While intriguing, this is mostly relevant to manufacturers concerned with the most basic improvement in adherence that directly affects the bottom-line from a sales perspective. How adherence contributes to or detracts from the bottom-line for the cost side of the healthcare equation (health plan, provider, employer) is murkier. That is to say, the impact of increased medication spend often appears at heads with longitudinal cost-savings from healthcare utilization. However, the time-value equation of a plan member with high healthcare utilization may on the contrary, lead to positive health outcomes due to the benefits of adherence from a long-term cost perspective.

Patients like Karen and David are actively making decisions with their care providers about how to take part in their own treatment plan, titrate, switch, and make lifestyle decisions. There are many other data points we are missing about the patient that can provide context (e.g., wearables, Internet of Things, sensors, self-reported measure). However, even then, there isn’t total accuracy in determining the nuances of adherence to therapy. Capturing context, however, is becoming increasingly possible and the ability to make sense of all the contextual data is even more accessible vial machine learning.

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With all this blabbering about the shortcomings of the business of adherence, the point is not so much that adherence is not relevant — it is very relevant. However, adherence is often a bloated, overused and misunderstood concept. At our firm, we have walked in the valley of darkness amongst stakeholders with positive, negative, and neutral outcomes from improvements in adherence. We have seen it all and what’s more, adherence as a stand-alone concept may be dying a slow death. But long live adherence and what we will coin “the clinically driven business requirement”. What exactly do we want to achieve within the domain of medication/treatment adherence: is it treatment initiation, medication refills and persistence, the identification of risk of graduation to more complex therapy or medication switching, or something else? And most importantly, why?

Why is the adherence concept so important? OK, Mr. Pharma Brand Manager, put your hand down, we all know why you think it is important, but what about the rest of you? What is it that you exactly want to achieve from your adherence or patient-engagement program?  Now, let’s tie that to a set of quantifiable metrics and ROI, and if you do not have any, please come back when you do or maybe ask for some help defining some. Adherence is too broad of a concept, what does it specifically mean to you?

Photo: Getty Images