Reverse anthropomorphism

Our philosophies around adherence reminded me of an article featured in the Modern Love section of the New York Times in 2006. The article entitled "What Shamu Taught Me About a Happy Marriage", which dominated the website's list of most emailed articles that year, described the author's "reverse anthropomorphism", or to put it another way, the application of insights on animal behavior to human behavior (she was researching a book about a school for exotic animal trainers). Setting any gender commentary aside, the article described her use of "approximations", or "rewarding the small steps toward learning a whole new behavior" on her husband."

Full article here

Let's get meds together

Daily meds all packaged into single blister packs seem like they could take a lot of the burden off of patients. As pharmaceutical companies become more focused on specific therapeutic areas, I can see a day where this service is offered free for branded medications to beat out generics.

The study focused on elderly patients who were taking multiple medications and therefore were at risk for poor adherence. The educational component included intensive and frequent counseling by a pharmacist. The structural component involved packaging of medications in blister packs that contained each patient's daily medications.

After 6 months of the intervention, the percentage of patients classified as adherent increased significantly, from 61.2% at baseline to 96.9%, with associated modest reductions in systolic blood pressure and low-density lipoprotein (LDL) cholesterol. Six months after randomization, high adherence persisted (95.5%) in patients assigned to continuing counseling and the blister packs, whereas those in the usual care group (ie, had the pharmacy care intervention removed) had substantial declines in medication adherence (69.1% at the end of 6 months). There were statistically significant but modest reductions in systolic blood pressure in the pharmacy care group compared with the control group, but no significant differences in LDL cholesterol levels.

Full article here

Futureshock: The cost of your health

Visualization by GE: Click on pie chart slices to see conditions and then play with the slider to look into our future.

Patient Centered Medical Home

In my best guess (if I were to look into the future), the PCMH (patient centered medical home) will be a new quality standard set by associations such as NCQA for physician practices...somewhat analogous to how JCAHO set the quality standards for hospitals. Meeting these pre-defined threshold standards will determine the physician pay mix based on performance.

"Patient Centered Medical Home" is ultimately grounded in the concept of "having the patient at the center of health care delivery and empowering the patient to play a more active role in health care delivery"....this implies a number of things, such as: (1) giving the patient a greater control in managing their health, (2) giving the patient flexibility in how they manage their health, (3) making education a critical component to optimal health care, and (4) keeping patients in the communication mix that historically occurred only between the providers and payers.

Gautam Gulati, MD,MBA,MPH
Vice President/Group Director, Science & Medicine, Digitas Health

Nudge nudge

The Nudge blog is the online companion to Richard Thaler and Cass Sunstein’s “Nudge: Improving Decisions About Health, Wealth, and Happiness.”

In it you’ll find more about nudging, choice architecture, libertarian paternalism, and many other terms you won’t read about in standard economics books. The blog contains great thoughts and content such as:



What if we added the real cost of drunk-driving to people's bar tabs?

What if we imposed the real cost of non-compliance to medication to US tax-payers?

Benefit-based co-pays

Why don't co-pays decrease over time? Most pharmaceutical companies will happily pay for a variety of tactics that extend patients' adherence by even one more script filled. But putting patients on a transparent, tiered payment system could give patients the confidence they need to stick to their medication regimens.

There is evidence that the amount of money patients pay for doctors visits and pharmaceuticals affects the frequency with which they take medication properly. Higher doctor visit fees can raise barriers to compliance (patients may not pick up a needed medication or skip a dosage period), meaning co-payment designs are one policy tool for affecting health care behaviors.

David Nash, a medical professor at Jefferson College, suggests that one option for governments and companies is the adoption of benefit-based co-payment designs. These systems have tiered co-payments where levels depend on the seriousness of the illness, where drugs required to treat chronic conditions and drugs that have strong records of effectiveness have lower co-payments.

Full article here

Lake Wobegon syndrome

In the US, no matter how long they've been practicing, doctors tend to drastically overestimate their patients' likelihood of sticking to regimens. It's the medical version of the Lake Wobegon syndrome: Doctors consider their own patients to be above average. One study asked physicians to predict adherence only among patients they knew well, and the doctors still grossly overestimated.

Full article here

Necklace intervention

Assistant professor Maysam Ghovanloo (left) and graduate student Xueliang Huo, both of Georgia Tech’s School of Electrical and Computer Engineering, test their drug compliance monitoring system on an artificial neck. As a magnetic pill passes through the esophagus, the date and time are sent wirelessly to the computer and recorded.

Full article here

Pills + program packaging

When a pharma company does nothing to enhance patient adherence, generally speaking, the number of patients who stay on their regimen falls by 50% within six months. When the company supports a comprehensive program, it can raise adherence by five or ten percentage points for a while, but then the rates slip again.

McKesson’s Patient Relationship Solutions (PRS) group emphasizes the success of its LoyaltyScript program, which has been used at over 12,000 pharmacies. LoyaltyScript is a patient identity card that, when presented at a pharmacy, connects the prescription to any type of co-pay reduction, sample incentive, or discount that a manufacturer (or other party) might provide.

Most recently, PRS has connected two distinct services—the LoyaltyScript program and McKesson Rx Pack, a contract packaging/repackaging unit of the company. Rx Pack has a partnering relationship with a packaging design firm, BurgoPak, and will be combining the LoyaltyScript card with the BurgoPak compliance package.

Technologically, this might not be particularly challenging, but operationally it represents an innovative way to both get the card in the patient’s hands (complementing its handout at a physician’s office) and presenting an adherence-enhancing form of packaging.

Full article here

Adherence stats

It costs pharmaceutical companies 62 percent more to acquire a new patient than it does to keep an existing one.

Low adherence represents $177 billion in lost revenue per year (approximately a quarter of total annual pharmaceutical revenues).

Low adherence represents an average per drug loss of 36 percent in potential sales.

Twenty percent of prescriptions are never filled.

Half of all prescriptions fail to have the proper effect because of failure to take the drug or follow instructions.

Up to 50 percent of people with chronic ailments are non-compliant.

Only one-third of all patients actually take their medications as directed.

Only about eight percent of U.S. consumers are aware of their own non-compliance.

Typical non-adherent patients visit HCPs three additional times per year and have increased treatment costs of $2,000 per year over those following prescribing instructions.

As many as 10 percent of all hospital admissions and 23 percent of long-term elder care admissions in the United States are a consequence of failed patient adherence.

Article and references here

Adherence in 160 characters

The teenager’s cell phone rang telling him he was getting a text message. He opened it and read, “Hi. Remember to take your medication.” Then he closed his phone and went back to whatever it was he was doing. And oh yes, he also took his asthma medication.

This is a daily occurrence for some teenagers who have asthma. They’re patients of Dr. Maria Britto at the Children’s Hospital Medical Center in Cincinnati, Ohio. Britto is a primary care physician working in the Division of Adolescent Medicine and the Center for Innovation in Chronic Disease Care. Britto, Jennifer Knopf, who is a project specialist, and others are developing new ways to deliver healthcare and to communicate with teens who have chronic illnesses. A common problem for many teens is medication adherence (or lack thereof). Knopf says that teens often forget to take their medication or, if they do remember, plan on taking it later. According to Knopf, the daily text message reminders are a way to get teens to stop for a second and say, “Hey, I need to take my medication."

Full article here

UK pharmacists intervene

A U.K. study aimed to assess the cost effectiveness of pharmacists giving advice via telephone, to patients receiving a new medicine for a chronic condition. With the required adoption of EMR in the U.S., ahead of the government's 2014 deadline, the opportunity for pharmacists to play a powerful role in patients' health is tantalizing.

Now, what incentives will it take for pharmacists to play their part?


Non-adherence to new medicines for chronic conditions develops rapidly so we developed a study intervention in which a pharmacist telephoned patients two weeks after they had started a new medicine for a chronic condition. Five hundred patients were recruited.

• At 4-week follow-up, non-adherence was significantly lower in the intervention group (9% vs 16%, p = 0.032).
• The number of patients reporting medicine-related problems was significantly lower in the intervention group compared to the control, (23% vs 34% p = 0.021).
• Mean total patient costs at 2-month follow-up (median, range) were intervention: £187.7 (40.6, 4.2–2484.3); control: £282.8 (42, 0–3804) (p <>

These findings suggest that pharmacists can meet patients’ needs for information and advice on medicines, soon after starting treatment. While a larger trial is needed to confirm that the effect is real and sustained, these initial findings suggest the study intervention may be effective, at least in the short term, with a reduced overall cost to the health provider.

Full abstract here

Don't rush to crush

Poor palatability and subsequent tampering with medicines can have dangerous consequences.

Swallowing difficulty (dysphagia) is a common symptom that has been reported to be 12% amongst inpatients, 35% amongst the over 50s, and 68% amongst institutionalized elderly. Regarding patients with specific muscle related illnesses such as motor neurone disease, it is reported to be 100%. Furthermore, in a recent UK survey in primary care 11% of patients over 75 reported difficulties in taking solid oral medicines.

It is reported that up to 80% of patients do not take their medicines as agreed with their prescriber and that this in itself has been estimated to cost the USA $100bn per year. Prescribing medicines to patients who physically cannot swallow them due to the inappropriate formulation not only serves to exacerbate the level of non-adherence, but increases the likelihood of therapeutic failure and ultimately is a waste resources.

Full article here

Should we consider non-compliance a medical error?

We can gain significant insight into non-compliance if we apply theories developed to explain human error in organizations. The resultant framework encompasses intentional and unintentional non-compliance, shifts blame from the patient, and recognizes the influence of other factors, including organizational ones. With further research and theory development, the application of human error theory will offer a useful new approach to understanding and reducing undesired non-compliance.



Full article here

Variables associated with compliance

From: "The Assessment, Determinants & Economics of Medication Compliance & Persistence"

Full presentation here

Tweet those pounds off

"You might do a better job keeping pounds off by letting friends and family monitor your progress."


The Wi-Fi connected scale will track your weight and BMI, then transmit that information to "Twitter, Google Health, Microsoft health Vault," and other sites.

Full article here

Packaging: The next blockbuster

‘There is a growing belief that patient adherence is perhaps the next blockbuster for pharmaceuticals – if you can make sure that the patient takes the medication correctly and gets the best outcome, then not only will the relationship with the doctor be good because the patient feels he is getting something that is doing him good, but the doctor will also be more likely to prescribe that medication in future, which will benefit the pharmaceutical company,’ he explains.

‘Payers are now saying that they want to pay for outcomes, not treatment, and this is changing fundamentally the paradigm in the industry about how important it is for patients to take the medication correctly. If they don’t take it correctly, they will almost certainly not get the outcome that the payer is prepared to pay for.’

When a patient receives his medication from the pharmacist, he will often be given the drug in a blister pack, inserted into a carton together with a leaflet. Three out of those four elements are packaging-related, emphasizing the influence that packaging can have on the patient experience of the drug.

‘For years it has always been about the drug, but now the pharmaceutical companies are beginning to see it is the confluence of all those things that will be a major aid driving patient adherence,’ asserts Spackman. ‘It is possible for pharmaceutical companies to have a real conversation with their patients through packaging.’

NextBottle’s benefits: ease-of-use, shelf storage and transport. Patients can keep track of what pills have been taken by looking at the day displayed on the dial and missed doses can be identified. ‘The end result is improved compliance. Better patient compliance leads to better health outcomes, which translates to greater patient satisfaction and brand loyalty,’ says One World DMG

The origins of compliance-enhancing packaging can be traced to the introduction of the birth control pill almost 50 years ago: today, this category of product boasts the highest rate of compliance – over 95% – because users understand that non-compliance can have a very rapid and tangible impact on their lives.

At the other end of the scale, compliance rates for chronic conditions such as congestive heart failure, diabetes and glaucoma, where disease progression may be more insidious, languish at around 42% – although in the case of glaucoma, this increases to 58% once sight has been lost in one eye.

Full article here

Virtuous circles powered by fun

Light exercise (stair climbing):




Keeping to speed limits:

From "Think Better" to "Think Different"

We have identified "non-adherence" as the central problem we are trying to overcome. Most vendors and agencies today will first look to the pharma and healthcare industry to see what has been done, what is not being done effectively, and what can we do better. This is a great place to start, but I would then continue the hunt for innovations and creative solutions that tackle the non-adherence challenge in other industries. As an example, convenience stores (lets use Duane Reade as our example) and grocery shops try to retain customers via loyalty programs. This is great to grow deeper knowledge of your customers' needs and track purchasing habits. As a result, these institutions can deliver targeted discounts and vouchers to motivated customers likely to make a purchase.

Great. So we've identified a solution in a different industry that has done a great job in establishing loyalty (interpreted as 'adherence to the store') for their customer base. Now what? How is this applicable to medication adherence (using this particular example)? Well, lets take this initial analysis to the next level...

What are loyalty programs designed to do besides just drive adherence to the store/brand? Answer: They reward their loyal customers for positive behavior with additional value (whether it be discounts, vouchers, etc.). Could we similarly reward our most compliant patients without breaking the bank for our clients? Perhaps. Lets explore further.

Most companies would tend to direct their initial focus on the existing market of those patients that have already been prescribed a drug. While this is certainly important to address as a baseline using tried and true techniques, it may be challenging to offer such a loyalty service without some revenue loss via reward payments. But is there a way to explore the "un-market", i.e. those 'potential' customers who are considering going on a drug, or contemplating not refilling their drug? I would argue, yes. Here is my thinking. We often think of adherence limited to patients taking their medication as prescribed. But does adherence start earlier in the treatment process? In many cases, yes. Knowing that many non-adherent patients may be price sensitive, we know that doctors first recommend (in most circumstances) lifestyle changes such as "eat healthier, or exercise". But this only further compounds the cost to the patient, defeating their initial behavioral hurdle of maintaining adherence to the drug.

So could we perhaps weave medication adherence to healthy lifestyle behaviors? We know that doctors oftentimes in conjunction with prescribing medications also recommend eating healthy. Tackling both may be prohibitively expensive for the patient and oftentimes making the patient choose between one or the other (usually the medication loses out of if the disease state is asymptomatic, such as hypercholesterolemia or hypertension). In a similar fashion to loyalty programs, could we 'reward' those patients who demonstrate compliance by offering discounts and vouchers to everyday healthy lifestyle purchases (such as organic foods, or heart healthy cereals)?

Sounds reasonable, right? But how can we do this on a confined budget? This is where we need to be creative. Could we (i.e. the pharma company) perhaps partner with General Mills, Nabisco, and other well known food brands to offer these preferential discounts to those patients who demonstrate compliance? At the same time the patient fills their script in the pharmacy, along comes out a receipt with the available discounts/vouchers on food and lifestyle items that are of importance to the consumer to help keep costs down and manageable. These types of partnerships can even expand beyond just food manufacturers to include gym discounts and so. This scenario requires minimal cost for each stakeholder, and is mutually beneficial for all involved -- pharma company enhances adherence, food company drives up sales at the point of purchase, duane reade attracts and retains loyal customers motivated to purchase at the point of script refill, and the patient is ultimately healthier and richer.

Gautam Gulati, MD,MBA,MPH
Vice President/Group Director, Science & Medicine, Digitas Health

Don't ask, don't know.

At face value, one would think that being “put on a new medication” would prompt patients to ask their doctor a few questions. Why do I need this medication? What are the side effects? How should I take it? What about other medications I am taking? When can I stop taking it?

If you think that way… you would be wrong.

A 2008 study was based on 181 patients who were prescribed a new medication by their primary care physician or a cardiologist during an office visit. In total, patients initiated 199 questions or comments (1.09 per patient) based upon a coding of audio tapes of each patient visit.

The following table shows a breakdown of the frequency of patient questions by type and duration of patient talk time (in seconds) associated with each question topic.

Full article here

If physicians better understood what makes their patients tick...

From a type 2 diabetes patient on a diabetes social networking site:

"I keep reading where (having) type 2 diabetes is virtually a certainty for heart disease and an early death. These may be the statistics but l just haven‘t witnessed this in my personal life. My grandfather, a type 2 from his mid-40s lived to be 86. My father and two of his brothers were/are type 2 and my father lived to 83, his brother to 82, and one living brother just turned 80. These guys have out lived/are outliving most of their friends who are not diabetic."

"To my way of thinking, if you read and put a lot of faith in articles like this you might as well throw your arms up and say “I give up…I’m doomed and nothing can save me.”

If you were this person’s physician, would you find it helpful if you knew this was how your patient thought? How adherent would you expect someone like this to be if you prescribed medication to lower their risk of heart disease (BP or cholesterol)?

Steve Wilkins, former hospital executive and consumer health behavior researcher

Original post here

Adherence Experts' Insights

"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."

Ann Friedman Ryan
SVP, Director of CRM & Interactive, EvoLogue, part of CommonHealth

"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."

Kenneth Freirich
Executive Vice President, Health Monitor Network

"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."

Cheryl Ann Borne
e-Marketing and Relationship Marketing, Novo Nordisk

"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."

Stanley Wulf, MD
Vice President, Chief Medical Officer, InfoMedics


Full article here

Donut hole coverage = worse adherence?

"Donut hole coverage resulted in lower total drug costs, but higher out-of-pocket spending and worse adherence compared with having no gap. Having generic-only coverage during the gap appeared to confer limited benefits compared with having no gap coverage."

From: The Incidental Economist
Full article here

Human nature: "hyperbolic discounting"

From: Patient adherence to drugs is low and what doctors can do
Shantanu Nundy, guest blogger on kevinmd.com

"We tend to place greater value on today than tomorrow. This practice of “discounting” actually makes economic sense and is the basis for a large segment of the financial industry. However, in general we tend to discount the future more than we should – a phenomenon called “hyperbolic discounting.” Because we place undue emphasis on today compared to tomorrow, we are even less likely to take a medication that does little for us today for the sake of future benefit."

"For example, for hypertension, by encouraging people to track the change in their blood pressure daily or weekly, we can help them better relate the act of taking their medication each day to its long-term beneficial effects."

Original post here

High blood pressure symptom report

Source: Patients Like Me