|Speaker Dr. Katrina Firlik|
This is a really interesting question because for decades, really, or even longer people looked at the problem of non-adherence through a couple of different lenses. One is people assumed that it was largely because of cost. In other words, medications cost a lot of money and so patients can’t afford them and so patients don’t take them. Now clearly, that is a problem most certainly. And it’s the problem for many patients. But what’s interesting is that for many other patients it’s not the main problem.
To give you a couple of examples. If you look at countries in Europe where medication is essentially free to its citizens, they have roughly the same adherence rates that we do here in the US. Using free medication as an intervention, in essence, has been tried here in the United States. It was most famously published a couple of years ago in the New England Journal of Medicine where patients leaving the hospital after having a heart attack were divided into two groups. One group got all of their cardiovascular medication for free and the other group had to pay the usual co-pay. The group receiving free medication had adherence rates that were only 4-6 percentage points higher than the controlled group. What that’s showing is that if you lower the cost of medication or give them away for free, it does definitely make a dent in the problem. But it doesn’t solve the problem, by any means. So, really, there is something else going on here.
The other lens that is most commonly used when looking at adherence is forgetfulness. Again, just like cost, forgetfulness is a cause of the problem, but not necessarily the cause of the problem. What is interesting about all the reminder programs out there – whether they are reminders by phone call or text or email or letters in the mail – is that they are definitely helpful for patients that are motivated to fill the medication in the first place and to take the medications. It’s the perfect application for somebody who is already 80% adherent or more and occasionally skips a dose or misses a dose unintentionally if they are travelling or they are busy and just accidentally forget a dose.
A reminder is very helpful for that sort of patient. But, those patients are not really the force of this non-adherence problem. In other words, what you really have to do is approach patients who aren’t already sufficiently motivated; the ones who are not already 80 or 90% compliant and you are simply trying to perfect their adherence.
The real goal is to improve persistence, meaning keeping people on therapy and keeping them filling from one month to the next. That’s the real issue. Not patients who miss a dose here or there. The real issue is people who quit medication or never even fill the first one. So, really, it comes down to a motivational issue. Even if you can come up with the perfect reminder program and give the medication away for free, there is still a significant adherence challenge.
We like to look at the problem through the lens of what we call “present bias”, which is a behavior economics concept that is quite simple. As humans, we are impatient. We value short-term rewards over long-term rewards. The fundamental problem with chronic medications is that they come with no short-term reward. In other words, the rewards are all downstream, maybe years or even decades in the future. So, it’s hard to do something today when the benefits are years in the future. That’s what we believe is the significant driver of the problem. In fact, it could be compared very simply to the failure to save for retirement. It’s actually a very similar psychological challenge. It’s hard to put away money today in your 30’s when it benefits you decades in the future. That’s exactly the sort of challenge that we are dealing with in chronic medication.Katrina also discussed what this impact has downstream in a patient's experience, the huge problem this is for the industry and the broader level than patients and physicians, potential interventions and more. Download the entire interview here.
Want to hear more from Katrina? She'll be joining us at ePharma this February for the presentation Improve Medication Adherence by Understanding What’s Actually Driving Non-Adherence. The event will take place February 24-26, 2015. As a reader of this blog, when you register to join us and mention code XP2006BL, you can save $100 off the current rate!