A write-up of the eyeforpharma and EXL Webinar from November 2018
Like a fly you cannot swat, non-adherence seems to elude efforts to stop it. Even in the age of Dr. Google, when patients can clue themselves up about their condition and what questions to ask their provider at the click of a button, non-adherence remains stubbornly high.
The result is poorer patient outcomes, sub-optimal healthcare provision and, for the pharma industry, losses that run into the billions of dollars annually. A three-year-old survey by HealthPrize Technologies and Capgemini Consulting put the costs at $637bn, due to patient non-adherence to medications for chronic illnesses.
Today that figure is likely to be in the order of $700-$800bn, John Pagliuca VP of Life Sciences for EXL, told attendees of the Addressing Adherence by Strengthening the Provider/Patient Relationship webinar, hosted by eyeforpharma.
“Non-adherence puts a tremendous burden on the health ecosystem, translating into poor clinical outcomes, patients not receiving the appropriate treatment, or having to go through multiple steps of treatment until they find the right treatment,” Pagliuca told webinar delegates. “Other conditions affect these patients over time and lead to skyrocketing costs of care and that in turn drives increasing patient insurance premiums.”
Despite these undesirable outcomes, the industry is not giving the issue the attention it deserves. Pagliuca cited a presentation at eyeforpharma Philadelphia 2018 in which Tom Kottler, HealthPrize Technologies CEO, listed the four ways pharmaceutical manufactures can make money:
- Launch new products
- Have physicians write more scripts of existing products
- Raise prices
- Get patients to take their meds as prescribed
Quoting Kottler, Pagliuca said: “The last one is the least done of the four. It should be top of the list.”
"We need to ask: ‘where do we have the most influence to have an impact and help people have better lives?
The changing patient information landscape
The ways in which patients engage with those offering information on their treatments is changing dramatically away from the established model. Payers and care programs are now by no means the only source of information, said Pagliuca.
How patients learn about treatments also varies by demographic and age, with younger patients more likely to turn to online sources first, he said . Simply driving millennials toward the most appropriate information online while also enabling them to share this information with their peers, for example, could be a more effective educational strategy than simply expecting them to listen to their MD .
Peer influence is an important factor for patients and is not limited to digital natives. The role of peers is significant regardless of age or demographics, said Egbuono-Davies. “Peers have been shown to be effective on other people’s behavior for a long time in everything from the addiction space to shared experiences in chronic diseases like diabetes. For a long time we have used groups and peers to try to support each other to enhance adherence and lifestyle changes.”
Panelist Haider Alleg, Global Head of Digital Marketing at Ferring, said education could be more effective if healthcare providers and pharma had a better understanding of the stages of a patient’s treatment journey where information would have the most effect. “We need to ask: ‘where do we have the most influence to have an impact and help people have better lives?’”
For example, nurses educating patients through an existing clinical practice have proved to be an “easy win” in improving adherence for Ferring, said Alleg. Closer patient/provider collaboration through workshops were also effective in driving adherence but an affordable model for these had yet to be demonstrated, Alleg added
“Knowing the patient and collaborating with the patient are really the two accessible initiatives that we embed but educating the patient usually comes back to cost. We are trying to find this perfect way of having an impact but it is not easy. The cost of running direct-to-patient consumer programs is another level of involvement.”
2. Is patient education really the issue?
A frequent assumption in the industry is that a lack of patient education is the problem and that more education is the clearest means to improving adherence, said panellist Dr Janos Penzes, Lead at the Gedeon Richter Digital Center of Excellence.
Penzes noted that this common assumption was confirmed by the 39% of webinar attendees who believed a lack of patient education was the most significant contributing factor to nonadherence in the poll, which was higher than the panel had expected to see.
For Penzes attributing such a large weight to a lack of patient education is a facile attempt to deal with issues that run a lot deeper..
“We tend to just gravitate back to education when we try to address non-compliance and perhaps it’s a bit of laziness,” he said. “Maybe instead we have to acknowledge that noncompliance is a symptom and not the diagnosis of what is really going on.”
Penzes cited one study of adherence for glaucoma treatments as an example of the complexities of non-adherence that suggest patient education is only part of the problem. “Despite being well educated about the very grave effects of non-compliance, 58% of them were non-compliant,” said Penzes.
“The shocking part was when I learned that 42% of those patients who had already lost sight in one eye were non-compliant. So it is not just down to them being uneducated, it is more profound than that.”
Patients need to be asked more searching questions and engaged in ways that go beyond simply asking why they don't take their medicine, said Penzes. “To really understand why they don't take their meds, we have to work in more detail, provide more engagement, more face time with patients.”
The context of treatments also matter, such as the kind of systems patients are in, as well as the nature of their disease types, said panellist Lisa Egbuono-Davies MD, Global Head of Patent Outcomes and Solutions for Sanofi. Yet this is not given much attention in the industry.
“The OECD report talked recently about the focus on education and patient targeted interventions excessively without dealing effectively with the systems factors, such as barriers to obtaining medicine refills or healthcare provider communications,” she said.
Webinar poll result
What factors can patient nonadherence primarily be attributed to?
- 39% Uneducated patients
- 27% Complicated medication regimens
- 14% Patient apathy
- 12% Patient’s ability to pay
- 8% Patient denia
3. Improving adherence through deeper patient insights
In the webinar poll, when asked what pharma can do to increase patient adherence rates, the highest proportion of respondents (35%) chose the answer ‘Knowing their patients' socioeconomic and behavioral profiles better’.
The finding was a surprisingly positive one, said Penzes, as it suggested many in pharma are open to trying to go deeper in their understanding of patient lives and motivations, which in turn would point the ways to improving adherence. “We are now beginning to try to understand patients as experts in their disease as opposed to just asking, ‘Why don't you just take your meds?’”
“This can unearth very interesting findings if pharma product managers, for example, actually meet patients and try to put themselves in the shoes of the patient. That can really broaden the perspective of the work that they do and really help these patients.
“One of the most profound findings in one of our experiments was that when talking to patients about the medication, they revealed it was only a tiny fraction of their [daily] concerns. While the disease is 100% a concern to us, if you look at how the patient perceives it, it is only really a tiny part of their concerns.”
A better appreciation of these dynamics would in turn help patient and provider arrive at better solutions together, said Egbuono-Davies. The route to better adherence was through a deeper understanding of patient’s life goals and objectives and also by understanding how treatments may get in the way of patients living the lives they want to.
Doing this then creates the possibility of doing something about it. “We have worked with patients to co-create solutions that will help them manage their meds and conditions better,” she said. “Some are IT/digital services, some are tools to co-ordinate with healthcare providers.”
Webinar poll result
What can pharma do to increase patient adherence rates?:
- 35% Knowing their patients' socioeconomic and behavioural profiles better
- 33% Educate patients directly
- 25% Provide physicians better information and tools
- 7% Offer financial incentives (discounts coupons, etc.)
4. The promise of analytics and patient segmentation
For years, sectors such as financial services and retail have enjoyed great returns from honing their understanding of customers by segmenting them to gain deeper insights. The healthcare industry’s extensive sources of patient data from electronic health records, lab data and other related data sets affords it a great opportunity to reveal some valuable findings it can act on, said Pagliuca.
Deeper patient insights through an analysis that segments them into meaningful sub-groupings can help drive earlier and effective intervention and closer and more productive payer/ pharma/patient relationships that combine to drive adherence higher.
EXL has developed the machine learning tools and harnessed the datasets to enable this.
It uses de-identified medical and pharmacy claims over five or more years and maps these with ZIP4 socioeconomic and demographic data.
This sifts patients into groups based on their socioeconomic and demographic markers; their use of particular services and products; the costs, quality and access to particular kinds of care available to them; and their attitudes and specific behaviours.
One of the most profound findings in one of our experiments was that when talking to patients about the medication, they revealed it was only a tiny fraction of their [daily] concerns.
The deeper insights gained through such segmentation in turn offers the industry the ability to:
- Understand how different factors may impact current and future adherence levels.
- Determine which patient segments can be impacted the most and where.
- Inform HCPs of factors affecting patient compliance in their communities.
- Better develop patient education and other programs that address non-adherence.
An important potential value for pharma in engaging with such data is that it offers manufacturers the opportunity to enhance their relationships with healthcare providers who often refuse to see their sales reps because they don’t believe they have any new valuable information to share, added Pagliuca.
Being able to share high-level insights into patients that are being treated for a specific condition could change this and make HCPs more receptive, ensuring every party benefited from a deeper insight into the adherence problem. “Truly understanding who that patient is and what keeps them from adhering could help drive that relationship between HCP, provider and patient,” said Pagliuca.
Understanding the patient journey
EXL has developed a dashboard that helps HCPs easily understand a patient’s propensity for non-adherence including metrics such as their ‘Prospective Risk’ and ‘Impactability' scores.
These metrics can help healthcare players understand where patients are likely to head over the next 12 months in terms of their adherence, said Pagliuca. They also indicate whether certain patients were more likely to be closer to developing co-morbid conditions that would drive up the cost of care. These metrics also help identify potential windows of time in which to intervene and so have a positive impact before this happened.
“We can follow each patient down the pathway of what drugs or products they use initially and in subsequent treatments and look at where they are today on a historic timeline,” said Pagliuca. “We can follow that journey to see what happens along the way to see what are the adverse things that have affected those patients and that have driven up the cost in services. Could those have been avoided from the very beginning of that journey or somewhere in the middle?”
In an era when outcomes-based agreements are becoming more common, such insights have an increasing value, said Pagliuca. “If we can start thinking about the patient journey and specific key triggers and what key components drive the non-adherence, that becomes actionable information.
“That is a win-win which most importantly puts the patient at the center of that universe and it becomes a joint effort to drive them to better care treatments and ideally better adherence. At the end of the day, it is about how we put patients on the right product, at the right time and keep them there over time to improve the value of their care.”
5. Bridging the trust gap
The “shadow of distrust” hovering over the pharma sector is another feature companies have to contend with and acknowledge when considering how to present, communicate and reach target audiences if they want to improve adherence, said Penzes.
The trend in which patients are increasingly turning to new trusted sources, notably online and often peer-based ones, is clear. “Not so long ago Weber Shandwick and KRC research published an interesting finding from the US on where people get their health information and how much they trust that information.
"The survey revealed millennials have the biggest trust gap with doctors and 26% say they trust their peers more than medical professionals, while 49% believe online health information is as reliable as information from a doctor."
“The survey revealed millennials have the biggest trust gap with doctors and 26% say they trust their peers more than medical professionals, while 49% believe online health information is as reliable as information from a doctor. These trends must really be taken into account in the big picture when we talk about behavior.”
Egbuono-Davies agrees trust is a significant factor when it comes to adherence. “Trust is highly associated with patient adherence and the communication skills of healthcare providers are critical to enhancing trust as well.”
There are tools that are proving useful in helping healthcare providers increase trust with patients, she adds, such as informal training programs or simple training tools that serve to open up dialogue with patients.
6. Adherence and the role of the pharmacist
In answer to a question from a webinar attendee about the role of the pharmacist in driving adherence, there was a recognition from the panel that pharmacists’ unique status engenders high patient trust and thus enhances their potential to offer education and support that could drive better adherence.
Patients feel comfortable talking to and taking advice from pharmacists and factor that in their decision making process, said Pagliuca. “The question is how that firms up over the next few years with regard to programs at the patient level.”
Pagliuca envisaged a future in which pharmacists might help providers, payers and life sciences clients build a better general understanding of the patient types, which in turn could drive better messaging to patients.
The pharmacist plays a critical role in outcomes and acts as the ‘third leg of the stool’ in disseminating information with pharma and their client and in trying to develop more effective collaborations, said Pagliuca.
Where segmentation data is shared directly with the retail pharmacy, for example, it could give them insights to into how particular patient groups think, act or feel and enable them to communicate with them better at the pharmacy counter.
“Among the questions that our clients are starting to ask are: ‘Does the payer you are working with have the capabilities to affect that patient population through their care program and through their PBM partners?’ and ‘Can they get the appropriate message through to the appropriate patients as identified by the analysis?’”
The pharmacist could also take a more active role in augmenting technology to help drive better adherence cost effectively at scale, Alleg suggested. “In a near future, pharmacists could be the ones ensuring chatbots are giving the right information in marketplaces that give advice to patients. They would also play a part in prevention and support for complex or chronic diseases in paid tele-med services.”
In a near future, pharmacists could be the ones ensuring chatbots are giving the right information in marketplaces that give advice to patients.
Insights to act on
Dramatic improvements in patient adherence have largely eluded the healthcare industry despite years of effort to move the dial but there is reason to hope for far better results in the near future.
The healthcare sector’s increasing focus on patient outcomes is one factor driving new thinking on adherence, said Haider. “More and more payers are putting pressure on pharma for outcomes-based reimbursement models, which will potentially force us as an industry to think about programs that will help adherence as a companion package [to conventional treatments].”
A more open approach to talking to patients offers a chance to collaborate on solutions together that stands a better chance of working over time. A more rounded understanding of the patient experience through more effective segmentation of patient groups also promises to help target interventions at those who stand to benefit most.
"We are getting more sophisticated in using digital technology to measure and respond to patient behavior and to augment human intervention at a lower cost."
An emerging picture
The data analytics being used by EXL are relatively new but are expected to begin demonstrating their worth in the very near future, said Pagliuca. “We are only a couple of years into working at this depth with the machine learning capabilities of today.
“We have a number of clients that are using these data for various tactical purposes across the commercial spectrum, there are also various outcome and risk-based conversations happening to tackle particular patient bases.”
The fruits of these insight-driven interventions will soon be apparent, he said. “Over the next 12, 18, 24 months, ultimately, we should see a rise in patient adherence and also a decrease in patient cost and a decrease in healthcare costs. It is a win-win.”
Payers are also increasingly engaging with the possibilities on gaining insights from machine learning, he added. “On the payer side, there is a need and a want in those organizations to have these conversations and dialogues [but] they are not as prepared as they might be to go deep on these types of analyses. They are kicking the tires on this at the moment.”
Data analytics tools will evolve further still, becoming more visual and easier to read and will involve even larger data sets, helping track behaviors and yielding more insights that could help drive adherence forward in the years to come, said Alleg. “Big data and blockchain could be supporting layers for creating global disease observatories where we could really understand the bigger picture.”
Personalization at scale
Technology is also the key to enabling the healthcare industry to collaborate with patients more effectively in adherence while also meeting all the other parameters required for such initiatives to work at scale, said Penzes.
“The question becomes how to address something that is very complicated in a way that can be simply managed, that provides a good user experience and that is also sustainable for the practitioners. I think we cannot really address this without talking about personalization at scale. At the end of the day when we try to help the individual, we must personalize one to one.”
One promising means of containing the costs of such a personalized approach is new digital tools which hold great potential to offer a scalable way to deliver patient education and collaboration affordably and at scale, said Egbuono-Davies. “We are getting more sophisticated in using digital technology to measure and respond to patient behavior and to augment human intervention at a lower cost.”
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