The healthcare world is radically changing and, in the immortal words of Theodore Roosevelt, “The worst thing you can do is nothing”. Pharmaceutical companies need to evolve into delivering services ‘beyond the pill’. Services that add real value for healthcare stakeholders – solving payers’ needs to create long-term partnerships, improve health outcomes and enhance doctor-patient relationships.
These services are entwined with the need to enhance market access with a customer who has dramatically changed. What is the service that has the greatest potential to deliver against these criteria? The answer is patient adherence.
Why patient adherence?
The momentum for change has been building for several years, starting with the European Parliament launch debate in 2011, during which the European Patients Forum, the Standing Committee for European Doctors, the Pharmaceutical Group of the European Union and the European Federation of Pharmaceutical Industries and Associations called for concrete EU-level action for better adherence to therapies. In November 2012, IMS Institute for Healthcare Informatics and the World Health Organization were invited to contribute preparatory material for a Health Ministers Summit. The Responsible Use of Medicines: Applying Levers for Change modelled data from 186 countries and identified that, as cost containment was a key concern for health ministers, the opportunity lay in improving medication adherence in order to optimise overall healthcare and then reallocate avoidable costs to address other healthcare needs.
In the UK, the new NHS structure is now in place, and in May 2013, the Royal Pharmaceutical Society recognised the importance of medicines optimisation with the publication of a good practice guide, which sets out four principles to help healthcare professionals support patients to improve their quality of life and maximise health outcomes from the better use of medicines:
- Understand the patient’s experience
- Choose medicines based on the best available evidence
- Ensure medicines use is as safe as possible
- Make medicines optimisation part of routine practice.
This guide not only informs the practice of front-line healthcare professionals but is also expected to be used in the development of local care pathways and services. It recognises that support for medicines use may be needed at different points in the patient pathway and ensures that there are opportunities for discussions about a patient’s medicines with the patient or carer, between healthcare professionals and when patients move between care settings.
The report, which is endorsed by NHS England, Royal College of General Practitioners, Royal College of Nursing and the Association of the British Pharmaceutical Industry, states that “[t]he pharmaceutical industry has a key role to play in the new NHS through transparent and value-for-money partnerships that help secure better patient outcomes”.
The mounting financial pressure on healthcare systems indicates a pressing reason why the focus on adherence is so important. The annual drug bill for the NHS is £13.8bn per annum and it is conservatively estimated that at least £300m of treatment prescribed in primary care is wasted. Only 16 per cent of patients who are prescribed a new medicine are taking it in line with their healthcare professional’s (HCP’s) advice, experiencing no problems and receiving as much information as they need. Research shows that 10 days after starting a medicine almost 33 per cent of patients are already non-adherent, and explains why the total cost of non-adherence in the UK is estimated at £0.5bn annually.
Continuum of care business model
In this environment, payers expect more. They are putting pressure on the traditional models of business – pharma reps selling to script writers – and are increasingly expecting pharma to deliver a continuum of care model that delivers real value to stakeholders (payers, regulators, physicians, and patients). This model is still based around product, but focuses on working in new partnerships that address prevention, diagnosis and treatment. This new way of working requires new tools and capabilities and real world data to justify the economic and clinical value of prescription products.
Historically, pharma has focused on the acquisition of new patients, with the lion’s share of marketing budgets being spent on growing the market. Patient retention strategies have been poor cousins and yet in other sectors the model of keeping customers loyal – particularly evident in the retail sector – is highly advanced. After all, the average cost of acquiring a new customer is 5-10 times the cost of retaining an existing customer. Indeed a recent Gap Gemini study showed average adherence levels drop over the course of the patient journey from 69 per cent of patients filling their first prescription to 43 per cent continuing their treatment as prescribed after 6 months, leading to a potential 59 per cent revenue loss as a result of non-adherence.
To provide services that go beyond the pill, pharma requires a solid understanding of the local healthcare system; needs to create new business models; implement new cultures; and establish service-based structures. They need to build patient-centric services that improve health outcomes and support the HCP to manage their patients more effectively. Senior level stakeholder engagement is essential to elevate the importance of adherence and this should evolve at the formulation stage of drug development. Instead of silo working, market access teams, medical affairs and R&D teams need to be aligned at an earlier stage to support the securement of win-win partnerships with payers and to develop long-term relationships that continue to evolve.
Payers are typically looking for two types of partnership: the first is where pharma proposes a pre-formed project to improve health outcomes. This often takes the format of providing medication adherence programmes, homecare or nurse-based solutions. These types of programmes can support market access and demonstrate a commitment from the pharma company to go beyond the pill. The second type is a co-creation project, which often takes longer to set up, but is bespoke and addresses a locally defined problem. This opens up interesting opportunities for pharma to gather and demonstrate real world evidence outcomes, through local healthcare partnerships. As one commissioner told me recently: “We need to partner with pharma to buy eyesight, not one specific product.”
In this environment, payers expect more and they’re putting pressure on traditional models of business
One-size-no-longer-fits-all
Over the last few years there has been a paradigm shift in the belief that a patient adherence or support programme is a ‘nice to have’, with implementation of this strategy involving a one-size-fits-all range of tactics that educate the patient about his condition and treatment, training tools for the administration of the treatment and reminders about his medication timing and dosage – usually through pill boxes, websites or printed materials.
A good example of how this has changed can be seen from the success of altering the ways patients are taught to use their treatments. One of our clients produces a self-injectable product and was experiencing problems with patients administering their doses incorrectly. A simple review of the ‘patient-friendly’ materials showed that patients simply found the instructions too complicated and, because they also included a mini life story, were also finding the role models difficult to identify with. Our solution was to focus on the simplicity of the injection process, making it a step-by-step activity and to film it in a style that made the patients want to revisit the videos. The films were tailored to the average demographics of each type of patient but only revealed the person using the medication at the very end, thus avoiding the potential for the patient to disconnect from the training right from the start.
Historically it’s been very difficult to measure return on investment (ROI) on these types of one-size-fits-all programmes – with the reliance on patient reported outcomes.
Evidence-based behavioural change tools
Today, our adherence programmes utilise sophisticated clinical psychology techniques to support long-term behavioural change among those patients who are at the highest risk of non-adherence. Evidence-based behavioural change tools are used to screen patients to identify not only their risk of discontinuation, but also their beliefs and attitudes towards their treatment and condition. Targeting those high-risk patients with personalised communications, utilising cognitive behavioural therapy and motivational interviewing techniques, to address those beliefs, is proven to change treatment behaviour and maintain that behavioural change.
To have real behaviour change you need to understand three basic things about your patient:
- Barriers: What is stopping them from adopting the new behaviour?
- Triggers: How can you get them to start a new behaviour?
- Motivators: What will help them continue with the new behaviour?
Why is this necessary? Correctly adhering to a medication (or indeed any health-based lifestyle change) is an intentional behaviour. How often have you promised yourself you’ll start a new fitness plan only to procrastinate or quit after a few months?
Patients with asymptomatic conditions, such as osteoporosis, type 2 diabetes, hypertension and cholesterol disease often don’t see an effect or outcome from their treatment. If they feel well and the medicine makes them feel worse, why should they take it?
The three most commonly cited reasons for primary non-adherence are general concerns about taking the medication (63 per cent), a decision to try lifestyle modifications (63 per cent), and fear of side effects (53 per cent). One GP recently told me that during his consultation with an elderly patient, she had spent two minutes listening to his advice about the new treatment he prescribed and five minutes trying to negotiate with him as to why she shouldn’t take the prescribed treatment in the dosage and timing he had recommended. Like you and I, patients have their own views, beliefs and attitudes regarding their disease and treatment and, because of this, require personalised support to adopt new behaviours and habits.
Personalised care also brings with it the ability to truly measure ROI. One of our adherence programmes engaged with patients taking an antidepressant drug. The client was concerned that there was a 74 per cent discontinuation rate after six months on treatment. Utilising a mixture of tools, motivational interviewing and cognitive behavioural therapy techniques, driven by a nurse-led call centre, we demonstrated significant behaviour change and ROI by reducing this to 31 per cent.
To support improved market access different weighting should be placed on evaluating a drug earlier in the development cycle to consider the implications it will have on adherence and outcomes and ensure those benefits are communicated to payers. An adherence programme that we are currently delivering across multiple countries has been written into hospital protocol in one market with patients on the treatment automatically being enrolled on to the supporting programme.
Without real world data on medication adherence and clearly differentiated health outcomes, payers will focus on the cheapest treatment option or the treatment that truly does go beyond the pill.
