As regulatory hurdles increase and product pipelines shrink, pharmaceutical companies must identify new revenue drivers to maintain growth. Addressing patient non-adherence and thereby improving health outcomes, seems like a popular answer to the problem, yet improving patient adherence is an incommodious task.
As per a 2013 study by 'Cutting Edge Information', pharma companies in the US alone are trying to fight non-adherence costs of more than $290 billion, as almost 50 per cent of patients in the US don't take their medications as prescribed. Considering the socio-economic condition of patients in India, we can safely assume the non-adherence percentage to be higher in the emerging economies.
Let's take an example of patients with Type-2 Diabetes, who do not produce enough insulin to convert blood sugar (glucose) into energy, causing glucose levels to build up in their body. Effective management of Type-2 Diabetes, which includes up to 90 per cent of all diabetes cases, usually involves a multi-pronged approach that includes drug therapies and lifestyle changes. The challenge for primary care physicians (PCPs) is getting patients to adhere to the plan. A recent study in The New England Journal of Medicine found that between 33 per cent and 48 per cent of Diabetes patients did not meet targets for blood pressure, glycaemia control, or low-density lipoprotein levels.
Without making the article too scientific, let's explore what are the reasons for patients not adhering to the prescribed dosage:
a. Drug companies have limited direct contact with patients, compared to payers and pharmacists, and have struggled with how and when to intervene to make sure patients take their medications
b. All the patients don't really understand the value of adhering to the prescribed dosage of drugs by their doctors
c. Patients' inability to adhere to the prescribed dosage for genuine reasons such as forgetfulness etc.
d. In some cases, even the cost of medicines / treatments, make the patients not take medicines, as soon as they start feeling little better
e. Some patients even claim that their doctors don't spend enough time, explaining them about the requirements and importance of completing the full dose
Interventions have mostly centred on free drugs, reminders, or lower co-pays. But in Western European countries, such as the Netherlands, where medications are fully covered, adherence is still a major issue. We are yet to witness a winner, that is Made-in-India but, globally, a few companies have come up with innovative business ideas to tackle this issue.
Using reward mechanism (GAMIFICATION): Digital health start-up HealthPrize, rewards patients frequently and in small increments. It is working with patients recruited in collaboration with the pharmaceutical companies, and links its site to co-pay cards offered by drug companies through doctors. Patients who respond to reminders receive a variable number of points; they score additionally for engaging in educational quizzes pertaining to their disease. Patients receive the bulk of their points at refill, and rewards are determined by the pharmaceutical company. They can range from an Amazon to an iTunes gift card.
Using Predictive Algorithms: Another start-up RxAnte uses predictive algorithms to help its clients-pharmacy benefit managers and Medicare plans, hone in on patients, most likely to stop taking their prescriptions. RxAnte has drilled so far through a few years of claims data, such as age, sex, race, and clinical history, and assigned individual patients a score which predicts their likelihood of adherence.
Hardware-centric vs. software-only: Developers in the adherence space tend to break down the market into- a) software-only offerings (really cheap and marginally effective) like Smartphone apps and b) hardware-centric offerings, like smart pill bottles and caps, which are more expensive. Trials of hardware solutions, have shown increased adherence than a pure software play. Software solutions are much easier to scale, allowing them to target larger patient populations and to be rolled out more cheaply and easily. But, the biggest problem with software solutions is that using an app isn't part of the normal process of taking a pill. It's an added behaviour, which means to start using it requires a behaviour change.
Co-creation with the pharmaceutical companies, instead of developing solutions in silos:
a. AdhereTech's (smart pill bottle-maker) first pilot focuses on HIV medication, which is expensive, often complicated, and can be a matter of life or death for a patient.
b. Care4Today's (of Janssen Healthcare) new app wants to allow the user to track even vitamins and bottled water. Pharmaceutical companies are unlikely to subsidize that kind of adherence, but consumers might pay a little for it.
c. Ai Cure- a software company that uses a mobile device's webcam to interact with a patient and make sure they're taking their medication- has an advantage with drugs for mental illness.
Ai Cure and AdhereTech are taking different approaches technically, but they both boil down to monitoring a patient's medication behaviour in order to change it through outside motivation. That's been the pattern for a long time, and companies with those sorts of approaches do have some success. I believe, companies shall focus on two areas- a) creating a hardware + software mix solution and b) co-create with the pharma companies, with focus on some therapeutic area(s).
a. Nightingale takes in data from all kinds of consumer devices like Fitbit and Jawbone and combines that data and GPS data from the phone, with a medication tracking calendar. E.g. it learns that a patient takes his medications when he gets to the gym every single day. Nightingale will set up a GPS alarm so if the patient goes to the gym at six one morning or ten another morning, the alarms come in at the right time.
b. CyberDoctor's PatientPartner app that make patients think more about the effect taking their medication has on their overall health by playing through a role-playing game. A small clinical trial showed it increased adherence from 58 per cent to 95 per cent, just even three months after patients used the app.
In my personal opinion, there are a few critical questions companies need to ask before devising successful adherence processes- Are the drugs expensive? Is it extremely critical that patients take their drugs? Are there major negative consequences when patients don't take their drugs? Have the prescribers clearly understood the required dosage? Are the windows for taking these drugs rather tight?
There's a place in the market for a wide variety of adherence approaches, be it apps, smart bottles, smart caps, or smart pills. As it appears, if non-adherence is essentially a behaviour change problem, that's something of a catch-22 and it is in the hands of the patients to feel and decide to change. Companies that succeed will show value to patients above and beyond making sure they take their pills.