Non-adherence to therapy is widely recognized as an ever-present problem in healthcare generally and the pharma industry specifically, which forgoes some $250 billion annually in lost sales. The picture is changing, somewhat, from past years, as health systems now have incentives (through Medicare’s Star program of financial incentives and penalties for health outcomes) to improve patient adherence. In the specialty pharmaceutical arena, manufacturers now have substantial incentives to improve adherence and outcomes, through the expansion of value- or outcomes-based contracting.
Leveraging data from off-label prescribing
Patient-support and hub service providers assist their manufacturer clients in running adherence programs, and manufacturers are reaching out to the specialty pharmacies that they work with for assistance as well. For the most expensive specialty products, it’s not hard to justify the expense and effort of “high touch” personal interactions with patients, via care coordinators or pharmacy technicians. The trend now, though, is to use technology to automate some or all of adherence programs, thereby getting better results at lower overall cost.
There are two aspects to the technology trend: developing better analytics to predict patient behaviors during therapy; and establishing a line of communication through the latest digital technologies, notably smartphone apps, to reach patients “where they are at” in their day, or in their patient journey.
“Historically we’ve been very hypothesis-driven around adherence — we create a hypothesis and then a solution and then we measure whether the solution worked,” says John Doyle, [email protected] However, with advances in the breadth and depth of real-world data and real-world experience available today and advanced modeling and machine-learning analytic techniques, stakeholders “don’t necessarily need to start with a hypothesis. We can now look for patterns and then use inductive reasoning and run models to test the impact of newly identified trends.” For instance, he notes that the search for factors impacting adherence should integrate not just the usual healthcare data sources, such as payer and pharmacy databases, EHR and patient registry data, but financial data sources as well (such as de-identified credit scores). “This can shed light on how socio-economic challenges may further impact adherence trends, thereby allowing more-tailored interventions to be created.”
Analytics on EHR data
Adheris Health LLC, a Syneos Health Company, partners with large branded phama companies to deliver targeted adherence-support information and motivational messaging directly to patients and physicians, via the EHR system (at the point of care) and the retail pharmacy (at the point when prescriptions are picked up). Using proprietary analytical methodologies to gain insight into patients’ behaviors, needs, and emotions, the messaging and outreach can be tailored as needed, allowing for improved clinical outcomes and brand performance.
“Today we have insight into more than half of all retail prescriptions written,” says Michael Occhipinti, VP, Analytics. “Working with our EHR vendor partners and retail pharmacy partners, we have direct access to 295,000 prescribers, 197 million patients, 2.25 billion prescriptions per year dispensed from 26,500 pharmacies, so we are able to support the patient through the most critical moments of care to ensure they stay on their prescribed therapy to maximize both brand and patient performance.” He notes that the company routinely use several years’ worth of patient longitudinal data to help decide where and when to intervene with the most appropriate outreach (in terms of messaging and timing) for the biggest impact.
Adheris Health also uses data analytics (and randomized test controls) to assess the effectiveness of any brand-specific outreach efforts, so the adherence-related behaviors of patients exposed to the campaign can be assessed, and the program finetuned going forward, he adds. Using logic that is incorporated into the pharmacy workflow, the company also generates the familiar, targeted drug- and disease-specific messaging printed in the information packet that is stapled to the prescription bag, with messaging that may be related to not only the prescription being picked up, but to other diseases the patient may be managing, as well.
Upwell Health, a company that works primarily with pharmacies and insurers to support patients, makes use of direct shipment, telemedicine and educational support tools, according to Alison Wistner, CEO. Upwell also provides a variety of high-touch, wraparound services, helping patients work with pharmacies and insurance companies to ensure access to all of their medications at the lowest possible OOP costs, and curates and shares informative content, including news, videos, reports and research, through its website, to help patients remain informed and engaged.
The adherence challenge becomes more acute when the condition is asymptomatic and patients “feel fine” without their medications — until an episode occurs — despite the known threat that poor adherence poses to their long-time prognosis and overall health outcomes. “Each solution being explored today has its own strengths and weaknesses, but it’s important that patients arrive at a point where they view taking prescribed medications as an important part of their overall health — rather than a burden,” says Sub Datta, CEO of CompanionMx, a spinoff launched in late 2018 from voice-analysis company Cogito. “If patients are engaged through a more holistic program, they feel empowered as an active and critical part of the process. Then we can meet them where they are through digital applications, clinician dashboards or other interventions.”
CompanionMx’s Companion smartphone app uses voice-analysis technology with weekly check-ins with patients; patented algorithms analyze the voice recording to assess patient status, which can then be shared with a care team. In a preliminary six-month study of more than 100 patients with diagnosed mood disorders, CompanionMx found that 86% of survey responses were taking their medications as prescribed — “a rate that is significantly higher than typical medication adherence statistics for mental health, which is a reflection of increased patient engagement through the platform,” says Datta.
Groove Health offers an interactive mobile app that combines existing healthcare data, patient-generated input and predictive analytics to provide more personalized engagement. The company’s mobile app not only streamlines medication management (with automatic reminders, alerts to potential drug-drug interactions and more), but features an AI-powered chatbot, dubbed Maxwell. “As Maxwell interacts with the patient, it learns more about the patient’s particular barriers to adherence and can respond with tailored content, in order to spur behavior change among patients,” says Andrew Hourani, CEO and Co-Founder of Groove Health. Besides the information forwarded to the patient, the chatbot collects voice data “provides a unique view into the types of barriers the patient may be facing and build a more-detailed profile of that patient so that someone on their care team can take provide tailored support.”
“Human interaction and empathy are the hardest to replicate — you will never really be able to fully replicate a trained medical professional interacting directly with a person,” says Hourani. “But maintaining dedicated staffing is costly, and even if a pharmacist or coach talks to a patient once or twice when the patient is initiating treatment, there will be long stretches of time that the patient has no interaction with that specialist.” For a typical patient living with Type 2 diabetes, “you can count the time spent with a doctor in terms of a few hours in any given year — yet the need to properly manage medications and side effects and symptoms of disease progression is happening every single day,” he adds. “The Maxwell chatbot offers a great complement to that, by collecting and delivering the best information to answer any question that arises for the patient.”
The initial commercial-scale versions of the Groove Health platform have had a disease-specific focus (targeting patients with cardiovascular disease (CVD), diabetes, high blood pressure or high cholesterol) developed in conjunction with several hospital and payer systems, with the specific goal to reduce readmission rates through improved adherence. These drug-agnostic platforms help patients to overcome adherence challenges, no matter what medications have been prescribed. The company is also in the process of developing partnerships with several pharma companies and hub providers to configure its adherence-improvement app.
HealthPrize Technologies has put its money on another behavioral strategy — gamification, an interactive offering that combines education, encouragement and rewards with proven gaming techniques — to improve medication adherence. Gamification-based efforts aim to counteract what behavioral economists call “present bias” — that is, one’s preference for immediate short-term rewards over longer-term (but more nebulous) gains. This is particularly important when it comes to asymptomatic conditions that require a lifelong commitment to therapy yet the perceived long-term gains (say, staving off a heart attack or stroke, or reduce the risk of progressive limb loss or blindness) may seem abstract today. “Because there is little in the way of instant gratification in the lonely, burdensome process of daily medication, apps that are based on gamification aim to provide fast, fun and engaging feedback to overcome present bias,” says Tom Kottler, CEO.
Importantly, gamification has been proven effective with people across all age, gender and education-level demographics, and have been proven across many disease states, drug types and drug-administration routes. “We address medication adherence by addressing the psychological barriers many patients have, and we support habit change by rewarding patients for engaging in healthy activities, such as verifying prescriptions, reporting compliance and engaging with positive educational experiences like quizzes, surveys and videos,” says Kottler.
HealthPrize claims over one million patient users, and half of the top 20 pharma companies as clients.
Dealing with diabetes
Diabetes has proven to be a dynamic therapy area for raising patient adherence. In mid-2017, Roche acquired mySugr GmbH, the creator of a gamification-based mobile app to help patients with diabetes. The mySugr platform already had a million users in 52 countries at the time. Through this partnership, the app is now integrated with Roche’s existing Accu-Chek brand of blood glucose meters and test strips) and other forms of patient support (such as access to advice from certified diabetes coaches). Roche is now collaborating with Novo Nordisk, the world’s largest insulin provider, to integrate dosage information from Novo’s “connected pen” dispenser with Roche’s digital therapy-management platform.
Novo Nordisk also made headlines in 2017 when it partnered with Glooko, a diabetes data-management platform, and IBM Watson Health, to further expand its existing digital health offerings, enabling patients with diabetes to use their smart phones to sync their blood glucose measurements and self-reported activities, and integrates the data with up-to-date clinical content and resources and the company’s personalized support program.
HealthPrize is notable among adherence-technology providers for forging relationships with other parts of the drug-delivery ecosystem, specifically West Pharmaceutical, which manufactures syringe components and full-fledged prefilled syringe systems, WestRock, a compliance-packaging vendor, and Noble, which develops patient-training and education tools.
“Patients who are able to get hands-on practice with auto-injection and inhalation devices not only gain experience and muscle memory, but increase confidence while reducing anxiety about administering their medications at home,” says Joe Reynolds, research manager for Noble. Noble’s Smart Injection Practice Pad is an error-correcting trainer that uses proprietary electronics, smart sensors, audio, LED and tactile simulation to make patients aware of their errors in real time.
In a recent longitudinal study, Noble studied three patient cohorts that received different training stimuli during the14-day “decay” period following initial treatment in the doctor’s office. Among the group that had received no training (only written instructions), 56% made mistakes on critical steps during self-injection. By contrast, those who received basic training (using a resettable autoinjector training device and injection pad plus written materials) with or without an interactive training video, the combination of practice and mental preparation resulted in 100% successful completion of critical steps.
“We’ve put a lot of thought into how we design our training devices, in terms of human factors engineering, how people learn, how they forget and more, so our devices can most closely mimic the patient’s experience at home,” says Reynolds. Today, Noble has more than 30 different training devices on the market (each married to a specific branded therapy), and works closely with many major device manufacturers (including BD Safety Systems and SHL), to develop training devices and materials to ensure proper injection of medications for chronic, acute or episodic (emergency) therapies.