Medication adherence could get an EHR boost

Another year, another batch of studies lamenting the dismal performance of patients on extended medication therapy, such as chronic or longterm conditions. Most recently, the National Center for Patient Information and Education (NCPIE; Rockville, MD) paired up with Prescription Solutions, a Cypress, CA pharmacy-benefit management company (and unit of insurer UnitedHealth) to find that 54% of US adults do not take meds as instructed, either ceasing consumption early, skipping doses, neglecting to get refills, among other actions. Yet 87% believe that prescribed meds will make a difference in their health.

This statistic pairs up well with the generally believed figure that 50% of patients go off therapy by six months after the initial prescription The reasons are not always adherence-related: cost of medicine, changed prescriptions or other factors also play into the process. But the consequences are substantial: An earlier estimate from the New England Healthcare Institute pegged the cost to the US healthcare system of non-adherence, in terms of increased hospital visits, more medical interventions and the like at $290 billion/yr.

NCPIE, having studied adherence for over 20 years, has called it “the other drug problem,” and issued a major report in 2007 calling for a renewed effort to address it (Pharmaceutical Commerce, Nov/Dec, 2007, p. 1).

Pharma companies have long tried to address adherence issues, but the primacy of the patient-physician relationship, and patient-privacy rules have limited industry impact. Pharma companies have routinely employed service agencies to run adherence programs, and occasionally make use of compliance packaging—blister cards and “calendarized” packages, best exemplified by the well-known containers for birth-control pills.

Adherence in a wired world

Now there seems to be a trend to make adherence and medication therapy management almost an automatic feature of drug dispensing. Managed care organizations recognize that better adherence translates into healthier patients and potentially lower costs to client insurers or employer plans. Pharmacies and PBMs are stepping up their efforts, partly for competitive reasons. All of these players are benefiting from the growing digitization of health records, from e-prescribing to full-blown electronic health records (EHRs). The latest trend is to jump on the consumer health bandwagon via the growing number of websites that allow individuals to store their medical records online, as well as to create their own reminders and wellness programs.

In the past several months, several new online services have been launched to catch the wave of interest in consumer-driven health. Google Health, Microsoft HealthVault, WebMD and others allow consumers to store EHRs. Keas.com, founded by Google alum Adam Bosworth, will combine the capability of posting one’s own medical records with access to “care plans” created by healthcare professionals for disease conditions or wellness; the company received funding from Pfizer last month.

It is not clear, however, that the availability of these record-storage and —access functions actually translate into better adherence, or even better overall outcomes. But the theory is that by putting patients in the driver’s seat to manage their healthcare, better adherence should be one of the expected results.

PBMs, which have the combined responsibility of lowering medication costs through bulk purchasing, while at the same time improving health and thus lowering overall costs for their clients (usually, employer-based health plans), have jumped onto adherence as a demonstrable financial benefit. In

At the beginning of the year, CVS Caremark announced that it was switching physicians using its iScribe e-prescribing system over to the EHR system of Allscripts (Chicago; see also p. 22). In a statement, CVS Caremark says that its goals “are to promote savings for the patient, payers and employers; enhance the customer experience at the pharmacy; and improve patient medication compliance which can help improve health outcomes.”

This month, CVS Caremark said it is funding the creation of a Behavior Change Research Partnership with three schools, Carnegie Mellon, Dartmouth’s Tuck School of Business, and the University of Pennsylvania’s Wharton School of Business as well as its Medical School. The researchers will use “behavioral economics and social marketing” to understand better why patients remain noncompliant to their treatment regimens. A previously announced three-year collaboration with Harvard and Brigham and Women’s Hospital to study claims data “to better understand patient behavior around medication adherence.”

Medco Health Solutions (Franklin Lakes, NJ) makes better adherence a centerpiece of a variety of initiatives under its “Smarter Medicine” campaign. Besides combing its claims and prescription data for noncompliance, the PBM has launched a study in January with community pharmacies the state of Illinois, the Illinois Pharmacists Assn. to link its claims data (Medco handles the state’s employee pharmacy plan) with pharmacists who will be in a position to “close the gap” in both prescribed medications and adherence. MirixaPRo, a communications network among community pharmacies sponsored by the National Community Pharmacists Assn, will be the conduit for delivering this information. The pharmacists, in turn will counsel patients and coordinate care with physicians—and be compensated for their efforts.

The University of Illinois School of Pharmacy will provide guidance in appropriate care to pharmacists under the 26-week study. When it is completed, Medco and the pharmacists will hope to show the benefits of closer coordination of care in lower overall health costs.

The Medco and CVS programs show the potential power of wired healthcare for therapy management. From a pharma business perspective, it’s a mixed blessing. The therapy management is one of the ways that PBMs aggressively push the use of generics in place of branded drugs. On the other hand, Medco has recently published a number of studies showing how more energetic therapy management results in higher prescription use for rheumatoid arthritis patients or multiple schlerosis patients using beta interferons, resulting in fewer hospital visits and lower medical costs. The two-year RA study involved Abbott’s Humira (adalimumab) and Amgen/Pfizer’s Enbrel (etanercept); the intervention resulted in 16.0% increase in adherence. That study did double duty: Medco used its Accredo subsidiary to manage the therapy program, and says that the improved health results demonstrate the value of specialty pharmacy as compared to retail pharmacy, where the control group obtained their medication.

Loyalty cards play a role

For manufacturers who want to take a direct hand in supporting adherence, the usual option is to hire companies that have call centers or mail/e-mail programs, run loyalty card programs, or provide co-pay assistance, or perform interventions with physicians. InfoMedics (Reading, MA) has a program called Adherence Driver that combines physician and patient contact. McKesson Patient Adherence Solutions runs a call center and sponsors a loyalty card program that includes automated messaging to pharmacists when prescriptions are refilled. Quintiles’ Innovex division (Durham, NC) has a Health Management Services group that can provide nurse-educator interventions with patients.

A relatively new entrant among pharma service providers is Pleio Health Support Systems (Boston), which started the Pleio GoodStart program for interventions with pharmacists and patients in late 2008. The program has a group of modules that train pharmacists, or produce customized reminder messages that can be delivered by voice, text message and e-mail.

AdherenceRx (Arlington, VA) announced in October a trademarked Patient Adherence Index (PAI) that can be used to score patients’ “activation” (willingness to follow a regimen); using it, an adherence program can be tailored either for relatively simple reminders or more intensive health coaching. The company is partnering with Healthwise (Boise, ID), which specializes in medication therapy management support for providers and health plans.

Packaging and devices

The benefits of providing medication, especially tablets or capsules, in unit-dose packaging—a blister card or case with individualized compartments—has long been recognized; most starter kits or sample packages are in unit-dose form to help guide the new user on the prescriptions’ use, and unit-dose packaging is common outside the US. Many contract packagers provide design and manufacturing services to this end, including Nosco (Gurnee, IL), Catalent Pharma Solutions (Somerset, NJ), Howell Packaging (Elmira, NY), Sharp Corp. (Allentown, PA), Anderson Packaging (Rockford, IL) and MeadWestvaco Healthcare Packaging (Richmond, VA).

Keystone Folding Box Co. (Newark, NJ) recently introduced its KeyPak folding carton, which employs a relatively simple, inexpensive design with security features that make the carton both “senior friendly” and child-resistant—criteria that are mandated by the Consumer Products Safety Council for pharma packaging. “In healthcare sectors around the world, this patented package affordably addresses the goal of directing today's patients toward improved adherence/compliance,” says Ward Smith, director of marketing. The KeyPak, long used in clinical trials, has just won a client for commercial use for a steroid product.

Catalent recently introduced a security feature for its compliance packaging customers in partnership with Digimarc, a product security firm (Pharmaceutical Commerce, Jan/Feb, p. 34). The technology employs an optical pattern which can be authenticated once the patient takes a picture of the package and visits a website that would be set up by the product owner, which in turn opens up a line of communication between the patient and the product owner. Eric Caro, business development manager at Catalent, calls the application “media enhanced packaging” that can change the dynamic between patients and pharma manufacturers.

Even product returns or disposal can create such a communications channel. Sharps Compliance (Houston) announced an expansion of its “Disposal By Mail” program late last year that involves patients disposing of syringes and sharps with a mail-in container (similar to the medical waste containers at physicians’ offices). The company says that it will set up datagathering system to track returns back to a patient; if no returns show up, that can become an opportunity to communicate with the patient.

Behind measures like these is a large and growing movement to connect medical devices and diagnostic monitors at patients’ homes (or on their person) with healthcare providers. The Continua Health Alliance (continuaalliance.org), an industry-led consortium to develop communication standards around these devices, now has over 200 members (Pharmaceutical Commerce, (October 2009, p. 7). Their vision is a combination of diagnostics and communication devices (portable and stationary) that would enable patients to be monitored for their medical conditions on a near-continuous basis. Manufacturer input (or access) to these communications remains to be worked out, however.