Increasing medication compliance can save money where it doesn’t hurt
Medication non-compliance by patients is a huge issue for the healthcare sector. This article focuses on the role of digital health tools to help reduce medication non-compliance, thereby saving a lot of money.
A large problem and huge cost savings potential
A large study1 estimated that in the US some 3.8 billion prescriptions are written every year, yet over 50% of them are taken incorrectly or not at all. Even among chronically ill patients who regularly fill their prescriptions, only about half the doses taken are taken as their physicians intend.
Among many similar surveys, the American Pharmaceutical Revue performed an analysis based on surveying 800 American adults2. While the numbers between the different surveys are slightly different, the number of non-compliant patients is uniformly stunningly high. The cost implications of non-compliance are a severe burden to the overall healthcare expense.
The New York Times3 says nonadherence to prescribed medications is “an out-of-control epidemic” in the U.S. and quotes a review in Annals of Internal Medicine, which found “20-30% of medication prescriptions are never filled, and approximately 50% of medications for chronic illness are not taken as prescribed.”
For example, “a third of kidney transplant patients don’t take their anti-rejection medications, 41% of heart attack patients don’t take their blood pressure medications, and half of children with asthma either don’t use their inhalers at all or use them inconsistently.” Many reasons for nonadherence were discussed — aversion to chemicals, a desire to do things “naturally”, pills represent reminders of sickness, self-experimentation with stopping medications and noticing no change in perceived health, and drug costs.
Using estimates for the Swiss healthcare system, the cost share of chronically ill patients is close to 80%. In Switzerland, 2.2 mio. patients are chronically ill.4
On average, non-compliant, chronically ill patients cause 4 times the cost per patient compared to perfect compliance. This would amount to 52’000 CHF instead of 13’000 CHF per year. Even if just 5% of the chronically ill patients – in other words 110’000 – became compliant, it is estimated that the cost savings would amount to almost 4 billion CHF per year. This could reduce the overall healthcare bill by almost 5%.
Drugs don’t work in patients who don’t take them. The most expensive pill is that which is not taken or taken inappropriately.
C. Everett Koop, M.D.
Better information of the caregiver about his/her patients’ compliance helps guide the therapy
To better explain another practical issue with poor patient compliance, let u use an example: A patient presents with a disease at his physician’s office. Based on a couple of tests, clinical data, and using his/her experience, the doctor decides to start the patient on a specific therapy. For this purpose he/she writes a prescription. However, what if the patient never picks up the medication at the pharmacy? What if he/she picks it up, but then often forgets to take the pills? What if the disease burden diminishes and causes the patient to stop taking the pills against his/her doctor’s advice?
In this situation, patients would often not, or not fully, benefit from the prescribed therapy. Not only do they remain ill and cause more costly interventions – it is also not possible for the caregiver to judge on the medication’s effect on the patient. If the treatment is not effective because the patient was not compliant, the caregiver will likely decide to take the patient off the treatment, thereby forgiving a chance to keep an effective treatment.
Compliance is largely a function of the disease category: While cancer patients more often stick to the prescribed therapies (80%), smoker’s lung patients are only around 50% compliant. The difference is largely due to the more severe immediate threat of disease progression, but also the way of administration (hospital versus self-administration).
So why? Top reasons for medical non-compliance
The most common reasons given by patients for not taking their medications are forgetfulness (30%), other priorities (16%), deciding to omit a dose (11%), lack of information (9%), and emotional reasons (7%); 27% of patients give no reason. The risk of nonadherence is especially high when multiple predisposing factors converge, such as cognitive impairment and the use of numerous medications for multiple chronic conditions in the elderly.5
Digital solutions to increase medication compliance
One of the first tools is the notification of the prescribing physician whether the patient has in fact picked up the prescription at a pharmacy or failed to do so. Because about 25% of prescriptions are not even filled6, this information could prove to be a more valid basis for further treatment and patient interaction.
In addition, there are a couple of simple but very useful digital solutions which help enhance the information exchange. Because forgetfulness is the major factor in medical non-compliance, tools that remind the patient can be very helpful.7
- Smartphone apps
- E-mail and text notifications
- Remote monitoring devices
- Patient portals
- Smart pills
Smartphone apps provide a way for patients to consolidate health information and to manage their health, and alerts remind the patients. Because many patients carry their smartphones with them, they can easily access the information. Remote monitoring devices can provide a valuable feedback on the treatment progress and give early signs in case the treatment is not working for this patient. Patient portals are also very important. If optimally informed about a treatment, patients are often willing to be more engaged in their own treatment compliance.
The new digital solution: Smart pills
Smart pills equipped with sensors and cameras are in the early use stages to help with diagnostics and administer medications. Ingestible sensors and electronic pill bottles or boxes can record when patients ingest a medication or open a medication container and remotely monitor their adherence with more granularity. For example, the time a patient actually takes the medication can be time stamped, providing a remote version of directly observed therapy.
The first smart pill has just recently been approved by the U.S. regulator.8 It is important to note that the patient has to agree to the smart pill version. However, there are diseases where patients are well aware that medication compliance is necessary, and they want to ensure themselves that they are compliant at all times.
We believe the rather poor patient compliance with its huge cost implications has to be addressed on many fronts. In order to have a valid basis for further treatment, but also to address patient’s concerns, the hurdles to compliance have to be addressed and corrected. Digital health solutions can offer a variety of tools to increase the necessary information. The most prevalent of the reasons behind medical non-compliance, like forgetfulness, are well possible to tackle by technological means. Others, like skepticism on the treatment by the patient will require more explanation and interaction from the physician’s part – but it is still crucial to have a better idea about whether the patient was likely compliant or not to detect the issue.
In the past, many patients would not dare to have an open discussion with their physician – which often meant to either not pick up the medicine or, pick it up but then not take it or even throw it away. It is very clear that this behavior is far from being optimal, whether from a medical nor from a cost point of view. Many patients wish to be more compliant, but often their disease interferes with compliance. The digital health tools are meant to help them to reach the treatment goals, and thereby also lower the healthcare cost – and not an undue interference with their private sphere.
In the future, we think a more thorough and balanced discussion with the caregiver will be possible with the use of digital health tools.