What do you think is the most common topic that comes up when physicians complain about their patients? According to a 2011 Consumer Reports survey of physicians, noncompliance with medication and other treatment recommendations was number one.
I can understand that. Non-adherence is a demoralizing problem for physicians. Think of all that effort on diagnosis, clinical decision-making, and education going to waste because the patient decides not to fill the prescription, or quits after a few weeks, or takes it only sporadically. As former Surgeon General C. Everett Koop famously quipped, “drugs don’t work in patients who don’t take them.”
It turns out that not only does non-adherence rank as physicians’ number one complaint, it is also one of healthcare’s number one problems.
In 2009 the New England Healthcare Institute estimated that poor compliance with prescription medication is the root cause of $290 billion in “otherwise avoidable medical spending” in the US per year. That’s a staggering number, but it makes sense if you think about it.
Heart attacks and strokes, for example, are very expensive, but largely avoidable if you control known risk factors with lifestyle modifications and medications as needed (which are dirt cheap by comparison to other popular drugs).
I can’t tell you how many times, as a neurosurgeon, I admitted a patient to the ICU with a classic “hypertensive bleed” in the brain, only to find out that the patient hadn’t been very good about taking his or her blood pressure medication over the years (as regretfully disclosed by the spouse or adult child).
Before you jump to the usual conclusion that the high cost of medication is the driver here, let me tell you that it is not, at least not for most people. Look at countries in Europe where medications are essentially free to its citizens, like the Netherlands. They have the same adherence problem. Or, look at a recent New England Journal of Medicine publication that stratified post-myocardial infarction patients into two groups upon discharge: (1) a control group, in which patients paid their usual out-of-pocket co-pays for their cardiac-related meds, and (2) a “free medication” group; i.e. no co-pays required. The “free medication” group demonstrated adherence rates only 4 to 6 percentage points higher than the control group (whose adherence rates were only 36 to 49 percent–and this was after an MI!)
It’s not a cost problem. It’s a value problem, and a fundamental human nature problem. A common quirk of human nature, across educational, income, and cultural stratifications, is that short-term rewards are favored over long-term rewards. Chronic medications typically offer long-term rewards, and those rewards (like stroke prevention twenty years down the line) are often too abstract to provide sufficient motivation to take a pill this morning and the next morning (we have written about this topic previously). Plus, we often suffer from a failure of imagination. (What would it actually be like to live with a stroke?)
On top of all that, medications tend to make you feel old, or remind you that you are a “patient” with a “condition.” All of these deeper psychological barriers end up leading to irrational behavior, like a patient stopping his valuable blood pressure medication even though he knows the goal is to prevent a heart attack and can afford the $30 co-pay (and spends more on his cable bill each month).
So how do you fix this fundamental human nature problem?
I don’t think non-adherence can be fixed, per se, but I am confident that technology combined with innovative thinking will be able to make a dent in the problem, and hopefully a sizable dent.
Now that we understand the problem better, and realize that traditional co-pay discounts, reminder systems, and education alone can’t accomplish enough or topple the most relevant psychological barriers, I believe that Internet and mobile connectivity, combined with intelligently designed short-term rewards inspired by the “patient as consumer,” can go far.
So yes, “mobile health” and “digital solutions” will most definitely play a role in improving medication adherence, enhancing clinical outcomes, and lowering healthcare costs. However, that role will prove successful only if the technology is informed by a deep knowledge of the adherence problem in combination with a fresh perspective on how best to inspire the human being at the center of it all.
About the author
Katrina S. Firlik, MD is Co-Founder and Chief Medical Officer of HealthPrize Technologies. Prior to founding HealthPrize, Katrina was a neurosurgeon in private practice in Greenwich, Connecticut, and on the clinical faculty at Yale University School of Medicine. She is also the author of Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside, published by Random House.