by Clay Keene, Vice President
Medication adherence represents an ongoing clinical and financial challenge within the healthcare continuum. The clinical outcomes and costs associated with medication non-adherence has been long-recognized, with literally thousands of articles on the topic. This is especially true for individuals with chronic illnesses that require long term medication therapy. For the purpose of this discussion, the terms patient, member and individual can be used interchangeably, and barriers to medication adherence will be placed under three broad categories: (1) Concrete barriers belonging to specific, actual things (convenience, lack of transportation, language preferences, cost); (2) Cognitive/Behavioral barriers involving conscious intellectual activity (mental attributes, education, religion, feelings, thoughts, and beliefs); and (3) Psychosocial barriers, involving both psychological and social aspects (the “outside” and “inside” struggles of the individual). None of the categories are mutually exclusive, and most often medication adherence barriers involve a combination of factors.
While a tremendous amount of focus has been placed on addressing the first category, the second and third can be overlooked or not weighted equally. This is perhaps because concrete barriers are generally easier to identify, measure, and successfully address. The psychosocial and behavioral components contributing to non-adherence are often insidious, subconscious, and difficult to identify. This can be further complicated by the interpersonal relationship (or lack of) between the patient and provider.
One example of an underlying cognitive/behavioral barrier is the “I don’t trust Western medicine, or doctors, or insurance companies”, often leading to the “I know better” psychological construct. This can drive determination to “show them”, heal a chronic illness “naturally”, or turn to “Dr. Google” for answers. Psychosocial barriers can present when a patient generally wants to comply with medication instructions but struggles due to extenuating circumstances or life challenges (childcare, eldercare, divorce, poverty, loss of job, complexity of managing co-morbid conditions, mental illness, etc.).
To address the issue of medication non-adherence, many health plans have invested significantly in Medication Therapy Management (MTM) services, leveraging nurse/case manager interactions to optimize therapeutic outcomes. For MTM programs to achieve their objectives, it is imperative that the models include a baseline of consistent, honest, and healthy communication that extends beyond the case manager and patient phone interaction to the direct relationship between the patient and the provider (medical provider and pharmacist). To get there, we must address the “elephant in the room”: the patient’s perception of the provider, and more specifically, the provider’s perception of the patient.
Patients, even those with the same chronic illness, present with unique challenges. Not all providers possess the same level of interpersonal skills to assist with overcoming these life challenges. The clinician, especially doctors and pharmacists, cannot be faulted, as most are not trained or are minimally trained on how to understand the patient’s psychosocial systems that drive their behavior. With that said, any provider deficits should be identified and ameliorated to allow the best opportunity for success. This requires that the provider objectively evaluate their own interpersonal skills and ability to build relationships and seek training if needed. For some outpatient settings, onsite nurse case manager or social worker engagement and coordination may be available. There are also online resources for providers, such as https://www.physicianreferralmarketing.com/physician-sensitivity-training/ and https://www.patientbond.com/psychographics. Please contact your Excelsior solutions associate for assistance in identifying a training tool that would best benefit your organization.
It is important to keep in mind that each member is unique, and in our effort to address the issues around medication non-adherence, it is key to recognize that many patients present complex underlying challenges. Successful intervention requires routine, focused interaction by the providers to gain a more comprehensive understanding of the issue. For MTM to have the best chance of success, a multifaceted systems-based approach to understanding the individual, their immediate challenges, and ability to comply is needed. An essential component is having providers committed to identifying any interpersonal skill deficits and obtaining the necessary training that will help foster deeper patient engagement. Striving to build a provider/patient relationship based on trust and communication without judgement is vital to positive and effective interactions. Investing in this effort can offer a more comprehensive approach to helping the individual successfully achieve sustained adherence and optimal outcomes.
Clay has over 25 years of experience in health care, with a focus in the areas of specialty pharmacy, managed care, government drug pricing and health policy. Clay’s expertise includes pharmaceutical care management, integrated delivery network coordination, behavioral health care, specialty pharmacy optimization and strategy, and federal discount drug pricing (340B) administration and oversight.
Prior to joining Excelsior Solutions, Clay was the vice president of managed care and client services at ReCept Healthcare Services, director of business development at CVS Health, director of strategic planning and policy in the New York City Mayor’s Office, independent health care consultant to federal health care grant recipients, and the national director of sales and marketing for Stadtlander Drug Company.
Drug Prices Will Soon be Seen in TV Ads How Will Patients React?
by Barb Hawes, Vice President
On May 8, 2019, HHS (Health & Human Services) finalized the first rule of the American Patient First blueprint which aims to increase transparency for patients and bring down overall drug costs. DTC (Direct-to Consumer) television advertisements for prescription drug and biological products paid for by Medicare or Medicaid will soon include the list price if the list price—the Wholesale Acquisition Cost—is greater than $35 for a month’s supply or the usual course of therapy, with the prices updated quarterly.
DTC drug ads started on TV in the United States in 1999 when the Food and Drug Administration (FDA) finalized guidelines that reduced the requirements on side effect statements. Since then, spending on DTC ads skyrocketed. According to JAMA¹, from 1997 to 2016 spending increased from $1.3 to $6 billion for DTC prescription drug advertising. According to FiercePharma, TV ad spending alone was $3.7B in 2018. Humira lead the pack with $375 million spent on 18 commercials.
Although there is some debate about how relevant list price is to consumers, HHS shares these statistics about patients who either pay list price or pay prices calculated based on list price.
- 47 percent of Americans have high-deductible health plans, under which they often pay the list price of a drug until their insurance kicks in.
- All seniors on Medicare Part D have coinsurance for certain types of drugs, which means their out-of-pocket expenses are calculated as a share of list price.
- List prices are also what patients pay if a drug is not on their insurance formulary, and list prices help determine insurance plans’ placement of drugs on their formulary.
Before the new rule could be finalized, PhRMA (Pharmaceutical Research and Manufacturers of America) member companies announced their own voluntary commitment to providing more transparency about medicine costs in direct-to-consumer (DTC) television advertisements. The companies pre-emptively pledged to include information about medicine costs – including the list price of the medicine, out-of-pocket costs or other context about the potential cost of the medicine and available financial assistance.
In March of 2019, Johnson & Johnson’s (J&J) anticoagulant Xarelto became the the first-ever TV drug ad with a list price included. The company tweaked two already-running ads to add Xarelto’s $448 list price at the end of the spot, along with a range of typical out-of-pocket costs. J&J is not entirely alone in its TV ad strategy. Eli Lilly, for instance, began adding on-screen link referrals in January to its dedicated pricing website in TV ads for drugs including Trulicity and Emgality.
The conversation continues regarding the pros and cons of including list price with prescription drug advertising. The hope is that if patients are more aware of drug costs, they will price compare and move to lower-cost options that provide similar clinical value. Pharmaceutical companies will have to compete, and price and costs will lower. However, although many Americans pay a cost related to list price for their prescription medications, many do not. The disclosure of list price could further confuse an already complex system. One concern raised by PhRMA is that patients might avoid seeking treatment altogether if they see a very high list price without understanding the list price is not what they would ultimately pay.
Although debate continues, the final rule is set to go into effect 60 days after it was published in the Federal Register.
What do you think about list price being included in drug advertising? Is this an opportunity to educate patients on the real cost of drugs or will this bring further confusion to an already complex topic?
Please let your Excelsior Solutions pharmacy team know if you would like additional information or
conversation on this topic.
¹JAMA. 2019:321 (1):80-96 Medical Marketing in the United States, 1997-2016
Barbara Hawes, RPh, MBA
Barbara has over 20 years of experience in the pharmacy industry and spent eight years at Aon Hewitt as the pharmacy practice director prior to joining the Excelsior Solutions team. Barbara earned her master’s degree in business administration from DePaul University and a bachelor’s degree in pharmacy from Purdue University. Additionally, Barbara is a registered pharmacist in the states of Indiana, Illinois and Georgia and is an active member of the Academy of Managed Care Pharmacy.