Whitepaper: Improving Patient Adherence by Combining Medical Education and Telecommunication Technologies

A novel and timely approach to improving health outcomes.

The Problem: The Root Causes: The Economics of Patient Adherence: Overcoming Barriers What to look for in a Solution: MEMOTEXT personalized adherence interventions in practice Summary: EndNotes

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By Amos H. Adler M.Sc. MEMOTEXT Corporation

MEMOTEXT Personalized Adherence Interventions Toll Free: 1877.636-6898 Tel: 647.430.8233 Fax: 416.946-1088 www .me mot ext. com

The Problem:
Medication non-compliance costs North America more than 100billion dollars and 125,000 lives every year.i Non-compliance: A failure or refusal to adapt ones actions to prescribed treatment regimens and lifestyle changes. This problem costs entire healthcare systems, employers and numerous health related industries tens of billions of dollars each year. Using media and education relevant to the patient, solutions using the optimal mix of patient involvement, education and technological support are now possible. Non-compliance (aka non-adherence) impacts all levels of health management, from treatment effectiveness to unnecessary hospitalizations. In addition, high expenses and lost revenues for payers, pharmaceutical companies, pharmacies and employers have a material effect on the healthcare system, payers, the insurance industry and the economy itself. Figures outlining the losses to pharmaceutical sales alone due to unfilled prescriptions range from $25bn to $30bn annually.ii It is also estimated that almost six percent of all hospital admissions are due to failed patient adherence. iii Research indicates that 70% of all prescriptions are never consumed and 20% of all new drug prescriptions are never filled the first time.iv For some disease states, adherence rates are as low as 10-20%.v

The Root Causes:

Patient adherence has been a topic of research for decades. Although no root cause is shared by all patients, scientists have uncovered a number of factors that contribute to non-compliance, including: Low Perceived Benefit Ignorance (condition and purpose of the treatment or therapy) Stakeholder Communication Barriers Adverse Side Effects Failure to Remember Financial Constraints Cognitive Impairment Lack of Motivation

As such, multifaceted but highly personalized approaches work best to overcome non-compliance. Individual preference, age, knowledge level, disease state and motivating stimuli should be considered when designing a solution. Rather than approaching adherence as an authoritarian or Direct-To-Consumer (DTC) marketing initiative, it is important to approach patients as partners in their health care, raise awareness, education, inform, encourage and reward them according to their individual circumstances.

MEMOTEXT Personalized Adherence Interventions Toll Free: 1877.636-6898 Tel: 647.430.8233 Fax: 416.946-1088 www .me mot ext. com

The Economics of Patient Adherence:

The economics of adherence are comprised of three main elements. 1. 2. 3.
Economics of Adherence Preventive Treatment Revenues

Healthcare System Burden Productivity Costs Lost Revenues

1. Healthcare System Burden Achievable savings and cost efficiencies derived by improving patient adherence levels include the costs associated with preventable hospital inpatient admissions, emergency room visits along with the preventable insurance and payer costs all made available by low cost technologies. Non-adherence is very costly as third party payers reimburse patients for unused medication and then pay again to help patients who did not take their medication. Preventive treatment is far less expensive than hospitalization. The total cost of diabetes alone has been estimated at $132 Billion per year. It is estimated that per capital medical expenditures for individuals with diabetes alone were $13,242 annually.vi Telephone based intervention programs for patients with cardiovascular disease have shown reductions in inpatient admissions by 40% as well as reductions in emergency department visits by 73%.vii The cost of non-adherence represents almost two percent of US hospitalization costs and accounts for approximately six percent of all hospitalizations.viii The potential savings made available by improved adherence are in the magnitude of $80bn in the US alone. ix 2. Productivity Costs The social costs of adherence include resource wastage, lost productivity, absenteeism in the workplace, and the burden on the economy of disability and other indirect costs. Benefits available through improved adherence are linked to savings achieved by reducing absenteeism, reduced travel times and maintaining productivity. Cost estimates for payers range from $290 for hypertensive employees, $631 per employee for heart disease, and $1458 per employee managing diabetes.x In Canada in 1998 nine billion dollars in prescription non-adherence costs were generated by losses in work resources.xi 3. Lost Revenues Increased revenues for pharmaceutical companies and pharmacies are made possible by the improved adherence and requirement for treatment refills. For a $1bn product, a five percent increase in patient adherence can reap $30 to $40 million in revenue.xii The median reported improvements in adherence rates from theory-based (education), disease-based (skill-based) and behaviour-based (interventions) range from 4% to 40% with a median improvement of 20%.xiii

Systemic Costs

Systemic cost savings generated by improved adherence are logically coupled with an incremental increase in preventative treatment

MEMOTEXT Personalized Adherence Interventions Toll Free: 1877.636-6898 Tel: 647.430.8233 Fax: 416.946-1088 www .me mot ext. com

Improved return on investment (ROI) is attributed not only to adherence programs, but also to technologies that provide a cost-benefit advantage. For example, research on a telemedicine program for Type1 Diabetes patients showed levels of metabolic control similar to traditional skill-based programs (manually teaching patients) but were provided at a significantly lower cost. One study showed a cost savings of USD $800 per patient per year by using technology based adherence solutions.xiv

Overcoming Barriers
Barriers to adherence can be overcome with a patient-centric approach that works with the stakeholder organization to: 1. Gather requirements to determine what the barriers are for a specific patient population and how best to communicate with them. Provide the right set of patient-centric solutions that meet the needs of the patient community and the requirements of the stakeholder organization in a way that maximizes ROI. Provide a solution to measurably improve the quality of life of the patient.

2.

3.

What to look for in a Solution:

There is no universally optimal solution, but through patientcentered communication, education and the precise mix of technologies appropriate to the patients knowledge level, we can now provide a level of support and intervention that is tailored to the needs of individual patients. The pervasiveness of voice/data, wireless, wire-line, Internet and (mass scale-customizable) paper-based communications media now allow for an experience that is as immersed or removed from technology as the patient desires. Successful program development requires people, processes and technology for real success. As a prelude, accurate assessment of individual requirements must occur. Following this, service provided must combine planning, communications and relationships with stakeholder organizations to complement the use of technology, processes and education. The results of Datamonitor's Patient Compliance Survey 2004 suggest that personalized communication with patients is an important tool in compliance initiatives. Direct-to-Patient communication (DTP) should be

Each patient segment requires an appropriate mix of education and behavioral intervention using the most discrete but effective set of technologies.

MEMOTEXT Personalized Adherence Interventions Toll Free: 1877.636-6898 Tel: 647.430.8233 Fax: 416.946-1088 www .me mot ext. com

provided throughout the treatment relationship to provide continual support to compliant behavior.

The most effective solutions which also happened to provide the greatest ROI possess the following characteristics:
easy-to-use omnipresent highly accessible feedback loop of qualitative and quantitative data captivates interesting and informative to patient discreet not overwhelming or irritating the patient flexible adapts to the needs of the patient comprehensive aligns interests of patients and stakeholders scalable cost effective

MEMOTEXT personalized adherence interventions in practice

SMS Contraceptive Reminder Program Aimed at sexually active young women, MEMOTEXT provides pharmaceutical industry client with a solution that consists of sending subscribers SMS/Text Message and pre-recorded voice call reminders to help them maintain a regular contraceptive regimen. This solution tailored specifically for contraceptive users allows the subscriber to customize repeated messages in order to ensure maximal discretion. As per the client requirement, the second daily reminder is provided within three hours of the initial message. No branding is requested by the pharmaceutical company (though this option is available). Subscribers are directed to enroll online by their physician. The physician community in-turn was informed and educated by the pharmaceutical sales force. This program continues to achieve daily growth and measurable, significant improvements in both compliance and brand awareness. Education and Follow-Me Communications for Diabetes Care A blood glucose device manufacturer is embarking on an aggressive strategy to improve adherence for patients with Type1 diabetes mellitus. The educational intervention will use an Internet and offline communications strategy along with a full voice and text message reminder system. Through the diabetes educator community, patients will receive up to 4 daily SMS or Voice reminders to any contact telephone number requested. Once contacted on a daily basis, patients will enter their glucose score into the phone via IVR. The results will be available to the patient online via a secure web-page. The patient will be able to share results with caregivers and educators. The daily interactions also serve as a deidentified measure of increased adherence and improved ROI to the pharmaceutical manufacturer.

MEMOTEXT Personalized Adherence Interventions Toll Free: 1877.636-6898 Tel: 647.430.8233 Fax: 416.946-1088 www .me mot ext. com

Summary:
Non-compliance/adherence is one of the most critical issues threatening all levels of health management. Treatment ineffectiveness, unnecessary hospitalizations and lost revenues for pharmaceutical companies, pharmacies and employers, have had a significant impact on healthcare systems, third party payers, and the insurance industry. Personalized and localized solutions that transcend social, cultural, language, literacy, and economic forces using a omnipresent approach to patient adherence has been proven effective. MEMOTEXT offers turnkey telecommunication-based adherence solutions that are highly adaptable, quickly scalable, and cost effective. On average, MEMOTEXT patients are significantly and measurably more compliant than those acting alone. Ultimately this leads to better health outcomes, reduced healthcare costs, and greater profits for pharmaceutical manufacturers and pharmacists.

MEMOTEXT Personalized Adherence Interventions Toll Free: 1877.636-6898 Tel: 647.430.8233 Fax: 416.946-1088 www .me mot ext. com

Document Version Log

Version 1.0 1.1 2.0 3.0 4.0 5.0 Date Dec. 14, 2005 Dec. 31, 2005 Jan. 4, 2005 Feb 2, 2006 May 20, 2006 Jan 7, 2009 Description Release Draft 1.0 Edited Edited Updated Updated Updated Changed by Amos Adler M.Sc. Jay Keystone MD, FRCPC, M.Sc. (CTM), Danielle Keystone Adler LLB Amos Adler M.Sc. Devin Shelley Elisha Zavier B.A.

EndNotes
i Understanding patients needs is key to medication compliance, Walker, T., Managed
Healthcare Executive, 2001 ii Patient-Centered Care for Better Patient Adherence, Lowes, Robert, AAFP, 1998 iii Understanding patient non-compliance, Roner, Lisa, eyeforpharma Briefing - June,28,2005 iv Improving Patient Compliance: Utilizing online and mobile compliance tools, Datamonitor, July 16, 2003 v Supra, note iii. vi The Case for Diabetes Disease Management, Landis, Darryl, King, allen, Cua, Patrick, Walker, David, Health and Productivity Management Vol. 2, No. 3 vii Cardiovascular Risk Reduction at United Healthcare of North Carolina: The first 12 Months, Landis, Darryl, Georgiu, Archelle, MD, Apple, Joanna, MPH, RN and Durand, Jennifer, RN., JCOM, April 2000 viii m-Healthcare Initiatives for Improving Outpatient Adherence: Opportunities and Barriers, Cocosila, M. and N. Archer, McMaster University eBusiness Research Centre (MeRc), June 2005. ix Assessing the damage: Estimating the Economic Burden of Prescription Drug NonAdherence in Canada, Iskedjian, M. Canadian Healthcare Manager x A review of the literature on the economics of noncompliance. Room for methodological improvement. Cleemput, I., K. Kestelot., The Lancet, 2002 in m-Healthcare Initiatives for Improving Outpatient Adherence: Opportunities and Barriers, Supra note vi. xi The economics of compliance: managing compliance is one way to contain climbing healthcare costs. Coambs, R. Canadian Healthcare Manager, 2002 in m-Healthcare Initiatives for Improving Outpatient Adherence: Opportunities and Barriers, Supra note vi. xii Supra, note iii xiii The Pharmacists Role in Treatment Adherence Part 4: Do Adherence Interventions Really Have An Impact?, Krueger, K.P, Felkey, B.G., Berger, B.A, US Pharmacist: Vol. No: 30:05 xiv Diabetes and telemedicine, Klonoff, D., Diabetes Care, 2003 in m-Healthcare Initiatives for Improving Outpatient Adherence: Opportunities and Barriers, Supra, note vi.

MEMOTEXT Personalized Adherence Interventions Toll Free: 1877.636-6898 Tel: 647.430.8233 Fax: 416.946-1088 www .me mot ext. com