Investing in Adherence Starts With Figuring Out What Works - if Anything

Research has given patients with diabetes the tools they need to live far healthier lives and spend far less on medical care. Unfortunately, no one has figured out how to make patients use those tools effectively.

A panel discussion on “Paying for Adherence: Measuring Short-Term vs Long-Term Return on Investment,” part of Patient-Centered Diabetes Care, outlined what research and experience say about the medical and financial efficacy of various efforts to change patient behavior. The speakers voiced some hope that cheap and easy technology will soon provide patients with the timely and customized reminders they need to take better care of themselves. The speakers noted, however, that most interventions— even the really logical ones that seemed destined to save money by keeping patients healthier— have thus far failed to demonstrate affordable benefits, particularly when they are evaluated in the real world rather than carefully-controlled trials.

“There’s just a gestalt that these programs calling people asking [them] to take their medicine [will] work. They don’t. The last person who’s been able to influence just about everyone’s behavior here has been his or her mother. We don’t have the ability to call patients and get them to take their drugs,” said Scott Breidbart, MD, chief clinical officer at Emblem Health.

There is, of course, evidence that interventions can work when they make adherence less expensive or when they remind genuinely forgetful patients to follow treatment regimens. “But where the intervention is expected to change someone’s lifestyle, to get someone to take injections where they don’t want to take injections, to get someone to eat less or live a healthier lifestyle, or to get someone to exercise when the person prefers to sit on a couch, that’s not something we [payers] can accomplish,” Breidbart said.

Research does indicate that patients who receive advice from their doctors, rather than their insurers, are more likely to modify their lifestyles. But for most patients, the scope and duration of the changes tend to be limited. To make matters worse, studies that appear to test very similar interventions can produce very different results.

In an “intervention that targeted statins, when they decreased the co-pay or waived any payment for statins, patients were much more adherent,” said Joanna Mitri, MD, a clinical investigator at Joslin Diabetes Center. However, a similar intervention that reduced costs for blood pressure medication did not lead to lower blood pressure for the patients, she said.

Mitri suggested that payers experiment with increased payments for physicians who take the time to provide patients with more lifestyle counseling. Breidbart countered that he’d hesitate to test such a nebulous intervention. Each doctor would provide different counseling.

“I can measure if a patient got a hemoglobin A1C [test],” he said. “I can’t measure the counseling that went on. So that’s the difficulty. I accept that it takes more time, but I’m not sure how I would institute a process to pay for it.”

Measurable outcomes are likewise important to the evaluation of any effort to improve treatment adherence. It is difficult to see whether a given intervention changes what patients eat at home. It is somewhat easier—though by no means easy—to see if the intervention reduces their risk of heart attack. Advances in information technology might make such analysis easier to perform. They might also enable payers and physicians to target different interventions at patients with different individual characteristics.

“Most adherence solutions improve adherence by 5% to 7%. So anybody that looks at any intervention sees a trivial improvement. But the truth is that in any intervention, there is a population of people that responds exquisitely well to that intervention, and we actually haven’t been able to unlock that combination lock where a set of interventions customized to the individual would work tremendously well,” said S. Sethu K. Reddy, MD, a senior consultant at Joslin Diabetes Center.

The panelists also saw some hope that lower-tech solutions might provide significant benefits, simply by making treatment adherence easier for patients. Deneen Vojta, MD, executive vice president at UnitedHealth Group, pointed out that research from lowincome and middle-income countries shows that treatment adherence increases significantly when pharmacies combine several medications into single “poly pills.” One pill might combine 2 blood pressure drugs, a statin and an aspirin.

“If we actually had an approved cardiovascular poly pill in this country, we would have more risk reduction than we would get with the PCSK9s for under a dollar a day,” she said.

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