Detailing Adherence

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  • 01/16/2013

“Human action can be modified to some extent, but human nature cannot be changed.” Those are the words of Abraham Lincoln (16th President of the United States and Academy Award nominee).  And they pretty well sum up a major issue in American healthcare – adherence/compliance.

I’ve just returned from the speaker’s podium at the Optimizing Pharmaceutical Patient Adherence conference. There’s a lot to be done. There are a lot of good ideas. There seems to be a lot of commitment. The better angels of our nature were on display.

Now it’s time for action.

Zig Ziggler once said, “If what you’re doing isn’t working, try something else. If what you’re doing is working, try anything else.” While there are certainly success stories and validated methodologies in the battle for better adherence/compliance, we’re losing the war. It’s time to reconsider what we’re doing.

And the first thing to admit is that we can’t relegate the conversation to healthcare policy. While the conversations are fascinating – another white paper, another committee, another conference – isn’t going to move the needle. We need to act.

As I see it, there are six issues we are trying to impact – and they are linked:

1.     Sub-optimal patient outcomes (the Big Kahuna).

2.     Sub-optimal physician pay-for-performance metrics. (More important today than ever and back at the top of strategies to control costs. Alas – one of the unintended consequences of pay-for-performance is that some physicians will try to game the system by not seeing those patients who they see at high risk for non adherence/compliance,)

3.     Lower healthcare costs for payers. Not surprisingly, all of the big private payers are in the adherence/compliance game with both feet.

4.     Sub-optimal profits for pharmaceutical companies. (The sale doesn’t end once the script is written.)

5.     Impact on safe-use. The way to make drugs “safer” is to ensure they are used appropriately. Safe use begins with adherence/compliance. (Hear that FDA?)

6.     Lower healthcare costs for society. (You might have heard of this issue – it’s been in the news a lot.)

Alas, there are no magic bullets in the fight to improve adherence/compliance. News articles feature talking pillboxes that offer bells and whistles, rings, buzzes, and flashes, and that’s all to the good – but they only combat forgetfulness (purposeful or otherwise). It’s a part of the solution – but, just as in the battle against counterfeit medicines, it’s only a piece of the puzzle

Some think that (as with REMS), the FDA should insist that new drugs have adherence/compliance plans that can be monitored and improved through iterative learning. Should sales reps (or, better yet, MSLs)  “detail adherence/compliance programs and share validated tools for adherence/compliance “triage?” The only thing that’s currently on the table is that the FDA has promised to make MedGuides more user-friendly. (We can do better.)

Others talk about behavior modification through gamification – and that too is a useful pathway.  We talk about carrots – but what about sticks to address bad patient behavior (particularly sticks of the financial variety)?

All of these are important. But talking pillboxes and better MedGuides are only making existing tools better. And trying to “regulate” adherence/compliance is a slippery slope indeed. To really make a difference, to change the game, what we really need are solutions that impact social conditioning and address patient responsibility – and that means using innovative platforms such as social media and, specifically, apps.

Not apps that are medical devices (although those play an important role in 21st century healthcare), but apps that remind, cajole, educate, praise, incentivize, and assist patients in their quest for better health. Apps are at the nexus of sage use, treatment outcomes, and patient satisfaction. And it’s not science fiction.

At present, there are some 17,828 healthcare and fitness apps and 14,558 that can be deemed “medical.” While some are better than others, these numbers tell us one thing – this is not a fad or a trend. It is reality.

And as Philip K. Dick wrote, “Reality is that which, when you stop believing in it, doesn’t go away.”

Will our socio-economic “technology gap” lead to a more pronounced “adherence/compliance gap?” It’s an important question. That’s why it’s crucial we remember there is no one-size-fits all solution. But that’s mustn’t mean we disregard the reality of the growth and pervasiveness of apps, mobile apps. Let’s face it, when it comes to mobile phones, any gap is rather narrow.

Apps for adherence/compliance are “safe use” apps. Apps that can be “prescribed” by physicians to their patients are the wave of the present. Adherence/compliance “app-ens” and patients, physicians, payers, pharmaceutical companies – and society benefit.

As Walter O’Malley (the man who moved the Dodgers from Brooklyn to Los Angeles) famously opined, “The future is just one damn thing after another.”


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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