From Payer to Payee

Managed care providers are realizing that they may waste their investment in getting patients diagnosed and on therapy if patients don't continue to take their medication. "They take the hit on both ends," says Jonothan Tierce, general manager and center of excellence leader for IMS Health. "They pay for the diagnosis, pay for the first dose or two, and then the patient still gets the disease."

Meadows believes payers will have to become more involved in compliance than they are today. "It does little good if you are spending $4,000 on a patient and the patient is taking their medication four out of ten times," he says. "What you've done is spend a lot of money on what's likely to be a poor outcome."

Changing Techniques

What happens to compliance programs when a drug goes off patent, or the manufacturer stops promoting it? In some cases, they continue. MacGregor says that Lilly has invested heavily in patient education programs for drugs that have been around for more than 12 years. "The number of people who need this support is growing, but beyond the numbers, we believe that part of our role is education," he says.

"Today more than ever, Big Pharma has a huge economic incentive to stand behind compliance and adherence," says David B. Nash, chair of the department of health policy at Jefferson Medical College. "Pharma is supporting compliance and adherence technology by spending directly on these kinds of programs. They're also contributing to the literature about compliance, and they are changing aspects about the detailing story to focus on compliance."

That said, Nash notes that compliance is still at about 50 percent across all drug indications. "In spite of the technology, understanding, and efforts, we still only succeed about half the time," he says. "That means we have to change our approach. New technology, disease management, Internet-enabled reminder systems, nurse educators—every single thing has been evaluated, and still the rates are dismal."

One possible approach might be to change the way doctors discuss drugs with patients and improve behavioral teaching techniques, starting in the first year of medical school.

"I would not put all the blame at pharma's feet. I'd put the blame at primary care doctors because in the absence of an economic incentive to promote compliance, it will not be promoted," Nash says. "The only payment system that promoted compliance was capitation."

"New technology sounds exciting because it gets people right at the moment that they might be thinking of taking their medication," Tierce says. "We view those as the means of communication separately from the messages. The different channels of communication themselves don't make the difference you would think they would. It sounds great if you send a text message, but I don't think the research shows those as being any more effective as any other way of delivering a message."

Most experts agree that some patients will never be compliant. "The point that we emphasize is that the top people are always going to be compliant," Wulf says. "It's the low 20 percent that you're never going to change. If you make a program for all, you will affect none. You want to help those who want to get better but have something blocking them."