At Express Scripts, years of patient behavior research related to medication utilization have revealed some consistent patterns and interesting insights. We know, for example, that greater adherence is associated with females, older populations, individuals with higher incomes and those living with a partner who is adherent. We also know that, in most cases, increasing or decreasing copayments has only a modest effect on adherence levels.
Not All Nonadherence Is the Same
Medication nonadherence has been difficult for the country to address because one patient's obstacle to adherence can be very different than another patient's:
- Sporadic Forgetters (39% of all non-adherence instances): Patients who intend to take their medications each day but periodically neglect to take them.
- Refill Procrastinators (30%): Patients who have a positive view of therapy and take medications as prescribed when they have supply on hand, but they put off refills or renewals as supply dwindles
- Active Decliners (31%): Patients who do not place a positive value on their therapy for a variety of reasons, such as perceived ineffectiveness of medications, side effects or concerns about being overprescribed, or those who avoid their therapy because of a financial burden
For a deeper understanding of these categories and how Express Scripts can predict nonadherence, see our infographic.
Change the Message to Improve Adherence
As you can see, our research shows that approximately 69% of nonadherence is for behavioral reasons — simple procrastination and forgetfulness. Improving adherence in these instances can be as simple as altering the language the industry uses to communicate with patients. Words matter.
In a randomized controlled trial, Express Scripts researched the effects of message framing on adherence. The strongest increase was seen through letters to patients that combined the principles of authority (e.g., a letter authored by a trusted physician) and loss aversion (i.e., a theory that the threat of a potential loss is a more powerful motivator than the promise of a future gain).
As seen in the graph below, there is a 26% relative lift in the medication possession ratio — calculated using prescription-claims data — when minor changes are made to patient messaging. To achieve this same level of improved adherence using financial incentives alone, plan sponsors would need to decrease copayments $10 to $12.
Effect Of Framed Messages On Therapy Adherence
Tailored Interventions to Address Each Adherence Obstacle
To improve medication adherence, the healthcare industry should not rely exclusively on rational decision-making. Simply lowering copayments or providing more education will not solve the problem. Often, the most effective solutions come from our understanding of how to drive behavior change and how to activate underlying good intentions.
There are a variety of ways to trigger these good intentions. For example, Sporadic Forgetters may benefit from reminder systems or use of a pill box. Refill Procrastinators would gain from enrollment in home delivery, use of auto-refills or even refill reminders on pill bottle caps.
In the case of Active Decliners, Express Scripts' specialist pharmacists can help address medical concerns. And low-cost pharmacies, generic options and payment assistance help make medication more affordable.
This comprehensive, multifaceted approach leverages all aspects of Health Decision Science to better understand why people make the decisions they do and how we can provide solutions to drive out waste and improve outcomes.
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