MEDICATION NONADHERENCEEXPANDING THE CARE TEAM TO ADDRESS

Leveraging Untapped Resources

FOR EMPLOYER HEALTH CARE BENEFITS SPECIALISTS ONLY

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ABANDONMENT AND ADHERENCE— WHAT THEY MEAN

Definitions can vary, but in general:

ABANDONMENT AND NONADHERENCE— EVEN MORE COMMON THAN YOU THINK

Abandonment Nonadherence

The scope of the problem is enormous

20% to 30% of all new prescriptions are never filled1

Overall nonadherence rates range from approximately 30% to 60% and are highest among symptom-free patients5

No disease state is immune

Abandonment rates vary by disease state:• Immunology: 68%6

• Diabetes: 41%6

• Cancer: Up to 13% 7

Studies have found that nonadherence rates can be disturbingly high even with medications for chronic or life-threatening diseases:• Multiple sclerosis: up to 59%8

• Diabetes: up to 64%9 • Cancer: 38%10

Medication abandonment and nonadherence are prevalent across a broad range of chronic conditions and likely affect many of your members.

Failing to take a medication as prescribed1

AbandonmentAdherence Nonadherence

Following the prescriber’s recommendation with respect to timing, dosage, and frequency of taking medication during the prescribed period of time1

Direct measures of medication adherence include blood or urine drug assays, drug markers, and direct patient observation. Indirect measures assume the medication was taken, but cannot be verified; these include patient self-reporting, medication measurement, electronic monitoring devices, and review of prescription records and claims.4

Failing to pick up a new prescription, sometimes called primary medication nonadherence2,3

3

89%

64%

41%

32%

13%

Acknowledged that medication adherence was a

top objective11,*

Had analyzed prescription data for select health conditions12,†

Were evaluating the impact of nonadherence on medical and

pharmacy costs12,†

Were evaluating the impact of adherence on health outcomes12,†

Offered employee incentives to encourage and reward adherence12,†

ADHERENCE IS IMPORTANT BUT NOT ALWAYS ADDRESSED

In recent surveys of large employers, the vast majority acknowledged that medication adherence was a top health-management objective

Assessing adherence using direct and indirect measures can provide information on patient nonadherence

* Results of a 2009 survey conducted by the National Pharmaceutical Council (NPC) of health-management professionals with decision-making authority or influence in 75 large, self-insured corporations in the United States.11

† Based on a 2009 online survey of health- and pharmacy-benefit decision makers and influencers at 155 large self-insured corporations regarding the importance of medication adherence.12

Indirect measures of medication adherence include13:

Patient interviews and self-reported diaries are other methods used to gauge patient recall of adherence14,15

× 100%MPR (medication possession ratio) =Sum of days’ supply for all fills in period

Number of days in period

× 100%PDC (proportion of days covered) =Number of days in period “covered”

Number of days in period

Only a Portion of Employers Take Action to Improve Adherence

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ABANDONMENT AND NONADHERENCE CAN LEAD TO SERIOUS MEDICAL CONSEQUENCES

Nonadherence can increase the risk for poor health outcomes• Nonadherent patients with ulcerative colitis (UC) had a 5x higher risk for symptom recurrence

than adherent patients17

• Insufficient anti-inflammatory treatment of asthma may eventually lead to a COPD-like disease18

• Patients with MS who had gaps in treatment of longer than 90 days were twice as likely to experience a severe relapse than patients with shorter gaps in therapy19

Nonadherence is also associated with increased utilization of health care resourcesIn studies of patients with several chronic diseases (congestive heart failure, hypertension, diabetes, and dyslipidemia), nonadherence was associated with increases in:

Drugs don’t work in patients who don’t take them.16

C. Everett Koop, MD, former US Surgeon General

Hospitalizations20,21

Inpatient hospital days20

Emergency department visits20

H

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ABANDONMENT AND NONADHERENCE CAN ALSO LEAD TO SIGNIFICANT COSTS

Medication nonadherence leads to an estimated $100-$289 billion every year in health care costs to the US health care system3

The majority of these costs are the result of avoidable hospitalizations22

The costs of preventable hospitalization for diabetes, heart disease, and high cholesterol alone are responsible for more than $8 million annually in avoidable costs per 100,000 employer-paid insured lives.23

Additional health care costs result from22:• Increased service utilization• Avoidable pharmacy costs related

to therapy intensification • Diagnostic testing that could have been avoided

Poor Medication Adherence Can Lead to Further Escalation of Costs for Both Employers and Members

For an employer with 100,000 employees and an average annual salary of $50,000 (a $5 billion payroll), nonadherence can cost $300 million a year.24

COSTS PASSED ON TO PATIENT

POOR HEALTH

OUTCOMES

POOR MEDICATION ADHERENCE

INCREASED SERVICE

UTILIZATION

INCREASED HEALTH CARE COSTS

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BARRIERS TO ADHERENCEWITH TRADITIONAL THERAPY

• Social and economic conditions• Health care team/system• Behavior of patients• Characteristics of the disease • Speci�cities of therapies

ADDITIONAL BARRIERS WITH SPECIALTY MEDICATIONS

• High �nancial burden• Complexity of diseases

and therapies• Need for closer monitoring

MANY FACTORS CAN AFFECT ADHERENCE, ESPECIALLY COST25

Why your members may struggle with adherence

Adherence poses a challenge for many of your members for many different reasons—and there is no single, simple solution.

• Patients with a co-pay of $50 were nearly 4 times as likely to abandon a prescription as patients paying $1026

• MS patients with a >$250 co-pay were 7x as likely to abandon their prescription vs those paying $100 or less27

Abandonment

• Patients with chronic myeloid leukemia (CML) who had higher co-pays were 42% more likely to be nonadherent than patients who had lower co-pays28

• In RA, nonadherence due to cost ranged from 57% to 89% in one study29

Nonadherence

A direct correlation has been shown between out-of-pocket (OOP) costs and both abandonment and nonadherence

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EVERY PARTNER ON THE HEALTH CARE TEAM CAN HELP ADDRESS NONADHERENCE

Look beyond traditional partners on the health care team to address nonadherence

There are many opportunities for all key stakeholders to affect adherence and, as a result,

improve outcomes for all involved. This is a key and growing area within the health care industry.30

R. Stefanacci, DO, Managed Care Magazine, 2013

You, the employer, can play a role in promoting adherence to your employees30-32:• Reinforce its importance• Provide positive influence and support• Adopt value-based insurance benefits designs that encourage adherence

Employer

Pharmaceutical Manufacturers

Physician’s oce (doctor, nurse, etc)

Caregiver (formal or informal—eg, spouse)

Other patients (advocacy groups, etc)

Insurance provider (pharmacy bene�t manager [PBM], medical carrier)

Pharmacy (pharmacist, disease educator, etc)

TRADITIONAL PARTNERS UNTAPPED PARTNERS

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UNTAPPED PARTNERS TO ADDRESS NONADHERENCE

What can pharmaceutical manufacturers offer? Pharmaceutical manufacturers can offer a range of resources to support your members, especially those taking specialty medications.

These services are often provided at no cost to employers or their members

Connect Members to Financial Assistance

Programs

Provide Disease State

and Product-Specific Education

Offer 24/7 Telephone Support

for Patients and Caregivers

Help Navigate Prescription

Benefits

Connect With Patients Live/Face-to-Face for

Individualized Discussion and Training as Needed

Deliver Adherence Tools in a Multitude of Formats

(eg, Text Medication Reminders)

Leveraging the patient support services of pharmaceutical manufacturers can give your members additional support to follow their treatment plan as prescribed by their doctor.

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THE EMPLOYER—ANOTHER KEY MEMBER OF THE CARE TEAM

You are part of the care team and can partner with your members Educate members about the importance of medication adherence in maintaining optimal health

Work with all of your partners on the care team to maximize use of all available resources

Organizations that focus on health care quality and its measurement view medication adherence as a key metric—

you should, too!33

THE EXTENDED CARE TEAM

Pharmacies, particularly specialty

pharmacies for specialty medications

Caregivers

Pharmaceutical manufacturers

Employers

Insurance providers

Other patients (advocacy groups, etc)

Health care providers

Member

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PHARMACY BENEFITS CAN BE DESIGNED TO PROMOTE ADHERENCE

Some benefit design elements have been shown to combat nonadherence as well as reduce other health care costs

Keep OOP costs low for members

Incent members to use specialty pharmacies when appropriate

In 2001, Pitney Bowes redesigned its pharmacy benefits to move asthma, diabetes, and hypertension medications from the third and second tiers to the first tier34

One national health plan adopted a mandatory specialty pharmacy program for members on post–renal transplant medication35

• 25% ED visit reduction• 6% decrease in diabetes

health care costs• 50% reduction in short-term

disability (STD) days

• 30% lower transplant medical costs• Over 50% reduction

in discontinuation rates• 13% decrease in total health care costs

CA

SE S

TUD

IES

RES

ULT

S

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REDUCE ABANDONMENT AND NONADHERENCE WITH 4 KEY STEPS

Having the right benefit plan design is critical for reducing abandonment and nonadherence.

STEP

1Measure abandonment and nonadherence by disease state

Work with benefits partners to determine adherence patterns by disease state

STEP

2 Evaluate and modify your benefit design

Seek out value-based health plan designs with lower OOP costs for prescription medications

STEP

3Leverage ALL partners of the care team, even the untapped ones

Incent members to use specialty pharmacies as appropriate

Work with your benefits partners to facilitate enrollment in pharmaceutical manufacturer patient support programs

STEP

4Measure the impact, and adjust as needed

Identify best practices and opportunities for continued improvement

References1. Viswanathan M, Golin CE, Jones CD, et al; for Agency for Healthcare Research and Quality. Medication Adherence Interventions: Comparative Effectiveness. https://www.effectivehealthcare.ahrq.gov/ehc/products/296/1248/EvidenceReport208_CQGMedAdherence_FinalReport_20120905.pdf. Published September 2012. Accessed March 8, 2016. 2. Silverman E. Increased abandonment of prescriptions means less control of chronic conditions. Managed Care Magazine. http://www.managedcaremag.com/archives/2010/6/increased-abandonment-prescriptions-means-less-control-chronic-conditions. Published June 2010. Accessed January 25, 2016. 3. Network for Excellence in Health Innovation. Ready for Pick-up: Reducing Primary Medication Non-adherence. http://www.nehi.net/writable/publication_files/file/pmn_issue_brief_10_14_formatted_final.pdf. Published October 2014. Accessed April 4, 2016. 4. Farmer KC. Methods for measuring and monitoring medication regimen adherence in clinical trials and clinical practice. Clin Ther. 1999;21(6):1074-1090; discussion 1073. 5. Gottlieb H. Medication nonadherence: finding solutions to a costly medical problem. http://www.medscape.com/viewarticle/409940_2. Published 2000. Accessed March 23, 2016. 6. Data on file, AbbVie Inc. 7. Streeter SB, Schwartzberg L, Husain N, Johnsrud M. Patient and plan characteristics affecting abandonment of oral oncolytic prescriptions. J Oncol Pract. 2011;7(3 suppl):46s-51s. 8. Menzin J, Caon C, Nichols C, White LA, Friedman M, Pill MW. Narrative review of the literature on adherence to disease-modifying therapies among patients with multiple sclerosis. J Manag Care Pharm. 2013;19(1-a):S24-S40. 9. Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care. 2004;27(5):1218-1224. 10. Capgemini Consulting. Patient Adherence: The Next Frontier in Patient Care. Vision & Reality, 9th ed. 2011. http://adhereforhealth.org/wp-content/uploads/pdf/Patient_Adherence__The_Next_Frontier_in_Patient_Care%20-%20CapGemini_2011.pdf. Accessed January 25, 2016. 11. Leonard D. Medication compliance is a top concern for employers. Corporate Wellness Magazine. http://www.corporatewellnessmagazine.com/economics/medication-compliance-concern-employers. Published January 29, 2014. Accessed January 11, 2016. 12. Reynolds C, Martin D; the Benfield Group; prepared for the National Pharmaceutical Council. Employer Medication Compliance Initiatives: Executive Summary. http://www.tcyh.org/employers/downloads/Study-EmployersMedication%20Compliance.pdf. Published November 2009. Accessed January 25, 2016. 13. Crowe M. Do you know the difference between these adherence measures? Pharmacy Times. http://www.pharmacytimes.com/contributor/michael-crowe-pharmd-mba-csp-fmpa/2015/07/do-you-know-the-difference-between-these-adherence-measures. Published July 6, 2015. Accessed March 30, 2016. 14. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497. 15. Lam WY, Fresco P. Medication adherence measures: an overview. Biomed Res Int. 2015;2015:217047. doi:10.1155/2015/217047. 16. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009;119(23):3028-3035. 17. Kane S, Huo D, Aikens J, Hanauer S. Medication nonadherence and the outcomes of patients with quiescent ulcerative colitis. Am J Med. 2003;114(1):39-43. 18. Gillissen A. Patients’ adherence in asthma. J Physiol Pharmacol. 2007;58(suppl 5):205-222. 19. Patti F. Optimizing the benefit of multiple sclerosis therapy: the importance of treatment adherence. Patient Prefer Adherence. 2010;4:1-9. 20. Roebuck MC, Liberman JN, Gemmill-Toyama M, Brennan TA. Medication adherence leads to lower health care use and costs despite increased drug spending. Health Aff (Millwood). 2011:30(1):91-99. 21. Sokol MC, McGuigan K, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and health care cost. Med Care. 2005;43(6):521-530. 22. Iuga AO, McGuire MJ. Adherence and health care costs. Risk Manag Healthc Policy. 2014;7:35-44. 23. Bresnick J, HealthIT Analytics. Medication non-adherence brings millions in avoidable costs. http://healthitanalytics.com/news/medication-non-adherence-brings-millions-in-avoidable-costs. Published February 13, 2015. Accessed April 4, 2016. 24. Mercer; for Kronos Incorporated. The Total Financial Impact of Employee Absences: Survey Highlights. http://www.fmlainsights.com/wp-content/uploads/sites/311/2011/09/mercer-survey-highlights1.pdf. Published October 2008. Accessed January 15, 2016. 25. BriovaRx. The Role of Specialty Pharmacy in Managing Patient Adherence. http://www.unitedag.org/wp-content/uploads/2014/07/BriovaRx-Improves-Patient-Adherence.pdf. Published 2013. Accessed March 23, 2016. 26. CVS Health Research Institute. Understanding prescription abandonment. http://www.cvshealth.com/thought-leadership/cvs-health-research-institute/understanding-prescription-abandonment. Accessed April 1, 2016. 27. PR Newswire; Prime Therapeutics LLC. New study finds 1 in 4 multiple sclerosis patients with high out-of-pocket costs not filling prescriptions [press release]. http://www.prnewswire.com/news-releases/new-study-finds-1-in-4-multiple-sclerosis-patients-with-high-out-of-pocket-costs-not-filling-prescriptions-62149752.html. Published June 17, 2009. Accessed April 5, 2016. 28. Dusetzina SB, Winn AN, Abel GA, Huskamp HA, Keating NL. Cost sharing and adherence to tyrosine kinase inhibitors for patients with chronic myeloid leukemia. J Clin Oncol. 2013;32(4): 306-311. 29. De Vera MA, Mailman J, Galo JS. Economics of non-adherence to biologic therapies in rheumatoid arthritis. Curr Rheumatol Rep. 2014;16(11):460. 30. Stefanacci RG, Guerin S. Why medication adherence matters to patients, payers, providers. Managed Care Magazine. http://www.managedcaremag.com/archives/2013/1/why-medication-adherence-matters-patients-payers-providers. Published January 2013. Accessed January 25, 2016. 31. Chernew ME, Shah MR, Wegh A, et al. Impact of decreasing copayments on medication adherence within a disease management environment. Health Aff (Millwood). 2008;27(1):103-112. 32. Change Agent Work Group. Employer Health Asset Management: A Roadmap for Improving the Health of Your Employees and Your Organization. https://www.ihpm.org/pdf/EmployerHealthAssetManagementRoadmap.pdf. Published 2009. Accessed January 25, 2016. 33. Optum. Medication Adherence: Rx for Success. https://www.optum.com/content/dam/optum/resources/whitePapers/MedicationAdherence_WhitePaper.pdf. Published 2012. Accessed January 15, 2016. 34. Integrated Benefits Institute. A Broader Reach for Pharmacy Plan Design: The Disability Effects of Cost Shifting. https://www.acoem.org/uploadedFiles/Career_Development/Tools_for_ Occ_Health_Professional/Health_and_Productivity/A%20Broader%20Reach%20for%20Pharmacy%20Plan%20Design%20-%20The%20 Disability%20Effects %20of%20Cost%20Shifting.pdf. Published May 2007. Accessed January 25, 2016. 35. Tschida S, Aslam S, Khan TT, Sahli B, Shrank WH, Lal LS. Managing specialty medication services through a specialty pharmacy program: the case of oral renal transplant immunosuppressant medications. J Manag Care Pharm. 2013;19(1):26-41.

©2016 AbbVie Inc. North Chicago, IL 60064 400-1862510 July 2016