Improving Medication Adherence: The Need for Technology to Support the Patient Journey

According to the CDC, only 46.5% of U.S. adults who could benefit from cholesterol medicine are taking it. This is a problem because having high blood cholesterol raises the risk of heart disease, which is the leading cause of death in the United States. I am curious why this continues to be the case when treatment is affordable and easy to manage. To demonstrate this, I will share a personal experience that contains breakdowns that many patients face that can be solved within today's technology and regulatory framework.

Problem: How do you keep a patient adherent?

Case Study: Breakdowns in a patient's journey to receive their medication

Two years ago, my cardiologist diagnosed me with familial hypercholesterolemia, a genetic condition that makes it difficult to control LDL cholesterol with diet alone. I have been on a statin to address this. I receive my medication from an online pharmacy called Capsule, which has been working fine for me until they notified me that they could no longer fulfill my prescription and that I had to use Express Scripts. They told me to contact my insurer to sort it out.

Breakdown 1: The insurer makes a change but doesn't notify a member. This is missed opportunity where an insurer could be using this as a moment to build trust with their member. In this instance, they needed to work with current vendors to migrate their members easily to an alternative solution. Being proactive is necessary to avoid a patient getting confused and frustrated and becoming non-adherent. There was no outbound outreach from my insurer or provider to inform me of this change.

Breakdown 2: The insurer is relying on the member to be proactive. I had to hunt down who to call, wait on hold, and try to explain what I was calling about. In my case, it took me about six weeks to find the time to call, and by then, my medication had run out.

Breakdown 3: Insurers need to train their call center reps on information that will be relevant for a member to achieve adherence goals. The next problem occurred once I finally called. I was told that the issue was that I needed a 90-day supply, not a 30-day one. Now, I know why, but if I didn't, I would be confused by this point, and the insurer didn't help me understand that this would benefit me. They should have been trained to help a member understand why the 90-day thing is not arbitrary but an actual benefit.

Breakdown 4: Lack of coordination of care. The problem escalated when the call center rep informed me they couldn't change the prescription. I would need to call my doctor to get a new prescription, which may have meant booking a new appointment. The next day, I got notice that my cardiologist had retired.

These breakdowns in the healthcare system can make patients feel like they are battling the system. However, there are simple solutions to these problems. The primary thing to note is that the solution should work for the member. We can prioritize business goals while maintaining the user experience for a member. The way to do that is to look at this from the members' perspective.

One solution is to provide better framing and education for the members. A low-lift experience for a member should feel like they are getting notified that their plan is making it easier for them to get their medications without worrying. If there needs to be an opt-in to move to a 90-day supply, then the member should be informed in a clear and concise manner.

A second solution is to provide better training and, more importantly, tools for call centers. Now, two years ago, I wouldn't have said that, but today, with ChatGPT, you can easily create applications to empower your workforce to answer questions that are relevant to a specific member. This is so exciting for the future of lower frustration with the health system.

A third solution would be to examine the leakage points in medication adherence and address them with fixes in the technology that supports a provider. Here are three very simple fixes that could be implemented to improve member experience:

• The prescribing system should block sending prescriptions to a pharmacy that can't fulfill and shouldn't be able to send a supply request amount that is not covered. That should be just table stakes. We need the stakeholders within healthcare to be better equipped to do their jobs.
• As soon as a patient, especially a complex patient like myself misses picking up a medication for more than 30 days, it should auto-trigger an intervention. This requires better member and patient segmentation.
• As soon as a provider has notified their HR of a change affecting their network status, this data should be sent to the insurer.

In conclusion, many breakdowns in the healthcare system can be solved with technology and proper education. We should prioritize the user experience for the members to make healthcare more accessible, equitable, and just not as confusing as it currently is.

I know I am not the only one experiencing these types of challenges. I invite you to contact me if you have challenges you have faced that you would like to see solutions for and how they could be addressed.