Adherence Arena: Why forgetfulness isn’t the biggest obstacle to adherence
Want to inspire patients to value their medication and thus improve compliance? Reward them early and often
By on May 24, 2011Dozens of studies and surveys have been performed with the aim of revealing the reasons people don’t take their medication, and each comes with its own pie chart.
The biggest slice is usually labeled “I forget.” The next biggest slice is often something like “costs too much.”
These are also the answers that anyone off the street will usually come up with, without even having to do a study.
I’d like to examine both of these slices. I can’t argue with the responses—these are the responses people report—but I would like to poke at their validity, because I believe there is something else going on here, something deeper.
I believe that there is a more fundamental value problem here, masquerading as simple “forgetfulness” and “cost” problems.
I believe that if patients fundamentally valued their medication more, they wouldn’t forget to take it and wouldn’t complain as much about their co-pay.
I don’t want to ignore that some patients have very serious cost issues. Many of those patients, however, qualify for existing assistance programs.
It’s what you value
Why do I believe this? On the forgetfulness front, people tend not to forget things that they value, like watching American Idol (they value entertainment) or brushing their teeth every morning (they value not having bad breath at work).
On the cost side, studies have shown that even offering medication for free doesn’t lead to stellar adherence rates.
In fact, when something is free, the psychology is often: “This must not be worth very much.”
Typical pharmaceutical rebates and co-pay discounts, for example, can trigger this type of thinking.
As soon as the discount or rebate runs out, the patient then thinks: “Why should I pay a $30 co-pay for this? It used to be free.”
By the way, the average American household spends over $500 a year on lottery tickets (over $800 in Massachusetts) for arguably less benefit than their prescription medications, and you don’t hear a lot of complaining about lottery ticket expenses—they’re highly valued, and it’s fun.
A fascinating study was performed by Minds at Work, headed by two Harvard psychologists and commissioned by CVS Caremark.
They used innovative interviewing techniques to get at the real root of the noncompliance problem with a number of patients, many of whom specifically answered “I forget” as their knee-jerk response upon initial survey.
What they found was that there were often deeper psychological reasons, and that “I forget” was often just a simple excuse.
Some revealed that taking medication made them feel old or made them feel like they were losing control or interfered with their lives or other priorities in a number of ways.
Clearly, for those people, a simple reminder service or reminder device wouldn’t work, even though forgetfulness was their ostensible reason for noncompliance.
The short-term reward system
The big question then is how to inspire patients to value their medication more, to value it enough to overcome various obstacles—psychological, financial, or otherwise.
I believe that simple short-term rewards along the way could be quite effective.
Even a $10 iTunes gift certificate or a few Starbucks lattes as a reward for compliance, as crazy and superficial as it sounds, could actually work nicely.
The true reward, of course, is better health or complication avoidance or a longer life.
Unfortunately, though, due to a quirk of human nature that focuses our attention on the here and now, those rewards are often too hard to attach to the pill because they’re too far away or too intangible.
At this point, many people would conclude that, more to the point, it’s all really an education problem.
That’s clearly part of the problem, and we need to offer more and better education for sure, but in reality even that’s not enough.
Patients can often verbalize that their statin is designed to help prevent a heart attack years down the line—they already know that—but it’s still difficult to transform that knowledge into motivation to take that statin every day this week.
So I’m a big fan of offering little rewards, often.
It’s fun, it’s motivating, and it adds value to what might otherwise remain a forgettable little pill that just might save your life.
Katrina S. Firlik, MD, is co-founder and chief medical officer of HealthPrize Technologies, LLC. Prior to HealthPrize, she was a practicing neurosurgeon in Connecticut. She is also the author of Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside.
For more on adherence, join the sector’s key players at Patient Adherence, Communication & Engagement Europe on May 31-June 1 in Berlin and Customer Centric Marketing on June 27-28 in Philadelphia.