How to improve medication adherence [PODCAST]

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“Automation and technologies can enable adherence, but true change happens when physicians and pharmacists work together in collaborative teams to achieve common goals: Better managed chronic conditions, fewer complications, and improved experience for patients and physicians.”

Tony Willoughby is a health care executive.

He shares his story and discusses his KevinMD article, “Automatic refill and 90-day fill programs don’t improve medication adherence.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/follow. Today on the show we have Tony Willoughby. He’s a pharmacist and health care executive. His latest KevinMD article is titled “Automatic refill and 90-day fill programs don’t improve medication adherence.” Tony, welcome to the show.

Tony Willoughby: It’s great to be here, Kevin. Thanks for the opportunity to meet and speak.

Kevin Pho: We’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Tony Willoughby: Yeah, absolutely. Well, I’m a father of three boys. I grew up in Kentucky and went to pharmacy school. When I left pharmacy school, I had done a lot of research during my academic career and found a passion for solving hard problems. So I started in progressive leadership roles, first at Target, running pharmacy and clinics, and then I went to McKesson Corporation, where I served as chief pharmacy officer. I continued to always ask myself, “How do we improve the patient-provider experience around medication?” because that’s my subject matter expertise.

On that journey, I got to this question that I kept trying to answer by putting myself in the role of the patient and the physician. Let me share a caricature of a story, if we think about how that journey looks today. A patient goes and sees their physician, and they’re in an exam room for 15 minutes. During the first seven to 10 minutes, there’s a good conversation, a robust conversation. You get toward the end of the appointment, and the physician says, “Here’s the plan.” They’ve gone through the differential in their head, and they’ve got their plan for this patient. They say, “Here are the prescriptions. I’m going to send them to your pharmacy. I’m going to give you a couple of key messages about those medications.” And then they always ask the same question, which is, “Do you have any questions?” Right?

And 90 percent of the time, the answer in that moment from the patient is what? “No.” They’ve gone through this whole anxiety buildup of this appointment: new news, new labs, a new diagnosis. They’ve just been inundated with a ton of information, and they say no. Then they go through checkout, they go to their car, and about three-quarters of the way to the car, all the questions start flooding in, right?

And so they go to Dr. Google, and they start getting scared. Then they go to the local pharmacy, and somebody comes to the counter and tells them it’s going to be two hours, or it’s too much, or it’s not covered, or all this other information. If they stick through that process, they come back, and somebody comes back to the counter and says, “Do you want to speak to the pharmacist?” And how many people say yes to that? A smattering, right? If they do, a pharmacist comes over who’s understaffed, compressed, and not working at the top of their license. They pull the little bottle out, they turn it sideways, they turn it, they read the warning labels, and then they send them home.

So the physician gives them the key warnings, they’ve googled a bunch of scary stuff, a pharmacist gives them a bunch of warnings, and then we say, “We’ll see you in 90 days,” and we wonder why people don’t engage with their health care.

And so I was wrestling with that question along my journey, and I said, “Well, I’ve got to stop advising people how to fix this, and dare greatly and go try to fix it myself.” That’s what got me connected, through historical relationships, to the group at Catalyst Health Group, for us to wake up every day as one component of our population health solution and start answering that. Because it’s frustrating to the patient, to the caregiver, and to the physician, who does all this work and care to set up this plan for the patient. Time after time, that patient comes back in 120, 160, 180 days, and they’ve not progressed, not because the plan was wrong, but because the patient hadn’t been able to stay connected to the plan for a bevy of reasons. You put all this work as a physician into the patient, and then you let them loose out into the wild, and the system doesn’t maintain that continuity of care. When I say it in that caricature version, it goes, “Why would we ever do that?”

And so we’ve worked really hard, and it’s become a passion, to progressively try to answer that question. So, pharmacist by training, problem solver by trade. Having three teenage boys helps bring a lot of problems to the fold. But that’s what we’ve worked really hard to continue to do: take that big question and try to answer it.

Kevin Pho: Sure. So one of the problems that you certainly recognize is medication adherence, and in your KevinMD article, we talk about one aspect of that, “Automatic refill and 90-day fill programs don’t improve medication adherence.” But before you talk about your article, just give some context. Talk about the context of automatic refills and 90-day fill programs, for those who just aren’t familiar, and how common that is.

Tony Willoughby: A lot of our quality measurements that look at adherence are claims-based measurements, right? We are a metric-driven world, for all the right reasons, and every time there are right reasons, there’s a shadow to that. So the best way to drive that metric in the most facile, convenient way is to have to think about it fewer times a year. If my measure of adherence is that you’re on a drug and you’ve had a claim processed to cover that time period, then if I only have to worry about that four times a year instead of 12 times a year, it’s more efficient. It’s more efficient operationally, we think it’s more convenient to the patient, etc. And if it’s an auto-refill, even better. Nobody has to worry about it; it just runs.

And then we get really enamored, if we’re in a CMS space and we look at our Star Ratings, etc., with seeing this improvement line. Well, that’s because we’ve automated systems to build that measure. We haven’t addressed the core underlying problem. A lot of your audience, whether physician or patient, if they’ve ever been in a caregiver role at the end of life, they’ve gone to the home as part of the closure, they’ve gone to the kitchen pantry, and they’ve opened it, and all those automatic refills are still in the pantry, right?

So we drive adherence to improve quality of life, and we know drugs work when people take them. And we have medications because today, when you think about chronic disease, it’s the most common solution. That’s another podcast, whether it should be or not, but it is today, right? And then we use systems to generate the transaction of that, but not the true engagement to get the benefit out of the medication.

Kevin Pho: Sure. So what are the biggest reasons, just from your perspective, why people have those automatic refills, say, in the pantry, just piling up? What are the biggest barriers, from your perspective, that prevent optimal patient adherence to medications?

Tony Willoughby: I think it’s human nature. It’s not about adherence to drugs, right? If you think about being a pharmacist, when I was in pharmacy school, kinetics was one of my favorite classes. I’m a little bit of a nerd deep inside, and I think about drug dosing, how we dose drugs, right? We dose drugs, we get a peak, we try to keep it above a certain concentration level, and once it falls below, we dose again, right? That should resonate with all your clinicians.

Human behavior is the same way. You go to the physician’s office, you’ve got a new lab, you’ve got a new diagnosis, you’ve got a new opportunity to sit and talk to your physician and learn from him or her, and your engagement goes way up. Then you go home, and that dose starts falling under this minimum engagement. When we think about other programs, you get a trainer in a gym. Would you ever pay and go to a trainer, get a workout plan, and then look at him or her and say, “I’ll see you in 90 to 120 days,” and think that that would stick? But we decided that medications are our answer for chronic disease, and we built systems that allow you to come in, we give you 90 days, and then we say, “Go figure it out.”

I don’t think it’s a medication adherence problem. I don’t think it’s a human behavior problem. We’re not going to fix that behavior; it’s just going to get worse and worse because of our attention spans as individuals in a fast-paced world. What we’ve forgotten about is how we use collision points to keep pulse dosing engagement. Medication adherence is about medication engagement, and about patient engagement and empowered self-care, more so than all the transactional tools we try to solve it with.

Kevin Pho: So tell us some stories or case studies of how we could increase that engagement, because what you’ve been talking about pretty much describes my life as an internal medicine primary care doctor. I have patients come back every three to six months. We have automatic refills go until then. I see them in six months, I give them another six months of refills, and then that cycle keeps perpetuating. So tell us about some of your solutions. Tell us about how we can improve that engagement in between visits.

Tony Willoughby: I want to pull on that thread you introduced there. We talk a lot about the impact this has, and our solution that I’ll describe, on the quality of life of the patient. We also think it has a huge impact on quality of life across our provider spectrum. From a point of empathy, if I put myself in your shoes, the frustration is: “I set a plan, and I have plan one, and I’ve got this stair-step of plans I’m going to take this patient through. But each time they come back, it’s Groundhog Day, because stair-step one was never fully executed by the patient, no matter how much I advise, care, and passionately plead.” It’s just a frustrating part of our health care system in total, and that’s part of what we’re trying to solve there. It’s not blame on the system or on individuals in the system; it’s just a cultural view of it. It’s a system that’s flawed. How do we work together, not point at the individuals within it, to solve it?

So what we try to take advantage of is the dynamic of the medication: not seeing that the medication is a hindrance, or that adherence is the hindrance, or that there are noncompliant patients, but using the transaction to drive points of connection. That’s why I don’t like the idea of 90-day fills, because it erodes the frequency of the connection with the patient.

So in our model, we have to improve convenience, because we all want convenience in our lifestyle, but we wrap clinical interaction into all of what we call the moments that matter. If we go back to my caricature at the beginning, during the last few minutes of that physician interaction with the patient, when they give the medications, instead of asking, “Do you have any questions?” they say, “I’m going to connect you to a pharmacist who works side by side with me, who can help answer your questions in perpetuity,” right? And they bond that connection. Those pharmacists work in trusted-advisor relationships and panels, not just with their physicians but also with the patient. So there’s this trust triad that begins to form with those groups.

Then we use the natural rhythm and cadence of what’s common across chronic condition patients’ medications to allow those synchronized points of the transactional component to wrap around other clinical interventions. And then there’s a base frame there: Because they’re impaneled, and they know who their physician is and they know who their pharmacist is, they have free-rein access, when it’s early in the morning and they forgot to take a dose and they don’t know what to do, to connect on demand to one of those trusted members of the triad that they’re working with.

I’m a pharmacist, so I can critique this. A lot of pharmacists, well, we label pharmacists community pharmacists and clinical pharmacists. We’re all clinicians, right? So why do we, even in our own industry, separate the two? A lot of our pharmacists who’ll say, “I’m a clinical pharmacist,” like to divorce themselves from the product: “I don’t do dispensing. That’s something else.” I would argue that it’s one of the only places in the health care ecosystem where patients have to interact for something concrete in exchange. So instead of seeing that as a barrier, how do you see that as a gift to drive patient engagement behavior? We use all those little moments around a transaction to have a clinical interaction that’s really a patient empowerment and engagement interaction.

Kevin Pho: So from a practical standpoint, will that patient then have an app or a 1-800 number? How would that patient get in touch with the pharmacy consultant that you’re talking about?

Tony Willoughby: Yeah, we like to meet patients where they’re at, so we have multimodal approaches. We have an app to empower that, for those who work that way. For those who want to pick up a telephone and talk, we can do that, and for those who want to chat asynchronously or want to email. When I first started doing adherence research 10 or 15 years ago, everybody was looking for the silver bullet of what drives adherence, and the answer is an “all of the above, none of the above” type of answer, right? It’s multimodal, and it’s highly personal. What motivates each person, and also how we each like to communicate, is individual. So we try to meet patients where they’re at and give them flexibility in those answers. We’re expressing convenience in that way, not trying to speed them up through the queue to rush the transaction.

Kevin Pho: Sure. We’re talking to Tony Willoughby. He’s a pharmacist and health care executive. We’re talking about his latest KevinMD article, titled “Automatic refill and 90-day fill programs don’t improve medication adherence.” Tony, tell me about some of the outcomes from your intervention. How does it improve patient care?

Tony Willoughby: Yeah, it’s great. We look at it as a journey of an equation. First, we look at engagement: What’s the repeatability of the engagement with the patient? Once we see engagement start to solidify, we see adherence start to improve. As we see adherence start to improve, we see clinical markers begin to improve. And as clinical markers begin to improve, lo and behold, utilization and cost improve. It’s actually pretty linear and predictable, and it almost happens in these 30- to 60-day increments as you start to see each of those measurements improve.

So we have a high retention rate in the model with patients; it’s around 98 percent that we see as a retention rate. We see key clinical adherence improve. Usually, if you look at the traditional PDC measures, we’ll see average adherence rates in the low 90th percentile. We’ll break that measure: If we call a patient and they’ve had a tough month and they didn’t take all their metformin, we’re not auto-shipping them to manipulate a measure. We’re going to meet the patient where they’re at. So we’re happy with the range that we’re in.

As we see that engagement improve, we see clinical markers like A1C, hypertension, and hyperlipidemia measures improve. And then, on average, we’ll see a 15 to 25 percent change in total cost of care after we’ve stabilized patients over an 8-12 month period. These are chronic condition patients who have a higher total cost of care than the typical healthy patient, so there’s a bigger number to take a cost reduction off of, but we’ll see $200 to $300 PMPM reductions in costs, and we see it consistently. We’ve measured it in a bunch of ways, a bunch of different times, in different patient populations. When patients engage in their own health care and take their medications as prescribed by their physician, it works. We’re not doing anything special. We’re just driving engagement to the plan that the physician puts in place.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Tony Willoughby: Whether it’s my own kids at home or the audience itself: We live in a fast-paced world, and technology is fantastic, and we should use it in the moments where it makes sense, to accelerate and to gain efficiencies. We should also slow down in important moments and listen to the people that we’re caring for, to really hear them, because it’s easy to rush to “I’m going to give you a pill reminder,” or “I’m going to send you a text,” or “I’m going to do that.” But a lot of times, a patient will heal themselves if you listen to them long enough and find out what really matters to them, and you can solve it. Each human is unique. So the take-home that we learn over and over again is that when we slow down and listen in key moments, and hear what the patient or the physician is saying as feedback on a system, that’s when we make incremental improvements for that human, or for that client, or for anybody in any relationship.

Kevin Pho: Tony, thank you so much for sharing your time and insight, and thanks again for being on the show.

Tony Willoughby: All right, thank you, Kevin. Enjoyed it.

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