Cognizant 20-20 Insights

Medication Adherence in the Real World

Medication non-adherence is a growing concern, as it is increasingly
associated with negative health outcomes and higher cost of care.
Tackling the burden of non-adherence requires a collaborative, patientcentric approach that considers individual patient needs and results in
intelligent interventions that combine high-tech with high-touch.
Executive Summary
Its 11:00 AM, and Jack diagnosed just last week
with diabetes is in a state of uncertainty. His
doctor prescribed multiple meds: the critical insulin shot, oral anti-diabetics and multivitamins to
build immunity, with a total of five doses to be
taken per day. Having just finished a late breakfast, Jack is pondering the instruction to take
his meds with breakfast every morning, followed
by another dose before noon. He takes out his
pill box but wonders, Should I take both doses
together or skip the first one?
Adherence to medication is one of the most
intriguing and complex of patient behaviors. Nonadherence to a therapeutic regimen can result
in negative outcomes, and it can be compounded in populations with chronic illness because of
the extended duration of multiple drug therapies.
This white paper explores key issues and provides
solutions to crucial challenges concerning medication adherence, including:

How changing industry dynamics are reshaping

healthcare delivery.

The impact of non-adherence on healthcares

so-called Triple Aim.

How non-adherence is being managed today.

cognizant 20-20 insights | october 2014

The causes of non-adherence behavior by

patients.

The emerging paradigm of patient centricity in

adherence.

How the healthcare industry should tackle the

burden of non-adherence.

How adherence is related to return on

investment (ROI).

Industry Dynamics Reshape

Healthcare Delivery
The burden of chronic disease is rapidly increasing
worldwide. Expected to account for three-fourths
of all deaths globally by 20201, chronic illness
is straining the healthcare capacity of many
countries that lack the resources to provide
adequate healthcare services. By 2035, the global
shortage of healthcare providers is expected to
be 12 million.2
These problems, coupled with increase expenditures on health and long-term care, will continue
to put pressure on public budgets over the coming
years, with healthcare costs in the U.S. alone
expected to reach nearly 4.8 trillion in 2021.3 As
these trends continue, more healthcare systems
will seek innovations to combat these challenges.

Quick Fact
A recent study shows that nearly half of the pharmaceuticals
industry (45.7%) believes that value-added services and a
beyond the pill strategy will show a financial return within
two to three years.7

Growth Opportunities
Meanwhile, industry growth has been fostered
by an aging population, the prevalence of chronic disease and increased physician acceptance of
home care, a market that was estimated at nearly
$74 billion in 2013.4 The industry will continue to
transition toward cost-efficient treatment options
from public and private payers.5 Increasing adoption of smartphones, as well as the prevalence of
3G and 4G networks, are significantly boosting
the use of mobile platforms for providing healthcare services; indeed, by 2015, approximately 500
million people will use healthcare apps on their
mobile device.6 All of these trends are culminating in a digital revolution and sparking a set of
innovative services to combat the challenges
facing the healthcare system.
Industry interest in patient engagement has
spiked, influenced by the release in late August
2012 of the Meaningful Use Stage 2 Final Rule by
the U.S. Centers for Medicare & Medicaid Services
(CMS). Now that patient engagement is being
called the biggest blockbuster drug of the century,
pharmaceuticals and healthcare industry players
need to reconfigure their resources to develop
innovative business models that are based on value-added services related to prescription drugs
for chronic conditions.

Non-adherence and the Triple

Healthcare Aim
Understanding and addressing the impact of
medication non-adherance dovetails perfectly
with healthcares Triple Aim, a framework developed by the Institute for Healthcare Improvement
that is intended to optimize health system performance. Its three tenets include improving the
patient experience, improving population health
and reducing the per capita cost of healthcare.

cognizant 20-20 insights

Non-adherence increases the cost burden on all

major stakeholders in the healthcare system, as
the resulting health declines can require utilization of more expensive services, such as those
found in the acute or long-term care system. This
creates a vicious cycle of deteriorating health
outcomes and increasing healthcare costs.
For instance, non-adherance amounts to $289
billion in annual wasted costs in the U.S. alone.8
Aditionally:

Payers and providers losses due to increased

hospital readmission for medicare patients is
$26 billion per decade.9

The average cost of non-adherence for adult

patients diagnosed with diabetes, hypertension and dyslipidemia is $453 per adult.10

Non-adherence leads to One school of thought

deteriorating health outpostulates that instead
comes across patient
types. In a study of of spending billions on
mortality rates in dia- creating new medications
betes and heart disease
to cure chronic diseases,
patients,
non-adherers
had much higher mortal- applying a fraction of
ity rates (12.1%) compared that cost to helping
with adherers (6.7%).11
patients adhere to their
Non-adherence due to
communication
inef- medications would have
ficiencies among care a more significant impact
providers in U.S. hospitals
on the health of the
costs approximately $12
12
billion per annum. One population as a whole.
school of thought postulates that instead of spending billions of dollars
on creating new medications to cure chronic diseases, applying a fraction of that cost to helping
patients adhere to their medications would actually have a much more significant impact on the
healthcare system and the health of the population as a whole.

Plummeting Adherence Levels Across Therapeutic Areas Over Time

60

50

60%
52%

53%
48%

43%

Adherence Rates (%)

47%

40

30

Cholesterol
41%
38%

41%
34%

Diabetes (type 2)

35%

30%

Obesity
20%

20

Hypertension

10

Depression

10%
8%

0
3 months

6 months

12 months

* Adherence rates were averaged. Source: Various sources; A. T. Kearney analysis

Figure 1

Traditional Management of
Non-adherence
Conventional health models have historically
placed patients with different health conditions
into distinct disease management programs.
The traditional approach of designing programs
that address individual adherence barriers has
resulted in extremely siloed health management
programs. These programs are less effective
because they dont account for the fact that nonadherence is caused by the presence of multiple
factors.13 Studies reveal that many patients stop
taking their medication, and adherence rates
plummet, in just a few months, with 50% to 90%
of patients stopping their prescribed therapies by
the end of the first year of treatment (see Figure 1).14
Individual adherence solutions, such as patient
education, pharmacy programs, awareness
campaigns and financial rewards, can impact

adherence in certain situations, but a one-sizefits-all approach is not effective; one-tool

solutions often become marginalized if the program does not address the underlying barriers
of adherence.

Understanding the Causes of

Non-Adherence
The reasons for patient non-adherence are
complex and multifactorial, and an effective
coordinated care model needs to consider all of
the underlying causes. Both internal factors (a
patients intentional and unintentional beliefs)
and external factors (those related to the healthcare system, family support, the therapy regimen,
the condition itself and socioeconomic factors)
can influence whether a patient follows the prescribed healthcare advice. All of these factors
have a powerful influence on patient decisionmaking and behavioral change.

Quick Fact
The Health Belief Model proposes that patients
act on treatment recommendations when they believe that
the benefits of treatment outweigh treatment barriers.
cognizant 20-20 insights

Quick Fact
Patient adherence budgets for U.S. pharmaceuticals
companies have jumped 281% from $400,000 in 2009
to $1.5 million in 2012. In a study of 18 small, medium and
large pharmaceuticals companies, 12 had dedicated patient
adherence teams. Human health behavior professionals,
who can better understand patients motivations, psychology
and emotions are increasingly a part of these teams.17
Some studies have found that several features
of the therapeutic regimen are correlated with
adherence. For example, the more the patient
must change his or her lifestyle, the less likely he
or she is to follow recommendations. In addition,
the less complicated the treatment regimen, the
higher the rate of adherence.

Pharmaceuticals companies have more recently

ventured into adherence management, in the
interest of preventing patients from switching to
competitive offerings, influencing positive health
outcomes and reducing the overall cost of healthcare by offering a set of adherence services along
with their product.

The Emerging Adherence Paradigm

of Patient Centricity

Acquiring new patients costs pharmaceuticals

companies an average of 62% more than retaining
the ones they already serve.16 Since pharmaceuticals companies have limited
interaction with patients The more the
compared with healthcare
providers and payers, they patient must change
sometimes work collab- his or her lifestyle,
oratively with ACOs and the less likely he
payers to reduce the cost
of therapies and improve or she is to follow
outcomes. However, sever- recommendations.
al major pharmaceuticals In addition, the less
companies are now working to engage with patients complicated the
directly.
treatment regimen,

In the patient-centric model, patients are empowered to participate in their own care alternatives,
and healthcare providers are there to support
patients and engage in joint decision-making
based on individual patient situations. This new
model also places greater emphasis on leveraging healthcare technologies to engage patients in
the management of their own healthcare spending by encouraging them to pursue healthier
choices and lifestyles that can help contain longterm medical costs.
Approximately 69% of total healthcare costs are
heavily influenced by consumer behaviors.15 Thus,
in the new patient-focused paradigm, the basic
driver is to get patients to change their behavior
by making healthier choices and seeking appropriate preventive and primary care to manage
their health conditions.
What Patient Centricity Means for
Various Stakeholders
Todays healthcare environment has led hospitals, physician groups and payers to develop
accountable care organizations (ACOs), which are
designed to slow spending growth and improve
care quality. Each of these stakeholders (payers,
providers, ACOs, pharma companies) has a role to
play in increasing patient adherence. Traditionally,
providers have educated patients on adherence. However, payers are increasingly working
to ensure their members have better health
outcomes and lower costs. ACOs are also heavily incentivized to manage overall patient health,
making adherence an important factor for them.
cognizant 20-20 insights

the higher the rate

An example is the active

collaboration
between of adherence.
Medco Health (a pharmacy benefit manager) and Sanofi (a leading global
pharma company). Working together, these companies launched a head-to-head clinical trial of
Plavix (clopidogrel) and Effient (prasugrel) that
highlighted not just which molecule is more efficacious but also which patients would be best
suited to which drug. Plavix showed poor efficacy
in 25% of patients, who might respond better to
Effient; however, the other 75% could therapeutically benefit from the generic version of Plavix
and thus reduce their treatment costs. Such collaborative approaches will demonstrate the value
of determining appropriate treatment pathways
for a particular condition rather than just randomly assessing the efficacy of individual drugs
in a sample representing all patients.18

Three-Pronged Approach to a Coordinated Care System

TECHNOLOGY
Personal instrumentation
(BYOhD)

BEHAVIOR CHANGE
Social, gamification,
analytics

CONNECT
Virtual and human
health coaches

Improved Health Outcomes

Lower Costs
Enhanced Experience

Figure 2

Achieving a Patient-centric Approach

To develop a collaborative and patient-centric
accountable care system, stakeholders need to
adopt a three-pronged approach that combines
pure technology tools, behavioral modification
and a connected health ecosystem (see Figure 2).
Devices and sensors can increase self-monitoring
and management; gamification and analytics
techniques can be used to identify and engage
patients and bring about behavior change; and a
well-developed IT infrastructure can help connect
various stakeholders in the healthcare ecosystem physicians, paramedic staff, care providers,
payers, pharmaceuticals companies, pharmacies
and health coaches whose support is necessary
to develop an all-inclusive integrated support
system for the patient.

An Adherence Framework
To address the issue of medication non-adherence, we have developed a patient-centric model
that is sensitive to patient needs and wants. An
effective adherence model must use a holistic
patient engagement framework that is designed
to address the causes of non-adherence from a
patients point of view.

Understanding the Patient Journey and

Identifying Moments of Truth
Developing a patient-centric adherence framework starts with understanding the patients
beliefs and motivation levels throughout the care
journey. For any disease state, patients progress
through different stages, including diagnosis,
treatment and care. Patients also experience several moments of truth: They want to be heard,
receive feedback on their progress and share
their experiences. All of these interactions need
to be seamless so that patients can focus on their
care rather than being caught in a web of interaction challenges.
To resolve these challenges, key ecosystem players must leverage the many sources of rich data
available to them, as well as the latest technologies to collect and analyze this data. We call this
the 5 Cs: collect data, capture events, connect stakeholders, compress time and create
opportunities.
Patient-centric Adherence Framework
Patient interactions within the healthcare ecosystem are exceedingly complex; therefore, a holistic
medication adherence framework is needed to
facilitate critical interactions with and collabo-

Quick Fact
The collaboration of multiple stakeholders (physicians, nurses,
pharmacists and payers) is essential for patient adherence,
especially to prescription medications, as well as increasing
patient-centricity. With physicians and pharmacists involved
in the patient recruitment cycle, organizations can expect
a jump in program enrollments in the range of 17% to 36%
based on regions and disease type.19
cognizant 20-20 insights

An Approach for Monitoring

Patient Adherence

allows for the fact that each patient enters the

care cycle with different beliefs and motivation
levels (see Figure 3). Framework considerations
should include:

Patient enters
with specific beliefs
and motivations.

Patient stratification: Patients need to be

categorized in different ways, and customized
engagement programs need to be designed for
the different segments. Different adherence
methods are applicable to different situations,
depending on the type of adherence being
assessed, the precision required and the
intended application of the results. As there
is no gold standard for measuring patients
adherence to medicines, and no single tool
to detect all types of non-adherence, the
choice of method for measuring adherence
to a medication regimen should be based on
its usefulness and reliability for a particular
patient profile, therapeutic area, drug under
consideration, etc.

Data collection: Data received from predictive

surveys and past behavior (self-reported,
quantify-me device data, EHR integration)
can be used to segment patients into different
strata (see Figure 4). Patients should be able to
use their own health devices and smartphones
to measure, integrate and track their health
data; we call this a BYOhD platform (or bring
your own healthcare device). Such a platform
provides the flexibility to capture patient

Patient
stratification

Outcome
monitoring

Intelligent
interventions

Delivering
insights to
patients

Self-help and
education

Figure 3
ration among various stakeholders. The guiding
principle for such a framework is enabling patient
engagement to improve health outcomes.
An effective patient-centric adherence framework

Adherence Assessment Methods

DIRECT

INDIRECT

Direct Observation

Behavior/Physiological
Markers Assessment

Measurement of Biological
Markers

Figure 4

Secondary Data

Self Reporting
Data Collection
Surveys
Interviews
Patient diaries
Assessment
General scales
(e.g., Morisky, MARS)
Therapy-specific
(e.g., Hill-Bone
Compliance Scale for
hypertensive patients)

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Data Collection
Rx refill data
Claims data
Assessment
Parameters
Drug adherence
index
Medication
possession ratio
Proportion days
covered

Electronic Monitoring
Gold Standard of
Adherence Assessment
BYOhD-based
self-monitoring devices
(e.g., smartphone apps,
Fitbit, etc.)
E-pills

Industry-Approved Predictive Surveys

Illustrative List of Validated Predictive Surveys
Scale Name

Description

ASRQ Scale (Adherence Self Report

Questionnaire)

Outpatients taking anti-hypertensive

ARMS (Adherence to Refills and Medication Scale) Patients with coronary heart disease / hypertension
Brooks Medication Adherence Scale

Adults with asthma

Composite Self Report Measure

Homecare patients over 65 years of age

MAQ (Medication Adherence Questionnaire)

Used across populations

Shortest scale

MARS (Medication Adherence Rating Scale)

Psychiatric disorders

Morisky 4 and Morisky 8

Across populations

BMQ (Brief Medication Questionnaire)

Patients with hypertension, diabetes mellitus,

hypercholesterolemia, hypothyroidism or condition
requiring HRT

SEAMS (Self-efficacy for Appropriate Medication

Use)

Low-literacy patients

VAS (Visual Analogue Scale)

Across populations

Figure 5

surveys, health providers can obtain deep

insights into patient behavior. Advanced analytics techniques, such as causal networks and
group-based therapy modeling, can be applied
to this data to further help organizations segment patients based on behavioral patterns
and their risk of non-adherence, which in turn
helps to develop better intervention strategies
designed to improve adherence.

data across different systems and channels

to develop a unique virtual identity, or Code
Halo.TM 20 Metadata from a patients Code Halo
(i.e., diagnostic codes, treatments, elements of
the electronic medical record, etc.) can be used
to create a profile within a particular segment
to help personally manage the patients
wellness.
Predictive surveys are questionnaires supplied
to patients that can help predict their behavior
and enable segmentation. A list of industryapproved predictive surveys is presented in
Figure 5.

Self-help

and education: Enabling patients

with self-help tools and an understanding
of their condition is critical to helping them
manage and maintain wellness. While most
medical literature is written at a college (14thgrade) level, patient education should be made

By using the big data created and leveraged by BYOhD platforms and predictive

Quick Fact
Pharmaceuticals companies Boehringer Ingelheim and Eli Lilly
launched the largest ever global survey to investigate early Type
2 diabetes. The study was conducted in partnership with the
International Diabetes Federation in December 2013 and involved
more than 10,000 people with Type 2 diabetes and more than
6,500 treating physicians from 26 countries. The intent was to
investigate how early conversations between physicians and
patients with Type 2 diabetes could be optimized. Insights from
the survey will be used to develop solutions to support primary
care physicians and people with Type 2 diabetes.
cognizant 20-20 insights

Quick Fact
Pharmaceuticals companies are increasingly using
gamification to engage patients to improve adherence and
outcomes. Merck, for example, developed a game called the
Type 2 Travelers Project to encourage patients to follow
the treatment regimen of its diabetes drug Januvia, as well
as manage other aspects of their health.

them to review the progress of patients selfmanagement and predict behavior patterns
in order to identify high-risk patients who are
likely to stop engaging and design intervention models to motivate them. By analyzing
the patients Code Halo, organizations can not
only predict non-adherence among high-risk
patients but also correlate how multiple events
are interconnected, and then share these
insights with patients to help them embrace
healthier habits.

more engaging by simplifying medical and

clinical content to a fifth-grade level. Emerging
technologies and tools enable effective
education delivery to patients, including:

>> Collaboration

tools among healthcare providers (HCP), caregivers and patients.

>> Multiple access mechanisms such as Web

portals and mobile devices (BYOhD).

>> Multichannel

communications (SMS, email and IVR) that enable patients to use

their channel of choice.

For example, a diabetic patient who experiences a hypoglycemic attack may discover
that the episode is correlated to poor diet and
medication non-adherence, perhaps as a result
of an underlying attitude that the patient has
toward the drug. Correlating this information
and developing an effective intervention using
an analytics engine can help providers deliver insights to patients that encourage them
to change their behaviors. Strong analytical
and segmentation capabilities are also important for tracking and understanding changes
in adherence levels and behavior patterns over
time. As patients change, organizations must
map them to new segments and design new
interventions.

>> Gamification

techniques to increase engagement and adoption. Pharmaceuticals

companies often use interactive games and
other reward systems within their mobile
initiatives to keep patients engaged with
their healthcare. While self-reporting data
is essential to tracking and measuring patient outcomes and behaviors, self-reporting
rates are usually very poor due to low patient
motivation levels. Gamification can provide
a driving force for patients to involve themselves in the process and benefit from it.

>> Use of social media such as Facebook and

Twitter to create forums and user communities.

Delivering insights to patients: Health

providers need to develop analytics that enable

Quick Fact
When a U.S.-based PBM wanted to optimize expense management
on therapy adherence programs, it set a goal of offering the
right programs to the right members. The PBM used a statistical
predictive model to predict member adherence behavior and
deployed different retention strategies for patients on the basis of
observed behavior patterns. The improved targeting resulted
in high rates of adherence for diabetes/lipids therapies and a high
ROI for the adherence programs.

cognizant 20-20 insights

Providing intelligent interventions: Actively

engaging patients with self-help tools for
health management can be achieved through
captology21 concepts, in which virtual coaches
deliver alerts, notifications and motivational
messages to drive positive behavior change.
If virtual health coaches do not significantly
impact positive behavior change, real health
coaches can intervene to offer a human
element.
Outcome monitoring: It is critical for organizations to understand the impact of active
interventions on the health and well-being
of patients. Tracking which interventions are
effective and revising the ones that arent
is critical to properly monitoring outcomes.
The B.J. Fogg model helps to deliver small
behavioral changes that eventually drive
large behavioral change in patients.23 Personalized delivery of these interventions can be
achieved by building AI-based causal models
that increase understanding of the causes of
the current behavior and target the right areas
for intervention. Reusable models such as the
Health Action Process Approach (HAPA) can
also help explain causality in health behavior.24
Just as it is important to influence outcomes,
it is equally important to track the ROI of
patient segments to make adherence monitoring programs financially viable. Identifying
high-value patients and revising rewards
mechanisms to meet their needs is an equally
important component.

Measuring ROI of Adherence Programs

Adherence can be an important area of focus for
pharmaceuticals companies, payers and providers to maximize their ROI. An inherent problem
with adherence programs is the difficulty of
obtaining and demonstrating ROI. Recent studies
document the multiple issues that complicate the
determination of financial ROI:

The lack of a standard approach for reporting

costs.

The healthy user effect: Short-term studies

tend to yield highly positive results. The type

of patients who voluntarily enroll in a study
and actually follow the experimental regimen
is not typically representative of the general
population. Participants can be expected, on
average, to be healthier, as they are concerned
about their health and are predisposed to
follow medical advice, both factors that would
aid ones health.

Time preference trade-off: Stakeholders may

be willing to trade short-term increases in
medication costs and complementary goods
and services for long-term savings or health
gains.

The

time required to attain ROI differs

across stakeholders: Increased medication
adherance might result in an instantaneous
ROI for pharmaceuticals companies, but
adherence over a longer timeframe is required
for patients to observe a reduction in their disease-related health costs.

Quick Fact
Health coaching can improve lifestyle behaviors known to
prevent or manage chronic conditions. A study conducted by
AtlantiCare, a large not-for-profit healthcare system in New
Jersey, suggests that the involvement of primary care physician
and health coach teams can improve outcomes and reduce costs
for complex patients. The study found that improvements in
self-management behaviors and clinical outcomes led to lower
utilization, a significant slowdown in the annual rate of cost
increases and markedly higher levels of patient satisfaction.
Patients enrolled in the program reported much higher levels of
satisfaction compared with their previous experience, with gains
of 30 to 40 percentage points on questions related to access
and timeliness of care, respect for the patient, time spent with
the provider, communication and coordination of care between
the primary care team and specialists.22
cognizant 20-20 insights

Adherence Studies Included in Meta-analysis

Study

Research

Author

Year

Sample

Disease

Study 1

Costs of Chronic Disease

Sokol

2005

15,085

Diabetes
Hypertension
Hypercholesterolemia
CHF

Study 2

CVS Caremark and CSM

Roebuck MC

2010

135,008

CHF
Diabetes
Hypertension

Study 3

Blood Pressure Reduction,

Persistence and Costs in the
Evaluation of Hypertension

Bramlage P

2009

7,981

Hypertension

Figure 6

An ROI framework should take into account

common measures, such as annual medication
costs, direct medical costs and total healthcare
costs, as well as the savings associated with each.
An ROI calculation can be performed using the
following formula:

Financial Outcomes Resulting from Increased

Medication Adherence
We conducted a meta-analysis of a sampling of
studies related to adherence. The mean, median,
standard deviation, minimum observed value and
maximum observed value were calculated for
total healthcare savings, total medical savings and
increased pharmaceuticals revenue (see Figure
6). The cost-related benefits of proper medication
adherence included a mean increase in pharmaceuticals revenue of $1,129; a mean medical cost

Rx Revenue / (Medical Costs + Pharmacy

Costs + Intervention Costs) = ROI

Meta-Analysis of Adherence Studies Covering Cost-Related

Benefits of Medication Adherence

Study 2
Study 3
Mean

Total medical cost

>80% adherent

Total medical cost

<79% adherent

Total medical
savings

Rx costs >80%
adherent

Rx costs <79%
adherent

Increased Rx
revenue

Total health cost

savings / increased
drug cost

ROI

Total healthcare
savings

Study 1

Prescription revenue

Total healthcare
savings <79%
adherent

Study

Total medical cost

Total healthcare
cost >80% adherent

Total healthcare cost

Diabetes

8,886

16,498

7,612

6,377

15,186

8,809

2,510

1,312

1,198

6.4

Hypertension

8,386

9,747

1361

6,570

8,831

2,261

1,817

916

901

1.5

Hypercholestrolemia
CHF

6,752

10,916

4,164

4,780

9,849

5,069

1,972

1,067

905

4.6

22,164

23,964 1,800

19,056

22,003

2,947

3,107

1,961

1,146

1.6

CHF

37,762

45,823 8,061

33,113

42,549

9,436

4,649

3,274

1,375

5.9

Disease

Diabetes

19,311

21,116

1,805

14,725

18,501

3,776

4,586

2,615

1,971

0.9

Hypertension

14,292

19,006

4,714

11,041

16,835

5,794

3,251

2,171

1,080

4.4

Hypertension

4,871

6,062

1,191

6,570

10,286

3,716

489

31

458

2.6

$1,668

$1,129

3.5

$15,303 $19,142 $3,839 $12,779 $18,005 $5,226 $2,798

Figure 7

cognizant 20-20 insights

10

savings of $5,226; a mean total healthcare savings of $3,413; and a mean ROI of 3.5 (i.e., every
additional dollar spent on medicines by highadherence patients resulted in $3.50 in savings
on total healthcare-related costs). The maximum
adherence-related ROI was observed in diabetes,
followed by congestive heart failure), hypertension and hyper-cholesterolemia (see Figure 7,
previous page).
A wide range of cost offsets and healthcare savings for patients demonstrating adherence to
medications across chronic conditions are often
observed.

A collaborative patient-centric approach.

A solid foundation of cutting-edge technology,
such as BYOhD, gamification and analytics.

Customizable,

scalable
services for patients.

and

sustainable

Multi-channel capabilities and multi-modal

messaging to facilitate personalized patient
communications.

Live health coaches to support and augment

virtual interventions to bring about behavior
change.

Strong governance and capabilities to integrate

and support the entire value chain across

geographies.

Looking Forward
Medication adherence programs offer a vast
potential for reducing healthcare costs and
improving health outcomes. However, the design
and implementation of an adherence program
that engages patients and results in sustainable
change requires both expertise and experience
to determine which behavioral factors are relevant in each therapeutic area and for each brand.
When designing an adherence program, organizations need to ensure a focus on:

Patient-centered care is about enhancing the

patient experience. It enables players across the
healthcare landscape to better meet patients
needs by respecting their time, informing them,
understanding them as individuals, answering
their questions, connecting them with their data
and their ecosystem and allowing caregivers to
actively participate in patient well-being.

Footnotes
1

Global Burden of Chronic Disease, World Health Organization, http://www.who.int/nutrition/topics/

2_background/en/.

A Universal Truth: No Health without a Workforce, Global Health Workforce Alliance and World
Health Organization, November 2013, http://www.who.int/workforcealliance/knowledge/resources/
hrhreport2013/en/.

National Health Expenditure Projections, Centers for Medicare & Medicaid Services, 2011-2012,
http://www.cms.gov/Research-Statistics-data-and-Systems/Statistics-Trends-and-Reports/
NationalHealthExpendData/Downloads/Proj2011PDF.pdf.

Home Care Providers in the U.S.: Market Research Report, IBIS World, September 2014, http://www.ibisworld.com/industry/default.aspx?indid=1579.

Bobbi Coluni, Save $36 Billion in U.S. Healthcare Spending through Price Transparency, Thomson
Reuters, February 2012, http://www.hreonline.com/pdfs/06022012Extra_ThomsonReutersStudy.pdf.

Mobile Health Trends and Figures 2013-2017, Research2Guidance, http://www.research2guidance.com/

shop/index.php/mobile-health-trends-and-figures-2013-2017.

Value Added Services Report, Eyeforpharma, Sept. 16, 2013, http://www.eyeforpharma.com/

value-added-services-report/?utm_source=PR+WEB&utm_medium=External+website&utm_
content=press+release&utm_campaign=2445.

Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the U.S.,
Annals of Internal Medicine, Dec. 4, 2012, http://www.ncbi.nlm.nih.gov/pubmed/22964778.

Jordan Rau, Medicare Prepares Rule to Penalize Hospitals with High Readmission Rates, Kaiser Health
News, July 30, 2011, http://www.kaiserhealthnews.org/stories/2011/july/30/medicare-and-hospital-readmissions.aspx.

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10

Kamyar Nasseh, Sharon Glave Frazee, Jay Visaria, Anna Vlahiotis and Yuhong Tian, Cost of Medication
Nonadherence Associated With Diabetes, Hypertension, and Dyslipidemia, American Journal of
Managed Care, March 29, 2012, http://www.ajmc.com/publications/ajpb/2012/AJPB_MarApr2012/
Cost-of-Medication-Nonadherence-Associated-With-Diabetes-Hypertension-and-Dyslipidemia.

11

The Role of Medication Adherence in the U.S. Healthcare System, Avalere Health, June 2013, http://
static.correofarmaceutico.com/docs/2013/06/24/adher.pdf.

12

R. Agarwal, D. Z. Sands and J. D. Schneider, Quantifying the Economic Impact of Communication

Inefficiencies in U.S. Hospitals Journal of Healthcare, July-August 2010 , Vol. 55, No. 4, pp 265-81.

13

Patient Adherence: The Next Frontier in Patient Care, Capgemini, 2011, http://www.pt.capgemini.com/
resource-file-access/resource/pdf/Patient_Adherence__The_Next_Frontier_in_Patient_Care.pdf.

14

Various sources; A.T. Kearney analysis.

15

Medication Adherence: Managing for Total Value, The Foundation for Managed Care Pharmacy, 2011,
http://amcp.org/uploadedFiles/FMCP/Resources/FMCP_Adherence_Slides.pdf.

16

Patient Adherence: The Next Frontier in Patient Care, Capgemini, 2011 http://www.pt.capgemini.com/
resource-file-access/resource/pdf/Patient_Adherence__The_Next_Frontier_in_Patient_Care.pdf.

17

Stephanie Baum, Pharma Patient Adherence Budgets Have Increased 281 Percent in Four Years,
Medcity News, Oct. 12, 2012, http://medcitynews.com/2012/10/pharma-patient-adherence-budgetshave-increased-281-percent-in-four-years/.

18

Warren K. Williams, Key PBM Functional Areas Require Radical Transformation, Managed Care, August
2012, http://www.managedcaremag.com/archives/1208/1208.pbm-functions.html.

19

Sundiatu Dixon Fyle, Shonu Gandhi, Thomas Pellathy and Angela Spatharou, Changing Patient Behavior:
The Next Frontier in Healthcare Value, McKinsey & Co., 2012, http://www.google.co.in/url?sa=t&rct=j&q=
&esrc=s&frm=1&source=web&cd=1&ved=0CC0QFjAA&url=http%3A%2F%2Fwww.mckinsey.com%2F~%
2Fmedia%2Fmckinsey%2Fdotcom%2Fclient_service%2FHealthcare%2520Systems%2520and%2520
Services%2FHealth%2520International%2FIssue%252012%2520PDFs%2FHI12_64-73%2520PatientB
ehavior_R8.ashx&ei=Uj1hUoqNHsnsrAe7qoGwCg&usg=AFQjCNFa25xhB96amLMHyfqc3xp9xVH7NA&bv
m=bv.54934254,d.bmk.

20

For more on Code Halos, read Code Rules: A Playbook for Managing at the Crossroads, Cognizant
Technology Solutions, June 2013, http://www.cognizant.com/Futureofwork/Documents/code-rules.pdf,
and the book, Code Halos: How the Digital Lives of People, Things, and Organizations are Changing the
Rules of Business, by Malcolm Frank, Paul Roehrig and Ben Pring, published by John Wiley & Sons. April
2014, http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118862074.html.

21

Captology is the study of computers as persuasive technologies. This includes the design, research and
analysis of interactive computing products (computers, mobile phones, Web sites, wireless technologies, mobile applications, video games, etc.) created for the purpose of changing peoples attitudes or
behaviors. B. J. Fogg derived the term captology in 1996 from an acronym: Computers as Persuasive
Technologies, or CAPT. Source: Stanford Persuasive Tech Lab.

22

Primary Care Physician and Health Coach Teams Improve Outcomes and Reduce Costs for Complex
Patients, Agency for Healthcare Research & Quality, http://search.ahrq.gov/search?q=cache:he
gBt4Z85noJ:innovations.ahrq.gov/content.aspx%3Fid%3D2941+health+coach&output=xml_no_
dtd&proxystylesheet=AHRQ_GOV&client=AHRQ_GOV&site=default_collection&access=p&ie=UTF8&oe=UTF-8.

23

B. J. Foggs Behavior Model shows that three elements must converge at the same moment for a behavior
to occur: motivation, ability and trigger. When a behavior does not occur, at least one of those three elements is missing. Fogg founded the Persuasive Technology Lab at Stanford University, where he directs
research and design. In addition, he devotes at least half his time to industry projects and innovations, all
of which focus on using technology to change behaviors in positive ways. For more information, see B. J.
Foggs Behavior Model, http://www.behaviormodel.org/.

24

The health action process approach (HAPA) is a psychological theory of health behavior change. It was
developed by Ralf Schwarzer, professor of Psychology at the Free University of Berlin in Germany. HAPA
is an open framework of various motivational and volitional constructs that are assumed to explain and
predict individual changes in health behaviors such as quitting smoking or drinking, and improving physical activity levels. For more information, see The Health Action Process Approach, http://web.fu-berlin.
de/gesund/publicat/ehps_cd/health/hapa.htm.
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About the Authors

Nagaraja Srivatsan has more than 25 years of experience in the information technology industry and
deep knowledge of the healthcare and life sciences domain. Currently, he is part of Cognizants Emerging
Business Accelerator (EBA) leadership team. In this role, he identifies, incubates and grows innovative
and transformational ventures for new markets, platforms and solutions within the healthcare and life
sciences industry. In addition, he is the venture partner guiding Cognizants efforts to penetrate the government and energy-utilities sectors, globally.
Siva Thiagarajan is a team member of Cognizants patient engagement solutions team within its Life
Sciences Business unit. He has 18 years of experience in life sciences across the pharmaceuticals,
biotech and medical device sectors and has worked across the business consulting, technology and
business process services spaces, leading consulting engagements in the area of patient engagement.
Siva earned an M.B.A. from Columbia University.
Suresh Ganesan is an Associate Vice-President at Cognizant and heads the companys Solutions
Architecture & Technology Practice within the Life Sciences and Healthcare Business Unit. He is also
CTO of Cognizants connected health, patient engagement and BYOhD ventures within the EBA organization. He holds a masters degree in computer science from Indian Institute of Science, Bangalore, India.
Arvind Kumar is a Manager and a subject matter expert within Cognizants patient engagement ventures, working to incubate innovative and transformational businesses for Cognizants healthcare and
life sciences customers. Arvind holds a masters of business administration in marketing and in bioinformatics and completed a graduate degree in biotechnology.
Shweta Seth is a Business Analyst and a subject matter expert in Cognizants patient engagement ventures. She has played a pivotal role in the development of Cognizants patient engagement platform. She
works closely with venture leads and currently supports the go-to-market team in its business development activities. Shweta is a pharmacist and has received education in pharmaceuticals marketing.
Dr. Elby Nash is a Solutions Partner with Cognizant's Life Sciences Solutions Architecture & Technology
(SAT) practice. Dr. Nash has been a senior management consultant, executive and technology innovation
leader in the pharmaceuticals, medical device and other industries for over 30 years. He is an expert on
mobile technology, connected health and the deployment of wireless and mobile technologies to drive
business differentiation and productivity.
For more information, contact us at HealthActivate@cognizant.com.

About Cognizant
Cognizant (NASDAQ: CTSH) is a leading provider of information technology, consulting, and business process outsourcing services, dedicated to helping the worlds leading companies build stronger businesses. Headquartered in
Teaneck, New Jersey (U.S.), Cognizant combines a passion for client satisfaction, technology innovation, deep industry
and business process expertise, and a global, collaborative workforce that embodies the future of work. With over 75
development and delivery centers worldwide and approximately 187,400 employees as of June 30, 2014, Cognizant
is a member of the NASDAQ-100, the S&P 500, the Forbes Global 2000, and the Fortune 500 and is ranked among
the top performing and fastest growing companies in the world. Visit us online at www.cognizant.com or follow us on
Twitter: Cognizant.

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