"Better health and higher work productivity through sustainable changes in patient behavior" is the title of a recent meta-analysis by Booz & Co and the Bertelsmann Foundation, which aims to demonstrate the "effects of increased therapy adherence." In this analysis, the authors – Peter Behner, Ab Klink, and Sander Visser (Booz), as well as Jan Böcken and Stefan Etgeton (Bertelsmann Foundation) – drew on data from five selected chronic diseases, but attempted to capture not only the direct but, above all, the economic costs in this review. In this interview, Peter Behner (Managing Director of the Berlin office of Booz & Company and Head of the European Health Practice), Ab Klink (Senior Executive Advisor of the Health Practice of Booz & Company Amsterdam, previously Minister of Health, Welfare and Sport in the Netherlands) and Sander Visser (Member of the Executive Board of Booz & Company Amsterdam) explain their motivations, the learnings and the possible next steps to address adherence (see also MA&HP 4/13 and Pharma Relations 8/13).
>> Mr. Behner, Mr. Klink, and Mr. Visser, with the meta-analysis "Better health and higher work productivity through sustainable changes in patient behavior," your company – Booz & Co. – together with the Bertelsmann Foundation is attempting to demonstrate the effects of increased treatment adherence. Now, the topic of compliance or adherence is not a new one, but one that has never really been on the health policy agenda. Why not? Or, to put it like the devil's advocate: Who has an interest in non-compliance or non-adherence?
Behner: From our perspective, the question of who might benefit from noncompliance is irrelevant, because currently, none of the parties involved benefit. A doctor or pharmacist cannot charge fees if they invest time in supporting treatment adherence. There simply isn't enough time available for this, as we have imposed an enormous workload on our doctors. Doctors don't have time to consult with patients to discuss their treatment goals and understanding, or their fears and everyday problems. Of course, this doesn't mean that doctors are solely financially motivated—far from it. But they simply cannot invest a significant portion of their time in activities that are not remunerated.
Klink: It's not just about incentives and time allocation, but also about organization. The design and structure of our healthcare system dates back to a time when most medical care was acute and primarily required one-time diagnoses and treatments. Our hospitals and medical facilities are optimized for this, and they do so efficiently and effectively. However, such a model doesn't work to meet today's challenges regarding prevention and ongoing health maintenance. In our view, treatment adherence is less about traditional medicine than about behavior. Therefore, we should ask ourselves whether we can effectively leverage networks of patients, family members, friends, etc., to promote adherence.
In your meta-analysis, you draw on data from five selected chronic diseases in Germany, the United Kingdom, and the Netherlands, which recur annually and cause enormous economic damage. According to your meta-analysis, this damage amounts to between €38 billion and €75 billion in Germany, between €28 billion and €50 billion in the United Kingdom, and between €9 billion and €13 billion in the Netherlands. Until now, the cost of non-compliance in Germany has always been around €5 billion. Where does this glaring gap come from? Is it solely due to the fact that your analysis extrapolates productivity losses, taking into account restrictions due to absence, "presenteeism" (attendance with reduced ability to work), and incapacity for work?
Behner: Most studies on non-compliance examine the impact of poor adherence on medical costs. They typically estimate costs associated with hospital admissions or doctor visits for non-compliant patients. Our approach was different: We looked at the costs of non-compliance associated with lost productivity. Previous scientific studies in this area have examined the effects of sickness absence for a specific indication or the effects of specific interventions such as group coaching on adherence. In our study, we put the pieces of the puzzle together to obtain a holistic picture. We examined presenteeism, absenteeism, and incapacity for work. Incidentally, this is a rather restrictive definition—it doesn't even include the partially hampered career development of employees or the impact on their caring families, for example.
Visser: The reason we looked at labor productivity was the aforementioned lack of incentives among medical professionals and, to some extent, among health insurance companies. Our study showed that employers (and the tax authorities) would benefit most from improved treatment adherence, alongside individual patients. This simple conclusion shows us who needs to be addressed when developing adherence programs.
You've presented your analysis in both German and English-speaking countries. What were your experiences? How are stakeholders reacting, especially payers and politicians?
Behner: Most stakeholders welcome the idea of achieving productivity gains through investments in adherence programs. However, if you look at the practical side, there are differences. Important differences in the cultural context, the regulatory framework, and social systems. By this, we don't mean the differences between English- and German-speaking countries; the discussion in Germany and the Netherlands is also different.
Klink: In the Netherlands, we see that employers, employer associations, and unions are interested. For example, we are working with physiotherapists and pharmacists in the Netherlands to develop products for employers. The leading insurer, Achmea, is also interested in incorporating such elements into its group health programs.
Visser: There's a strong "non-interference culture" in Germany. This is also evident in the debate surrounding the health card, where doctors use their professional independence as a key argument. Consequently, there's also resentment against employers who exert influence, as some people think employers might overstep their bounds. We firmly believe that a solution must always be tailored to the cultural context. Employee privacy is something that must be guaranteed to be successful. We believe in voluntary participation in adherence programs, not mandatory monitoring measures.
Visser: In the US, for example, there's generally more freedom when it comes to data; IT data exchange occurs between doctors, pharmaceutical companies, and health insurance companies. This opens up opportunities for data-driven programs that are difficult to implement in Germany.
In your analysis, you consider approaches to improving therapy adherence to be complex to implement, yet quite a few of them have been successful in isolated cases and in specific individual settings. In your recommendation, you write: "If these were implemented more widely and rigorously, they could unlock enormous potential benefits." Which flagship projects are you referring to?
Behner: Of particular note here are the high-quality patient service centers in the biotech and orphan drug sectors (multiple sclerosis and rheumatoid arthritis). These centers achieve a significant reduction in treatment dropouts, but they are also very expensive (approximately €350 to €500 per patient in the first six months).
An important key question you raise in your analysis is whether there is a role for unions/collective bargaining partners in negotiating such programs and agreements? What is the position of unions and employers on this issue?
Klink: In the Netherlands, unions are increasingly interested in this. There are several reasons for this. First, it opens up new win-win opportunities with employers, so it's good to have such issues on the table during negotiations. Second, after years of moderate wage growth, which will likely continue to be under pressure in the future, they are looking for alternatives to create benefits for their members. Third, as retirement age increases, the issue of employability becomes increasingly important.
Behner: In Germany, the unions are probably less open than in the Netherlands, given the cultural background we discussed earlier. But here, too, this is an opportunity.
The analysis proposes four strategies that are suitable for removing existing barriers and ensuring the establishment of practices for improved treatment adherence: The creation and implementation of incentives for physicians, nurses, and patients to firmly integrate the aspect of treatment adherence into treatment plans, with a focus on quality rather than quantity. Then, the exploration and establishment of new business and service models in the healthcare system that are better suited to establishing treatment adherence with the involvement of all stakeholders. And finally, the reorientation of health services research to measure the effects of treatment adherence in a scientifically and evidence-based manner, to benefit from best practices, and to optimize incentive models. Furthermore, the expansion of the active participation and role of employers, payers, and health insurers in the context of treatment adherence, with a focus on health security and increased productivity, should be considered. What might a master plan that addresses these four points look like?
Behner: We will have to bring the individual stakeholders together within the framework of a large adherence alliance to put the issue on the agenda. The benefits of therapy adherence are largely undisputed, and everyone can therefore support such a mandate.
Visser: When it comes to the question of exactly how to achieve this, there are many conceivable ways. Our study shows that employers have the greatest direct benefit from adherence improvements. They can be expected to drive initiatives on this topic, either by directly purchasing corresponding services or by requesting specific services from health insurance companies. Benefit-sharing concepts for healthcare providers and pharmaceutical companies could also inform such program approaches.
Klink: We also strongly advocate for healthcare professionals to be compensated for the time they spend promoting adherence. For example, in 2011, new performance definitions for pharmacists were introduced in the Netherlands, allowing them to receive services such as medication reviews and treatment adherence monitoring.
Behner: We should also consider regulating research. The government should commission studies that evaluate adherence to certain medications after market access, as well as the services designed to promote adherence. This isn't just another hurdle for pharmaceutical companies, but a new way to create added value through product development that helps patients adhere to their treatment. The results of such studies must have consequences. They can be translated into a price discount or premium, or reimbursement itself could be tied to the results of the studies.
Your analysis certainly provides an important overview of findings, but due to the nature of the study, it only includes those already known from other experimental studies. Wouldn't it be time to use an RCT study with the highest possible level of evidence to demonstrate whether and what effects increased treatment adherence actually has? And, if possible, also which instruments show the best effects? What should be done?
Behner: We would definitely welcome more research in the area of treatment adherence, especially with high-quality RCT studies. In general, we believe there is great untapped potential in the field of health services research.
Klink: However, we also believe that we should approach such things through a learning-by-doing process. We expect few universally applicable answers. The question is, which therapy adherence interventions help whom and for which disease? This is a trial-and-error process, and the literature and practice already provide sufficient starting points to get started.
Mr. Behner, Mr. Klink, and Mr. Visser, thank you very much for the interview. <
The interview was conducted by MVF editor-in-chief Peter Stegmaier.
