Sept. 02--Bob Nease oversees a laboratory where two dozen researchers and analysts pick through computer data from tens of millions of patients and hundreds of millions of prescriptions claims.
As chief scientist at Express Scripts, he is steeped in the world of pharmacy benefits -- including the hundreds of billions of wasted health care dollars involving patients who do not take their medicine as prescribed.
"It's our belief that optimal clinical behavior and patient behavior are inextricably linked," Nease said. "About a third to half of patients don't take their medications as prescribed."
His research team not only evaluates the medical and pharmacy impacts of the St. Louis-based company's latest pilot programs, but also the chances that an individual patient will run into trouble in not following their doctor's orders.
Express Scripts' focus on this aspect of behavioral science is one of the strengths the pharmacy benefit manager brings to its proposed $29 billion merger with its longtime rival, New Jersey-based Medco Health Solutions.
Nease, who began working with Express Scripts about 10 years ago, has spent his career doing research on medical decision-making, exploring ways for doctors and patients to make better health care decisions.
He previously served as an associate professor of internal medicine at Washington University in St. Louis. Before that, he was an assistant professor at Darmouth Medical School in the community and family medicine program.
Nease earned his Ph.D. at Stanford University, and spent the early part of his career researching patient attitudes and preferences -- for example, how a doctor can best find out what a patient is trying to achieve and adjust his treatment to fit the patient's needs.
"Learning what a patient wants is often just as important as finding out how severe the disease is," he said.
The Post-Dispatch sat down this week with Nease for an interview on these issues and his ongoing work in what the company calls "behavioral economics."
Why is noncompliance with prescription drugs a serious issue for some individual patients, and how does their noncompliance affect society as a whole?
Obviously, the most effective medication -- if not taken -- won't do any good. So, from a health standpoint, taking your medications as prescribed is Job One. Our estimate is that nonadherence is costing the country as a whole about $300 billion each and every year. So the size of the problem at the societal level is quite substantial.
As a researcher, how can you delve into this subject matter without intruding on patient confidentiality or the doctor-patient relationship?
Therapy adherence is a challenging problem. We now understand that patients generally wildly overestimate the rate at which they adhere to therapy, and that physicians have almost no visibility into the problem at a patient level. Companies like Express Scripts are really the only ones in the health care system that have access to the data necessary to identify patients who are having a problem taking their medications as prescribed.
According to your research, why do patients fail to adhere to their prescriptions?
The problems come in four buckets. The first is people who simply forget to take their medications every day. The second is a different kind of issue, which is procrastinating on getting a renewal. They have a prescription, they've run out of renewals, and then they put off going to see their doctor. And that creates a gap in care. There's a much smaller fraction of patients who have issues with costs, and they benefit from moving to a lower-cost drug or a lower-cost delivery channel or pharmacy. In the fourth case, there are patients who have real clinical issues: They think the drug is not working, they think it has side effects, or they're feeling medicalized. And those are folks who need to talk with a health care professional.
What appear to be the best strategies for encouraging patients to take their pills as prescribed?
Two steps: First, we identify in advance the patients who are likely to be nonadherent to therapy, and second, we reach out to each and every one of them and identify the likely obstacle to adherence. Once we've done that, we can address it.
So for people who have a hard time remembering to take their medications, we give them reminders. These would be very simple devices: beepers that go off when it's time to take your medication, a pill box, maybe a text message reminder. We help people get renewals if they need it. For people who are having issues with costs, we help them find a lower-cost option. And then for patients who have side effects or think the drug is not working, we can connect them with one of our pharmacists.
What issues or questions is your research now focusing on?
One of the most interesting things we've discovered is that the gap doesn't seem to be between what employees want and what employers want; the gap seems to be between what employees want and what employees do when it comes to their health care.
People know they should be taking their medications as prescribed. They know they should be using lower-cost options when that's possible. They know they should be exercising more, they should be eating better.
People generally know what the right thing to do is. The most interesting thing we've discovered is the gap between people's intentions and their actual behaviors. So we're focused intensely on activating these underlying good intentions that most patients have.
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