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, patient-centric approach that considers individual patient needs and results in intelligent interventions that combine high-tech with high-touch.

1. 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, patient-
centric approach that considers individual patient needs and results in
intelligent interventions that combine high-tech with high-touch.
Executive Summary
It’s 11:00 AM, and Jack — diagnosed just last week
with diabetes — is in a state of uncertainty. His
doctor prescribed multiple meds: the critical insu-
lin 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 break-
fast, 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. Non-
adherence to a therapeutic regimen can result
in negative outcomes, and it can be compound-
ed 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 medi-
cation adherence, including:
• How changing industry dynamics are reshaping
healthcare delivery.
• The impact of non-adherence on healthcare’s
so-called Triple Aim.
• How non-adherence is being managed today.
• 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 expendi-
tures 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.
• Cognizant 20-20 Insights
cognizant 20-20 insights | october 2014

2. 2cognizant 20-20 insights
Growth Opportunities
Meanwhile, industry growth has been fostered
by an aging population, the prevalence of chron-
ic 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 adop-
tion of smartphones, as well as the prevalence of
3G and 4G networks, are significantly boosting
the use of mobile platforms for providing health-
care services; indeed, by 2015, approximately 500
million people will use healthcare apps on their
mobile device.6
All of these trends are culminat-
ing 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 val-
ue-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 healthcare’s Triple Aim, a framework devel-
oped by the Institute for Healthcare Improvement
that is intended to optimize health system per-
formance. Its three tenets include improving the
patient experience, improving population health
and reducing the per capita cost of healthcare.
Non-adherence increases the cost burden on all
major stakeholders in the healthcare system, as
the resulting health declines can require utiliza-
tion 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, hyperten-
sion and dyslipidemia is $453 per adult.10
Non-adherence leads to
deteriorating health out-
comes across patient
types. In a study of
mortality rates in dia-
betes and heart disease
patients, non-adherers
had much higher mortal-
ity rates (12.1%) compared
with adherers (6.7%).11
Non-adherence due to
communication inef-
ficiencies among care
providers in U.S. hospitals
costs approximately $12
billion per annum.12
One
school of thought postu-
lates that instead of spending billions of dollars
on creating new medications to cure chronic dis-
eases, applying a fraction of that cost to helping
patients adhere to their medications would actu-
ally have a much more significant impact on the
healthcare system and the health of the popula-
tion as a whole.
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
One school of thought
postulates that instead
of spending billions on
creating new medications
to cure chronic diseases,
applying a fraction of
that cost to helping
patients adhere to their
medications would have
a more significant impact
on the health of the
population as a whole.
Quick Fact

3. 3cognizant 20-20 insights
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 don’t account for the fact that non-
adherence 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-size-
fits-all” approach is not effective; one-tool
solutions often become marginalized if the pro-
gram 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
patient’s intentional and unintentional beliefs)
and external factors (those related to the health-
care system, family support, the therapy regimen,
the condition itself and socioeconomic factors)
can influence whether a patient follows the pre-
scribed healthcare advice. All of these factors
have a powerful influence on patient decision-
making and behavioral change.
0
10
20
30
40
50
60
Cholesterol
Diabetes (type 2)
Obesity
Hypertension
Depression
3 months
AdherenceRates(%)
6 months 12 months
60%
53%
48%
30%
20%
47%
41%
34%
43%
38%
35%
10%
8%
52%
41%
Plummeting Adherence Levels Across Therapeutic Areas Over Time
* Adherence rates were averaged. Source: Various sources; A. T. Kearney analysis
Figure 1
The Health Belief Model proposes that patients
act on treatment recommendations when they believe that
the benefits of treatment outweigh treatment barriers.
Quick Fact

4. cognizant 20-20 insights 4
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.
The Emerging Adherence Paradigm
of Patient Centricity
In the patient-centric model, patients are empow-
ered 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 leverag-
ing healthcare technologies to engage patients in
the management of their own healthcare spend-
ing by encouraging them to pursue healthier
choices and lifestyles that can help contain long-
term 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 appro-
priate preventive and primary care to manage
their health conditions.
What Patient Centricity Means for
Various Stakeholders
Today’s healthcare environment has led hos-
pitals, 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 adher-
ence. However, payers are increasingly working
to ensure their members have better health
outcomes and lower costs. ACOs are also heav-
ily incentivized to manage overall patient health,
making adherence an important factor for them.
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 health-
care by offering a set of adherence services along
with their product.
Acquiring new patients costs pharmaceuticals
companies an average of 62% more than retaining
the ones they already serve.16
Since pharmaceuti-
cals companies have limited
interaction with patients
compared with healthcare
providers and payers, they
sometimes work collab-
oratively with ACOs and
payers to reduce the cost
of therapies and improve
outcomes. However, sever-
al major pharmaceuticals
companies are now work-
ing to engage with patients
directly.
An example is the active
collaboration between
Medco Health (a pharma-
cy benefit manager) and Sanofi (a leading global
pharma company). Working together, these com-
panies launched a head-to-head clinical trial of
Plavix (clopidogrel) and Effient (prasugrel) that
highlighted not just which molecule is more effi-
cacious 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 therapeu-
tically benefit from the generic version of Plavix
and thus reduce their treatment costs. Such col-
laborative approaches will demonstrate the value
of determining appropriate treatment pathways
for a particular condition rather than just ran-
domly assessing the efficacy of individual drugs
in a sample representing all patients.18
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.
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
Quick Fact

5. 5cognizant 20-20 insights
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 ecosys-
tem — 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-adher-
ence, 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
patient’s point of view.
Understanding the Patient Journey and
Identifying Moments of Truth
Developing a patient-centric adherence frame-
work starts with understanding the patient’s
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 sev-
eral “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 interac-
tion challenges.
To resolve these challenges, key ecosystem play-
ers must leverage the many sources of rich data
available to them, as well as the latest technolo-
gies to collect and analyze this data. We call this
the “5 C’s”: collect data, capture events, con-
nect stakeholders, compress time and create
opportunities.
Patient-centric Adherence Framework
Patient interactions within the healthcare ecosys-
tem are exceedingly complex; therefore, a holistic
medication adherence framework is needed to
facilitate critical interactions with and collabo-
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
Personal instrumentation
(BYOhD)
TECHNOLOGY BEHAVIOR CHANGE CONNECT • Improved Health Outcomes
• Lower Costs
• Enhanced Experience
Social, gamification,
analytics
Virtual and human
health coaches
Three-Pronged Approach to a Coordinated Care System
Figure 2
Quick Fact

6. cognizant 20-20 insights 6
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
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 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
An Approach for Monitoring
Patient Adherence
Patient enters
with specific beliefs
and motivations.
Patient
stratification
Self-help and
education
Delivering
insights to
patients
Intelligent
interventions
Outcome
monitoring
Figure 3
DIRECT
Direct Observation
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)
Data Collection
• Rx refill data
• Claims data
Assessment
Parameters
• Drug adherence
index
• Medication
possession ratio
• Proportion days
covered
Secondary Data
Electronic MonitoringBehavior/Physiological
Markers Assessment
Measurement of Biological
Markers
INDIRECT
“Gold Standard” of
Adherence Assessment
• BYOhD-based
self-monitoring devices
(e.g., smartphone apps,
Fitbit, etc.)
• E-pills
Adherence Assessment Methods
Figure 4

7. 7cognizant 20-20 insights
data across different systems and channels
to develop a unique virtual identity, or Code
Halo.TM 20
Metadata from a patient’s 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 patient’s
wellness.
Predictive surveys are questionnaires supplied
to patients that can help predict their behavior
and enable segmentation. A list of industry-
approved predictive surveys is presented in
Figure 5.
By using the “big data” created and lever-
aged by BYOhD platforms and predictive
surveys, health providers can obtain deep
insights into patient behavior. Advanced ana-
lytics techniques, such as causal networks and
group-based therapy modeling, can be applied
to this data to further help organizations seg-
ment patients based on behavioral patterns
and their risk of non-adherence, which in turn
helps to develop better intervention strategies
designed to improve adherence.
• 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 (14th-
grade) level, patient education should be made
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
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.
Quick Fact

8. cognizant 20-20 insights 8
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 pro-
viders (HCP), caregivers and patients.
>> Multiple access mechanisms such as Web
portals and mobile devices (BYOhD).
>> Multichannel communications (SMS, e-
mail and IVR) that enable patients to use
their channel of choice.
>> Gamification techniques to increase en-
gagement 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 pa-
tient 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 them-
selves in the process and benefit from it.
>> Use of social media such as Facebook and
Twitter to create forums and user communi-
ties.
• Delivering insights to patients: Health
providers need to develop analytics that enable
them to review the progress of patients’ self-
management and predict behavior patterns
in order to identify high-risk patients who are
likely to stop engaging and design interven-
tion models to motivate them. By analyzing
the patient’s 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.
For example, a diabetic patient who experi-
ences 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 deliv-
er insights to patients that encourage them
to change their behaviors. Strong analytical
and segmentation capabilities are also impor-
tant 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.
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.
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.
Quick Fact
Quick Fact

9. 9cognizant 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 orga-
nizations 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 aren’t
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
Person-
alized 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 moni-
toring 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 provid-
ers 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 one’s 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 dis-
ease-related health costs.
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
Quick Fact

10. cognizant 20-20 insights 10
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:
Rx Revenue / (Medical Costs + Pharmacy
Costs + Intervention Costs) = ROI
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 pharma-
ceuticals revenue of $1,129; a mean medical cost
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
Meta-Analysis of Adherence Studies Covering Cost-Related
Benefits of Medication Adherence
Study Disease
Total healthcare cost Total medical cost Prescription revenue ROI
Totalhealthcare
cost>80%adherent
Totalhealthcare
savings<79%
adherent
Totalhealthcare
savings
Totalmedicalcost
>80%adherent
Totalmedicalcost
<79%adherent
Totalmedical
savings
Rxcosts>80%
adherent
Rxcosts<79%
adherent
IncreasedRx
revenue
Totalhealthcost
savings/increased
drugcost
Study 1
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
Hyper-
cholestrolemia
6,752 10,916 4,164 4,780 9,849 5,069 1,972 1,067 905 4.6
CHF 22,164 23,964 1,800 19,056 22,003 2,947 3,107 1,961 1,146 1.6
Study 2
CHF 37,762 45,823 8,061 33,113 42,549 9,436 4,649 3,274 1,375 5.9
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
Study 3 Hypertension 4,871 6,062 1,191 6,570 10,286 3,716 489 31 458 2.6
Mean $15,303 $19,142 $3,839 $12,779 $18,005 $5,226 $2,798 $1,668 $1,129 3.5
Figure 7

11. cognizant 20-20 insights 11
savings of $5,226; a mean total healthcare sav-
ings of $3,413; and a mean ROI of 3.5 (i.e., every
additional dollar spent on medicines by high-
adherence 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), hyperten-
sion and hyper-cholesterolemia (see Figure 7,
previous page).
A wide range of cost offsets and healthcare sav-
ings for patients demonstrating adherence to
medications across chronic conditions are often
observed.
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 rele-
vant in each therapeutic area and for each brand.
When designing an adherence program, organiza-
tions need to ensure a focus on:
• A collaborative patient-centric approach.
• A solid foundation of cutting-edge technology,
such as BYOhD, gamification and analytics.
• Customizable, scalable and sustainable
services for patients.
• 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.
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/.
2
“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/.
3
“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.
4
“Home Care Providers in the U.S.: Market Research Report,” IBIS World, September 2014, http://www.ibis-
world.com/industry/default.aspx?indid=1579.
5
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.
6
“Mobile Health Trends and Figures 2013-2017,” Research2Guidance, http://www.research2guidance.com/
shop/index.php/mobile-health-trends-and-figures-2013-2017.
7
“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.
8
“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.
9
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-read-
missions.aspx.

12. cognizant 20-20 insights 12
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-budgets-
have-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 technolo-
gies, mobile applications, video games, etc.) created for the purpose of changing people’s 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=UTF-
8&oe=UTF-8.
23
B. J. Fogg’s 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 ele-
ments 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.
Fogg’s 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 physi-
cal activity levels. For more information, see “The Health Action Process Approach,” http://web.fu-berlin.
de/gesund/publicat/ehps_cd/health/hapa.htm.

13. About Cognizant
Cognizant (NASDAQ: CTSH) is a leading provider of information technology, consulting, and business process out-
sourcing services, dedicated to helping the world’s 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.
World Headquarters
500 Frank W. Burr Blvd.
Teaneck, NJ 07666 USA
Phone: +1 201 801 0233
Fax: +1 201 801 0243
Toll Free: +1 888 937 3277
Email: inquiry@cognizant.com
European Headquarters
1 Kingdom Street
Paddington Central
London W2 6BD
Phone: +44 (0) 20 7297 7600
Fax: +44 (0) 20 7121 0102
Email: infouk@cognizant.com
India Operations Headquarters
#5/535, Old Mahabalipuram Road
Okkiyam Pettai, Thoraipakkam
Chennai, 600 096 India
Phone: +91 (0) 44 4209 6000
Fax: +91 (0) 44 4209 6060
Email: inquiryindia@cognizant.com
­­© Copyright 2014, Cognizant. All rights reserved. No part of this document may be reproduced, stored in a retrieval system, transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise, without the express written permission from Cognizant. The information contained herein is
subject to change without notice. All other trademarks mentioned herein are the property of their respective owners.
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 Cognizant’s 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 Cognizant’s efforts to penetrate the gov-
ernment and energy-utilities sectors, globally.
Siva Thiagarajan is a team member of Cognizant’s 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 company’s Solutions
Architecture & Technology Practice within the Life Sciences and Healthcare Business Unit. He is also
CTO of Cognizant’s connected health, patient engagement and BYOhD ventures within the EBA organi-
zation. He holds a master’s degree in computer science from Indian Institute of Science, Bangalore, India.
Arvind Kumar is a Manager and a subject matter expert within Cognizant’s patient engagement ven-
tures, working to incubate innovative and transformational businesses for Cognizant’s healthcare and
life sciences customers. Arvind holds a master’s of business administration in marketing and in bioinfor-
matics and completed a graduate degree in biotechnology.
Shweta Seth is a Business Analyst and a subject matter expert in Cognizant’s patient engagement ven-
tures. She has played a pivotal role in the development of Cognizant’s patient engagement platform. She
works closely with venture leads and currently supports the go-to-market team in its business develop-
ment 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.