“Medication Adherence” is a Lunatic Endeavour


John G. Singer outlines why a focus on patients’ adherence to their medication is not necessarily useful in working to improve health outcomes and why innovation is more sorely needed in markets and strategies, not technologies and analytics.


“Monty Python and the Holy Grail,” which opened yesterday at the Cinema 2, is a marvelously particular kind of lunatic endeavor.

It’s been collectively written by the Python troupe and jointly directed by two of them (Terry Gilliam and Terry Jones) so effectively that I’m beginning to suspect that there really aren’t six of them but only one, a fellow with several dozen faces who knows a great deal about trick photography…

…I particularly liked a sequence in which the knights, to gain access to an enemy castle, come up with the idea of building a Trojan rabbit. When Arthur calls retreat, he simply yells: “Run away!”

From The New York Times review of the film, April 28, 1975


Since time immemorial, “medication adherence” has been the Holy Grail, a rumored $300 billion a year treasure pursued by every dimension of the now USD 3.6 trillion health economy in the United States. And everyone follows the same journey to the same illogical and incomplete end, a circle of fragmented action through conceptual obsolescence that hasn’t changed perspective since the dawn of time: “Poor adherence to medication contributes to negative health outcomes.”

Into this passage of dead language we now add telehealth as the latest maybe fix, the central player in a heroic narrative in which new technology is positioned in the starring role. To wit this from “Silver Lining to Coronavirus Crisis: Telehealth May Improve Patient Adherence And Persistence” in the June 9 Forbes:


“For decades, poor medication adherence has been recognized as a significant and persistent problem in the healthcare system. Since a report published in 2000 by the US Department of Health and Human Services, numerous studies have shown that up to 50 percent of patients exhibit varying degrees of non-adherence and non-persistence.

Poor adherence and persistence contribute to negative health outcomes, particularly for patients with chronic illnesses, such as cardiovascular disease, diabetes, HIV, and depression.

Telehealth services can be deployed as a tool to improve medication adherence and persistence.”


Everyone is conjuring from pipe smoke.


The belief in technology as a benevolent, self-healing, autonomous force is seductive and addictive. It allows us to feel optimistic about the future while relieving us of responsibility for that future, explains Nicholas Carr in Rough Type, his blog exploring the intersection of business, technology and culture. Digital is the magical wave all can ride to growth, a surfboard of possibility that leads to ever-greater speeds, compressions, efficiencies.


It particularly suits the interests of those who have become extraordinarily wealthy through the labor-saving, profit-concentrating effects of automated systems and the computers that control them (good news for investors in Teladoc, which is now worth over $12 billion, and Apple, which on June 10 became the first US company to achieve a $1.5 trillion market capitalization).


“But the real sentimental fallacy is the assumption that the new thing is always better suited to our purposes and intentions than the old thing,” Carr writes. “That’s the view of a child, naive and pliable. What makes one tool superior to another has nothing to do with how new it is. What matters is how it enlarges us or diminishes us, how it shapes our experience of nature and culture and one another.”


There are many barriers to medication adherence. Cost, side effects, the challenge of managing multiple prescriptions (polypharmacy), patients’ understanding of their disease, forgetfulness, cultural and belief systems, imperfect drug regimens, patients’ ability to the health care system, cognitive impairments, a reduced sense of urgency due to asymptomatic conditions (“I don’t feel sick – I don’t need the medicine”), etc, etc, etc, etc….


Successful interventions mean reframing competition to centre on creating health system value. It calls for system entrepreneurship, collaboration on shared marketspace that pulls together and integrates a complete set of interactive tools and incentives, according to a research brief on the topic by the New England Healthcare Institute, a nonprofit, health policy institute focused on enabling healthcare innovation. Published in the summer of 2009, it asks the fundamental question:


“Whether poor adherence can and should be addressed as a stand-alone issue, or whether it is best addressed more indirectly by intensifying effort on other health policy reforms?”


The world has a technology problem in the sense that scientific and technological progress has been sputtering for a while. Which sounds weird but underscores the storytelling problem wired into our mental circuitry: the things that need “innovation” are markets and strategies, not technologies and analytics.


We’re at the moment of the Great Fork.


Navigating the moment begins with new narratives to invent new pathways. The unmet need is an alternative form of contemplation, a novel way of seeing and describing the world at a system level, without conceptual divisions, because the existing habits of making sense and tacking action aren’t tracking with reality.


Like the Flying Circus who cohered into one, the infinite and expanding galaxy of pieces that “can” produce health need to cohere as new economic systems.


Until then, “medication adherence” is a Trojan rabbit.




John G. Singer advises business and government on health system vision and value innovation. He leads Blue Spoon Consulting, the pioneer of ‘big design’ as a methodology to drive large-scale system change.

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