The Complicated Fight Over the Morisky Scale

Back in September, Avery Orrall at Retraction Watch reported on the retractions of two papers, both of which were retracted for using the Morisky Medication Adherence Scale (MMAS) without a license.

That, by itself, is not unusual. Retractions for copyright reasons aren’t common, but they do happen somewhat regularly. One year ago, almost to the day, I looked at two other studies that were retracted for using unlicensed software. 

However, these two latest studies are just the latest chapter in a long-running story over the MMAS. It’s a story that involves a protracted lawsuit between the scale’s creator and his business partner, license fees that can reach tens of thousands of dollars, and dozens of retractions by researchers who were unaware they needed to obtain the license.

The situation has left many researchers frustrated. Many have found themselves unable to use one of the field’s standard tools. However, it’s a standard that’s also being challenged both in the courtroom and scholarly publishing. 

To understand what is going on, we need first to understand what the MMAS is and why it’s become so controversial.

A Brief History of the MMAS

The MMAS is a questionnaire designed to assess a patient’s compliance with medication regimens. It asks questions such as “Do you sometimes forget to take your ______ medication?” and “Did you take your _______ medicine yesterday?”

The goal is to gauge patient compliance and enable doctors to intervene if issues arise. 

According to Adherence, Morisky codified the MMAS-4, the scale’s first version, in 1986. This version contains just four questions. According to them, this version has an internal consistency of .68. 

Between 1993 and 1997, Morisky, as part of a grant from the National Institutes of Health, codified the MMAS-8. The MMAS-8 is an eight-question variant of the MMAS-4 that provides more detail. According to Adherence, its reliability has risen to .83. 

Hospitals and other care clinics have widely used the MMAS to track patient compliance. It’s also widely used by researchers, including those testing new drugs for efficacy and safety, as well as those studying drug compliance itself.

However, it’s become such a standard in this space that many don’t realize they need a license to use it. Those licenses can be costly. If you’re running a study with 500 participants and wish to use the MMAS-8, it will cost at least $3,500. The cost will be higher with more administrations or any translations.

If that amount seems high, it’s still much cheaper than the cost of copyright litigation. According to Dave Hansen at the Authors Alliance, MMAS Research LLC and Adherence have filed dozens of lawsuits, many of which are still active, over the use of the MMAS.

However, that may not be the biggest fight over the MMAS. There’s a much bigger one going on behind the scenes.

The Battle Over Who Owns the MMAS

One interesting thing about the MMAS is that, even though it’s named after Morisky, he has had little involvement in its licensing, at least in the last ten years. 

According to a legal filing by Morisky, in 2011, Morisky founded MMAS Research CA to handle licensing of the MMAS. MMAS Research CA handled MMAS licensing from 2011 to 2014.

In 2014, Morisky signed a deal with Steven Trubow and a company named Olympic Labs. According to Morisky, Olympic Labs, and later MMAS Research LLC, would handle the licensing of the MMAS. In exchange, Morisky would retain ownership of all relevant intellectual property and receive 50% of all licensing fees.

The relationship lasted roughly 5 years. However, in 2019, cracks began to show and, in March 2020, Morisky says he terminated the licensing agreement.

According to Morisky, MMAS Research LLC had made false claims about ownership of the scale and had not provided a full accounting of the money owed. Morisky then filed a lawsuit in May 2020, but that was quickly settled.

However, according to Morisky, MMAS Research LLC quickly breached the settlement and continued infringing on his work. The two sides then sued each other in 2021. One of those cases is currently scheduled for a trial in March.

Of particular controversy is the MMAS Widget. This is a small piece of computer software that displays and scores the questionnaire. According to Morisky, this was coded by Dustin Machi at the request of Trubow and MMAS Research. LLC Morisky claims that MMAS Research LLC registered itself as the owner of the widget, even though the original agreement would have made him the owner of all derivatives of the MMAS.

To be clear, Trubow disputes this and claims that he has complied with the terms of the agreement and that any claims of ownership came from a proper transfer. He contends that MMAS Research LLC is the proper rightsholder.

The case is ongoing, with new filings being made just yesterday. However, a different ruling may make much of this fight completely pointless.

A Fight Over Nothing

In August 2024, MMAS Research LLC, under the name Adherence, filed a lawsuit against CVS. According to the lawsuit, a CVS subsidiary created the “Asembia-1 platform”, which included both the MMAS-4 and the MMAS-8.

However, CVS moved to dismiss the copyright claims. It cited a 1989 9th Circuit case holding that blank forms lacking information were not eligible for copyright protection. 

As such, in June 2025, the judge ruled that neither the MMAS-4 nor the MMAS-8 is entitled to copyright protection and dismissed the copyright claims. The other issues in the case were quickly settled.

To be clear, this case doesn’t address trademark issues or any issues attached to the widget. But it does mean that the scales themselves are, almost certainly, not protectable under copyright.

This puts the battle between Marisky and Trubow in an awkward position. Though they are wrangling over who owns what and which licenses were and were not granted, the protectability of the questionnaires is looking, at best, extremely dicey.

Though some elements are still in play, this ruling torpedoes the core argument that both Morisky and Trubow have used over the past decade-plus to charge high license fees for the use of the scales.

However, this may not even be the biggest threat to the MMAS. 

A Scientific Debate

Disclosure: I am not an expert on this kind of statistical analysis. I am relying on Retraction Watch’s reporting and the post’s comments for guidance on this issue.

One of the papers that pushed MMAS to become an industry standard was a 2008 paper by Morisky published in the Journal of Clinical Hypertension. It is the often-cited study that found the scale had a reliability of 0.83 and was a valuable tool for researchers.

However, that study has since been retracted. 

The story of that retraction began in 2019, when Michael Ortiz identified flaws in the reported sensitivity and specificity of the MMAS-8. He initially tried to bring the issues to Morisky’s attention, but nothing happened.

Ortiz then took his issues to the journal, but they ignored him until April 2021, when he published a letter challenging the paper. According to Ortiz, the MMAS was no better than a coin flip in detecting patients with uncontrolled blood pressure. 

The journal and its publisher investigated the paper and, in August 2023, formally retracted the paper. At the time, it had been cited nearly 1,900 times. 

In a comment to the Retraction Watch post, Morisky said that Ortiz’s analysis was flawed and that other studies have backed up his results. In the comment, he concluded:

“This issue is far from over. The Journal’s mismanagement of our responses/rebuttals, its false claims we never responded, will be appealed because of scientific, business, and legal ramifications. Retraction Watch and other blogs will be reversing Ortiz’s faulty analysis.”

However, as of this writing, the article is still retracted. 

Still, just as with the copyright questions surrounding the MMAS, these debates are ongoing as well.

Bottom Line

Bizarrely, this story reminds me of the controversy surrounding the song “Happy Birthday to You.” 

For decades, Warner/Chappell music charged licensing fees for commercial performances of the song. While you could sing it around your dinner table, if you featured it in a TV show, movie or a restaurant, you could face a hefty license fee.

For decades, many suspected the song was actually in the public domain. But it was always cheaper and easier to pay the license fee than to fight it out in court. However, in June 2013, filmmaker Jennifer Nelson filed a class action lawsuit against Warner/Chappell over the song.

Two years later, in September 2015, a judge ruled that the copyright claims were invalid.

However, one big difference is that, with the MMAS, it’s being besieged on all sides. A judge has already ruled that there’s no copyright protection for the scales, there’s an ongoing fight over ownership, and researchers are openly questioning their validity as a tool.

While I agree with Morisky that this isn’t over yet, there’s little doubt that things don’t look good for the MMAS right now.

It’s clear that some form of change is coming, though it will be interesting to see exactly what that change is.