The Collaborative Forum

I had the privilege of attending an expert round table meeting in Boston yesterday sponsored by the New England Healthcare Institute focusing on the healthcare waste associated with medication non-adherence.  The conference, entitled appropriately: “Thinking Outside the Pillbox – A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease”, was a deep and thoughtful discussion led by Cliff Goodman.  The blue ribbon panel included the likes of Troy Brennan, MD, Chief Medical Officer of CVS Caremark, John Fallon, MD, Chief Physician Executive of Blue Cross Blue Shield of Massachusetts, and John Halamka, MD, Chief Information Officer of Harvard Medical School, to name just a few.

The frame-up of the “problem” for discussion was a 2007 report by NEHI updating the cost estimates of poor medication adherence.  Key findings in the report, entitled “Waste and Inefficiency in the Health Care System – Clinical Care: A Comprehensive Analysis in Support of System-wide Improvements” and updated in the July 2009 NEHI Research Brief on Medication Adherence for Chronic Disease include:

• Poor medication adherence is increasingly recognized as another significant source of waste in our healthcare system
• An estimated 1/3 to 1/2 of all patients in the US do not take their medications as prescribed by their physician
• Otherwise avoidable medical spending, resulting directly from non-adherence, is as much as $290 Billion per year or 13% of TOTAL HEALTHCARE EXPENDITURES…ouch!

Further exploration of the problem of medication non-adherence suggest that a systems approach is required to both understand the issues leading to non-adherence, and to design simple and effective solutions to this problem.  A few of the “system” challenges that were discussed included:

• Patient out of pocket costs (more on this issue below)
• New daily behavior is challenging to learn and involves multiple issues like patient education, health literacy, patient “activation” level, and the challenges of remembering one more new thing.
• Solutions to everything from medication reconciliation to side effect monitoring to medication taking behavior will require INFORMATION TECHNOLOGY.  Not just information technology, though, but information process redesign.

Three pillars of system reform were discussed and ten “improvement levers” were highlighted.  The three pillars:

1. Improve Drug Regimens.  In other words, designing the right medication regimen for the individual patient.  This pillar was felt to be important because medication adherence could not be expected or sustained if patients were expected to take the wrong treatments based on appropriate care.  Some experts think that getting all patients on “appropriate” treatment would significantly reduce non-adherence.  A great additional insight was made by Bruce Berger of Auburn University…that sometimes non-treatment (ie no drug) is the best treatment regimen.  Point taken.
2. Reducing drug cost barriers.  Recent survey data by the Kaiser Family Foundation and the National Business Group on Health suggests that non-adherence has gone up since the beginning of the recession.  Even while we were discussing this pillar, the Commonwealth Fund announced an issue brief by Peter Cunningham, Senior Fellow at the Center for Studying Health System Change, called Chronic Burdens: The Persistently High Out-of-Pocket Health Care Expenses Faced by Many Americans with Chronic Conditions.  He sites Medical Expenditure Panel Survey data from 2001-2005 that shows that out of pocket expenses for prescription drugs represent fully half of the out of pocket spend for individuals with chronic disease.  Given the increasing prevalence of chronic disease, and expected increases in prescription drug costs, this burden is expected to grow.
3. Addressing the behaviors and preferences of individual patients. Experts agree that patients are individuals.  As such, they have differing levels of knowledge about their health or disease (health literacy), and differing levels of ability  or confidence in carrying out the necessary actions that their disease requires (patient activation).  Some are motivated; others need to be incented or held accountable.  An ideal medication adherence strategy must therefore be patient-centered and holistic.  However, our current system of care often lacks the ability to screen and assess patient knowledge, confidence or follow-through.  Besides lacking key information in order to “customize” the adherence approach to the patient, providers lack training and time to do much more than “prescribe” the treatment regimen.

The morning culminated in a very interesting exercise.  The panel and the audience were given the list of 10 “Improvement Levers” and after panel discussion, were asked to vote.  In an interesting approach, we were asked to allocate $1 Billion across the ten levers as we felt they would be most impactful and lead to the greatest improvement in medication adherence.

In a future post, I will discuss these 10 medication adherence improvement levers, and let you know how the vote came out…a very interesting and insightful exercise that I hope you will enjoy.