The Collaborative Forum

In a recent post (July 24, 2009), I introduced the topic of medication adherence and decribed three pillars of system reform that would seek to address the nearly $300 Billion in annual costs related to patients not taking their medications.  Recall, these pillars were: improved drug regimens, reduced cost barriers, and patient behavior.  In today’s post, let’s describe 5 of the 10 levers as put forth by the New England Healthcare Institute (NEHI) that represent high value opportunities to improve medication adherence.

NEHI’s medication adherence roundtable, held July 23rd in Cambridge, reported on research into a variety of interventions that hold promise for improving the care and costs of chronic diseases.  While 10 intervention categories were identified, none were felt to be independent of the others. Instead, each represented a potential area of healthcare policy and investment.

• Use of Multi-disciplinary Care Teams.  Seven minutes to see a patient… small wonder medication discussions center around “take this” and “get this prescription filled”.  Most patients don’t even remember what the prescription is for, let alone hear about tips for adherence or side effect management.  

But one promising approach would be to support physicians and patients with physician extenders, or care coordinators, who could implement medication therapy management and education programs.  Care teams could be made of nurses or pharmacists, and could be centered within the physician practice or coordinated regionally. 

An example of the former is the Medical Home model as played out at Geisinger Healthcare or Park Nicollet Health Services.  An example of the latter would be the Asheville Project, where pharmacists in the community help coordinate medication therapy and monitor adherence for diabetics. 

According to NEHI’s research findings, care teams could be virtually structured, and therapy management can be delivered either face to face, or through technologies, such as interactive voice (IVR) or the Web.

Policy makers will need to guide decisions about payment incentives, and care teams will need to address how best to integrate tools, patient education, and enabling technologies in order to optimize adherence.

• Medication Reconciliation and Regimen Setting.   Few patients know their list of medications, let alone the doses or who prescribed them.  It is a small wonder that simply having a single source of information about what medications a patient is on could go a long way to eliminating errors and duplication in prescribing.  Every physician has at least one story of a “near miss” medication related error that could have been avoided with a consolidated medication list.  If you are a patient with chronic disease, that list might include on average 13 medications!  For every physician involved in your care, an increase in the risk of adverse drug events goes up by 29%.

Reconciling medications will require communications between providers, which is made more difficult today because of time constraints, reimbursement priorities, and lack of simple HIT solutions.  While e-prescribing holds promise, until interoperable systems exist, we run the ongoing risk of errors and duplications. 

The pharmacy benefit manager could play a key role in solving medication reconciliation challenges.  PBMs are often the final clearinghouse of information about what medications have been prescribed; however, reconciliation with over the counter drugs and other remedies are also important considerations that may be missed by PBM reconcilations.

IT systems designed for e-prescribing or reconciliation often lack one important input, arguably the most critical to the process: the patient.  A more ideal reconciliation approach would be one where patients take an active role in reviewing their medication regimens, reporting on side effects, and tracking their OWN adherence, rather than simply whether or not a refill was ordered.

• Patient Profiling.  Adherence experts understand that individual preferences and sensitivities drive behavior.    Beyond understanding and intention lies patient activation.  Patient activation is a measure of one’s ability and willingness to take action regarding health and healthy behaviors.  While not exclusive to the adherence dilemma, patient activation measurement holds promise in assessing the individual readiness to succeed in adopting medication adherence behaviors.

“Profiling” has gotten a bad name, especially given the recent Professor Gates incident.  I prefer to think of this activity as “segmentation”.  By identifying the level of understanding, motivation, and readiness to adopt medication taking behaviors, care teams would be better able to “customize” their approach to individuals.  An example would be staging the addition of new drugs to a patient’s regimen if his/her level of “activation” precluded an “all or nothing” approach.

Patient activation can be assessed using standardized tools or instruments.  This implies that activation could be assessed by members of the care team, or potentially by web or IVR technologies.

• Patient Engagement and Education. Once motivated to take action, let’s say to initiate a medication, most patients lack sufficient knowledge about the “how to” or an understanding of the implications of their decision, such as “what if” or “what if not”.  What is the role of the medication in light of my other medicines? Will I experience side effects?  If so, what are they likely to be?  Will this make me better? If so, how long will it take? Do I take this with food?  What if I forget a  dose?  Who do I call if I have a problem or question?

Most experts agree that to sustain adherence over time, patients must be informed and understand their disease, their treatment and the role of good adherence.  For care teams to effectively communicate these answers, interactions must take into account health literacy as well as language and cultural factors.

So how might we ensure an informed, educated and engaged patient when it comes to medication taking behaviors?  One promising approach applies motivational interviewing techniques to assist patients in recognizing and resolving any disconnection between their behaviors and their personal goals and values about health.

When motivational interviewing approaches are applied, medication adherence levels can be maintained over time, compared to significant decline over time when this technique is not applied.

• Payment Reform.  This could be the topic of many posts, and rightly is by others.  But as it applies to the topic of medication adherence, payment reforms that encourage and incent a move FROM volume services TOWARD rewarding positive outcomes might go a long way to helping care teams form and provider behaviors change.

Several types of payment reform models are currently under consideration by Congress.  These include pay for performance structures, where specific outcomes like a reduction in hemaglobin A1C levels for diabetes are incented by bonus payments.  Since OUTCOMES are rewarded, the actions and efforts required to achieve these outcomes are encouraged but not proscribed.

Another such payment model that is getting attention is the Accountable Care Organization (ACO) model.  Here, populations are assigned to a group of providers linked together contractually.  Payments are based on population cost targets vs. an established benchmark or a control population.  Full population costs of care are considered, which leads to consideration of more effective and efficient care delivery models.

Yet another approach being proposed is the Medical Home model.  The Medical Home is organized around a group of patients linked to a group of providers who receive additional payments for activities, such as care coordination and use of information technologies.  Payments incent activities and tools that are not used much today, but could help launch medication management programs in the future.

All of the payment reform models under consideration have common goals that seek to address a common problem: namely, the lack of payment incentive for better outcomes.  While all could move the needle on medication adherence, the devil is in the detail on how they would do so, and to what extent they would be effective in doing so.

Nonetheless, payment reform holds great promise in allowing reimbursement for services that could add value and potentially reduce overall healthcare costs, such as technologies that support patient self care and care coordination.

Tags: Care coordination, Healthcare policy, Medical Home