Posted 12/19/11 on The Health Affairs Blog
©2011 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.
If we’re truly serious about reining in health care costs and improving patient outcomes at the same time, then improving medication adherence is absolutely key. And if we’re serious about improving medication adherence, then the time to strike is now.
That’s because there are major opportunities in health reform and major trends in the health care marketplace that together offer a golden opportunity to confront poor adherence once and for all.
The staggering costs of non-adherence are well documented by now: four out of every five patients leave a provider’s office with a prescription in hand, but as many as half of all patients do not take their pills as prescribed. This adds up to an estimated $290 billion a year in unnecessary emergency room visits, avoidable hospitalizations and additional trips to the doctor’s office, not to mention the resulting illnesses and deaths that could otherwise be prevented.
Against these daunting odds, the stars are beginning to align. A fortuitous combination of advantageous circumstances and system-changing innovations that can be tightly linked to medication management provide real opportunities today to improve the way patients take their prescription meds.
The Affordable Care Act can play a pivotal role. Although it does not make medication adherence an explicit goal, many provisions of the ACA (and of the earlier stimulus legislation) establish a foundation for improved medication management. Changes in the private health insurance market are providing new support for care coordination as well.
Trends Favoring Medical Adherence
From these shifts, a number of major trends are emerging that could and should enable improved medication adherence. For example care coordination, as exemplified by the patient-centered medical home, is paramount, as it frequently entails targets for patient outcomes that implicitly rest on good medication adherence. Care coordination itself is being greatly helped by the spread of health information technology, including electronic medical records and e-prescribing. And the momentum towards payment innovations is providing new ways to underwrite services, including care coordination fees for physicians and new performance bonuses.
Quality metrics are also helpful to improving adherence, creating performance goals that can be rewarded with payments. So too is the continued development of tools and incentives to help engage patients about their medications through counseling and incentives such as $4 generics and low insurance deductibles. Meanwhile, product innovations, including a surge of new patient reminder technologies such as smart pill bottles, also enable patients to improve their adherence. Finally, continued research will improve the evidence for how and when clinicians can have maximum impact on patient adherence behavior, such as when a new medication is first prescribed.
These trends will not solve the adherence problem by themselves, of course. Our prediction is that a focused effort at thoughtful coordination of these trends will be necessary to address the full and complex range of issues presented by nonadherent patients.
Golden Opportunities for Action
With that in mind, NEHI, a national health policy institute, has identified six major opportunities for coordinated action to improve adherence in the months ahead:
The patient-centered medical home movement: an increasing number of physician practices are receiving or planning to seek accreditation as medical homes from standards bodies such as the NCQA and URAC. (Some industry surveys suggest as many as half of primary care practices are actively planning for accreditation or have it already.) As noted already, PCMH accreditation standards tighten and formalize medication management procedures and, in URAC’s case, require adherence-specific interventions. Under the Affordable Care Act HHS is sponsoring PCMH pilots in over a dozen states. Meanwhile, numerous “ACO-like” private payer reform initiatives are providing care coordination fees, performance bonuses, or both, creating a funding source for physician investment in care team personnel, training, registries and other tools that support medication management and direct interaction with patients regarding adherence.
Transformation of the retail pharmacy: Most of the major retail drug store chains are implementing or planning strategies to leverage pharmacists beyond simple dispensing and into direct medication counseling of patients. Trade associations such as the National Community Pharmacist Association have promoted the creation of common infrastructure (such as the SureScripts network) and common IT platforms that will support counseling services such as Medication Therapy Management even among smaller and remotely located pharmacies. The parallel development of pharmacy quality measures, including measures for use at the level of individual stores, means that many retail pharmacies will have a capability to focus specifically on patient adherence — a capability that most physician practices do not have.
Hospital readmissions policy: Medicare and private payers alike are joining around efforts to reduce preventable hospital readmissions. While much debated, Medicare rules still call for hospitals to be penalized for unnecessary readmissions starting in October 2012 (1 percent of payments, rising to 3 percent in 2014). Discharged patients at risk of readmission invariably go home with medication orders. Improving the handoff of at-risk patients from the hospital to physicians in the community represents a highly focused opportunity to demonstrate effective patient adherence interventions and processes.
Medication Therapy Management: Medication therapy management (MTM) became a Medicare benefit with passage of the Part D prescription drug law in 2003. Under terms of the Affordable Care Act CMS is now acting to further refine and standardize MTM services reimbursed by Medicare, and to promote patient access to MTM through Medicare Part D and Medicare Advantage plans. Starting in 2012 Medicare Advantage plans will receive bonuses for demonstrating high aggregate patient adherence levels through pharmacy quality metrics. With further standardization MTM services could become more attractive to commercial payers and to employer-sponsors of employee health plans as a covered benefit. CareFirst, the Blue Cross insurer in Maryland, has pioneered just such an approach by building upon its Medicare prescription drug plan.
Cardiovascular health: Initiatives to promote cardiovascular health represent another highly focused opportunity to improve patient medication adherence. Cardiovascular health is the only disease-specific priority of the new National Quality Strategy, and is the target of the new CDC and CMS Million Hearts campaign. Heart failure and heart disease patients represent a high proportion of patients at risk of readmission upon discharge from the hospital, and are a target of the American College of Cardiology’s “Hospital to Home” improvement campaign. Since medication treatment of cardiovascular conditions entails medications that are used for millions of patients with conditions that are frequently asymptomatic (hypertension and hyperlipidemia), adherence promotion among cardiovascular patients may help demonstrate how the difficult problems surrounding adherence among asymptomatic patients can be solved.
E-prescribing and the growth of generic drugs: Last but not least, the increasing utilization of electronic prescribing and parallel growth in availability of generic drugs represents a major opportunity to improve patient adherence. According to SureScripts, use of e-prescribing systems to check prescription benefit information more than doubled in 2010, with growth propelled by pending availability of financial incentives ( and eventually, financial penalties) from CMS for the meaningful use of electronic medical records. Meanwhile many of the most popular brand-name medications for the treatment of chronic disease continue to lose patent protection and are available in generic form. The consequent reduction in cost to the patient should reduce financial barriers that have been shown to inhibit patient medication adherence.
The Moment of Truth
To be sure, many questions remain to be answered in both the public policy arena and in the competitive marketplace before patient medication adherence can be radically improved:
- Should explicit medication adherence quality metrics be applied to physician practice, just as they are being introduced into the retail pharmacy industry, notwithstanding physician wariness?
- Will expansion of patient services within retail pharmacies be integrated with services provided by the physician, or will they be a source of fragmented care?
- How quickly can electronic health care data networks and health information exchanges pull together comprehensive patient medication data and supply it securely to prescribers at the point of care, or to other professionals such as pharmacists as they counsel patients?
- Can rigorous and continuous evaluation be applied to the medication management and adherence interventions of leading organizations, so that promising and financially-sustainable practices can be adopted more widely?
Yet the bigger and more fundamental question is whether we can and should establish strong medication management and patient medication adherence as core values of health care quality, on a par with other fundamental goals such as eliminating medical errors and reducing hospital readmissions. At a point when health care is ever-more dependent on medication therapy for treating an ever-growing number of patients, this has become an unavoidable challenge for the health care system.
The good news is that the building blocks for improved patient medication adherence are forming – through trends in health care improvement and through policies and initiatives in national health reform. But it would be a mistake to simply assume that improved medication management and patient adherence is inevitable in a system as fragmented and contentious as ours. What is needed is for key stakeholder groups and policymakers for focus their attention on medication adherence and to capitalize on these happy circumstances by collaborating on a common action agenda for promoting improved medication adherence – starting right now.
Valerie Fleishman is Executive Director of NEHI, a broad-based health policy institute based in Cambridge, MA.