We’ve heard a lot of encouraging words lately about how the improved use of medications is an essential but overlooked pathway to improved patient outcomes and sustainable health care costs. Consider these three signposts.
- The Congressional Budget Office’s long-awaited finding last fall that a 5 percent increase in prescription drug use results in about a 1 percent reduction in medical spending. This means that good medication use can now be equated not only with doing right by patients, but doing right by the federal deficit — a huge advantage in a hyper-polarized health policy environment. Perhaps CBO, Congress’s fiscal scorekeeper, can now listen with open ears to proposals for targeted strategies for medication management that may deliver even better outcomes and greater savings.
- The IMS Institute for Healthcare Informatics’ most detailed recent estimates (registration required) of avoidable health care costs due to sub-optimal use of medications across six major chronic disease states in the U.S. The estimate is serious money: $213 billion per year. IMS suggests that a convergence of trends (such as increasing utilization of healthcare IT to manage medications, increased use of generic medications, and various improvements in medication practices) may already be responsible for improvements in patient adherence and thus contributing to downward pressure on health care spending.
- Finally, CMS’ first-year results of its original 32 Pioneer Accountable Care Organizations. As a group the 32 ACOs managed to hold aggregate patient medical spending below that of a comparable group while generally improving patient care, and thirteen of the Pioneers actually cut total medical spending below benchmarks. News reports focused on the 9 Pioneers dropping out of the program, but 7 of them are shifting over to the Medicare Shared Savings ACO program.
A New Target: Total Medical Expenditure
This transformation to accountable care is forcing providers to manage to a financial target that would have been unheard of only a few short years ago: Total Medical Expenditure. It is difficult to foresee how providers can hit current TME targets, much less a planned succession of tougher TME targets in the future, without safe, clinically effective and (let’s call it) “adhereable” medication management.
The marketplace is responding. CVS Caremark is reported to be sharing prescription drug data with Pioneer ACOs, and Walgreens is building three entire ACOs around an integration of its pharmacy network with local medical providers. CMS cited a patient who received conflicting medication orders from her ob-gyn and her primary care physician, a conflict resolved by a “care coordination pharmacist” employed by her ACO.
So three signposts, three takeaway points: (a) on Capitol Hill and among private payers the case can be made that better use of medicines and improved patient adherence are a pathway to better patient outcomes and appropriate cost control; (b) health care providers need to manage medicines well and improve adherence in order to achieve a new standard of performance (Total Medical Expenditure) and; (c) potentially there’s a lot of savings to be had from improved use of medicines and improved adherence.
As if to hammer this last point home, a July Health Affairs article by Bruce Stuart and colleagues finds significant variation in Medicare medical spending among beneficiaries in 2006-2008 depending on their level of medication adherence, even after controlling for a “healthy adherer” effect.
So now it’s explicit that better and more coordinated use of medicines and improved patient medication adherence are part of the solution, not part of the problem, and we need to act accordingly.
Toward A System-Based Approach
For starters, significant returns from improved use of medicines and improved adherence should be a central goal of health reform. The key to achieving this lies in the continued convergence of factors that IMS begins to trace in its report, a convergence that the health policy institute NEHI outlined in a medication roadmap exercise completed in 2011. The real question is just how well all these factors are clicking together right now, how they can click together better, and how we can speed the process up.
For example, can we clearly discern not only how rapidly electronic medical records and other e-health tools are being adopted, but how rapidly they are enabling resolution of actual drug therapy problems? Can we tell how rapidly providers are intensifying efforts such as Medication Therapy Management to resolve those drug therapy problems, and whether these efforts are leaving time and money available for patient counseling and education? Can we link all this to improved patient medication adherence and measurably improved outcomes, and then on to improved Total Medical Expenditure? Many of the means to speed up the returns from improved medication use are in our grasp already. We need to understand how well the various pieces of the puzzle are fitting together.
What we need is a system-based view of overall medication use, management and patient adherence. Improving medication use is a systems challenge. For one thing, the appropriate decision making is complex. It not only involves the clinical process of matching individual patients with the right medication regimen, but also matching the patient with the right education, counseling, and services that help sustain adherence.
For another thing, there are many entities involved in the whole process. While patients in surgery can expect to stay strapped to one operating table for the entire intervention, the chronically ill patient reliant on medications is strapped to the prescriber’s office, the dispensing pharmacy, and his or her own home, if not to his or her health plan, prescription drug plan, PBM, and other entities as well. If we expect better outcomes and lower costs from better medication use, we need to know whether and how these different settings and organizations are working with each other.
A system-based view of medication use would be a first step towards building a model that would allow stakeholders to track any given patient’s experience with medications over an entire continuum of care, allow stakeholders to visualize how and when different interventions are (or should be) delivered to patients over time, how and when they should be repeated, and when one type of intervention (perhaps a high-cost intervention) can be replaced by another (perhaps a low-cost intervention). It should allow a visualization of how various interventions will affect health care workflows when they are delivered to entire populations of similar patients at scale. It should make more evident where there are gaps and weaknesses in the continuum of medication-related care. Ultimately it should allow for modeling that will quantify the impact of entire competing strategies of medication management, or strategies offered by competing organizations or industries.
The development of a consensus around a system-based view would create benefits even if it does not result in quantitative modeling. For example, it could help stakeholders, payers in particular, make sense of the evidence base around patient medication adherence. Currently the evidence base is a mixed bag of many smallish, under-powered studies suggesting modest effects from one or another discrete intervention (witness a recent AHRQ-funded systematic review). These interventions may well prove to be more useful when delivered in the context of entire strategies of medication care.
The development of a system-based view would also drive a needed debate about what should be standard practice when it comes to the use of medicines in our health care system. For example, in our current system medication reconciliation is still far from a universally-delivered service, much less a service delivered at a consistent level of effectiveness. Is this really acceptable at a time when millions of Americans and their caregivers are trying to manage multiple medications every day?
Finally, a system-based view of medication use would support needed policymaking in both the public and private sector. For example, most patients continue to receive their medications in the traditional amber vial with labels many do not understand attached to leaflets few ever read. Couldn’t FDA policy strike a better balance between needed precautions for patient safety and packaging and labeling innovations that promote patient engagement, self-management and improved adherence? These and other questions should go on a consensus agenda for action supported by a common vision and understanding of well-coordinated medication use by entire patient populations, across the continuum of care.
Getting The Players To Work Together
The list of players in the medication management space in the health care system is large and growing. The advent of Medicare Part D and its pharmacy quality metrics are now making Part D drug plans and pharmacy benefit managers (PBMs) much more active agents in promoting medication management and adherence among patients. The fastest growing segment of the pharmacy world in recent years are non-traditional players such as Big Box retail and supermarkets. Big pharmacy chains and smaller independent chains alike are moving aggressively to provide medication management services.
Retail clinics based in chain pharmacies (staffed by nurse practitioners) and pharmacist-led services such as Medication Therapy Management are expanding just as the health care system is confronting how to overcome a nationwide shortage of primary care physicians. Formal alliances between retail pharmacy and Accountable Care Organizations or physician practices are beginning and could be the wave of the future.
It is time to take a look at how this expanding cast of players can best work together.