IMPACT OF HEALTH REFORM
I believe we have a group consensus that progress requires an integrated approach. Will the new federal health reform legislation
do much to facilitate that?
The law creates pilot programs for new forms of payment that act as incentives to encourage the formation of "Accountable
Care Organizations" and "medical homes," where hospitals, physicians, and pharmacists work in tandem to fix a course of treatment
for a specific condition. Again, there is a potential communications gap in how all this looks to the patient. The Medical
Group Management Association recently did a focus group around understanding what "medical home" means; most of the survey
population reacted negatively because it was seen as just another reference to a nursing home.
Is the insurer community working together to promote adherence through more efficient and safe prescribing?
It is hard for companies in the same business to do this on antitrust grounds. But Aetna is very proactive on behalf of its
prescribers. We have a dedicated team in Pittsburgh where every night the new claims data flow is examined against existing
claims and potential safety contra-indication problems are flagged and then forwarded to our network providers for action.
We also have the potential from electronic prescribing and health records. Physicians are now in a position to find out whether
the patient has filled his prescription. Upwards of 30 percent of all scrips somehow disappear in the path to the pharmacy.
As this is better tracked through new technologies, the opportunity exists to add tools to promote adherence as well. We also
favor putting adherence on the research agenda for new groups established through health reform, like the Patient Centered
Outcomes Research Institute (PCORI) on clinical effectiveness.
PHARMACISTS, PAYERS, AND THE PROMISE OF TECHNOLOGY
Pharmacy benefit managers have sophisticated data on longitudinal pharmacy claims. They can with little difficulty identify
patients who have cycled off a drug after 35 or 40 days and then make an appropriate intervention. The issue is the ROI that
would motivate them to do that.
Where does the pharmacist come in here?
ALEX ADAMS, DIRECTOR, PHARMACY PROGRAMS, NATIONAL ASSOCIATION OF CHAIN DRUG STORES:
Pharmacies are the face of neighborhood healthcare. At NACDS, we emphasize that pharmacies are key to improving health and
reducing costs. One way pharmacists do this is through medication therapy management (MTM), a pharmacist-provided service
to improve patient medication regimes and ensure patients are taking the right medications in the right way. Studies have
shown that every dollar invested in MTM results in $12 of savings from downstream health costs, such as avoidable hospitalization
and emergency room visits.
One opportunity the NACDS Foundation is exploring is "primary non-adherence," or what some have called the "strong start."
It's that golden moment when a prescription is written for the first time, but the patient fails to present to pick it up.
E-prescribing is providing the opportunity for a productive counseling session between the pharmacist and the patient. We're
analyzing the best ways to improve: Is it an automated standard phone message, a live call from a pharmacist directly, or
a message to the prescribing physician noting the status of the fill and whether a call from him or her is required as a reminder?
Does technology carry the potential to change the paradigm on adherence?
It has a role but the impact is often exaggerated. Adoption of the electronic health record will offer the opportunity to
track what has been prescribed and minimize negative interactions. It also gives other providers the ability to avoid duplications
and other sources of inefficiency.
What other tools can be productively applied to build a root and branch strategy on adherence?
Merck has developed the Adherence Estimator. It consists of "three Cs" to measure the risk of non-adherence: 1) commitment
to therapy; 2) concerns that relate to use of the medication; and 3) cost. This measurement tool takes less than a minute
for the patient to complete, and from this information we can create motivational messages to address the domains where the
patient scores sub-optimally. On a broader scale, one can apply the three Cs to try to create more structure around physician/patient
communication related to prescription medications.
A major barrier is that most health plans still fail to recognize the pharmacist as a provider. The pharmacist cannot charge
for that counseling session, coaching, or the cognitive visit. To address this, my group and other employer coalitions are
building on the Asheville, N.C., study on medications adherence, where an employer will directly pay pharmacists who serve
as diabetes coaches, as well as reducing or waiving copays for diabetic drugs if the enrollee agrees to see a specially trained
pharmacist for counseling. We call it a "mutual accountability" program, since the employee must take steps to manage their
own care in return for the waived copays. The city of Chicago is one of my members committed to this approach.
Incentives—including cash payments to reward appropriate behavior—do get the patient's attention, but experience demonstrates
that these can diminish over time. We have to keep the momentum going around motivation. One that counts for a lot is showing
the patient how adherence improves health and well-being so that he or she will be around to see their grandchildren graduate
from college. There is a lot of promise in the application of behavioral economics, that sweet spot where you can convince
the patient that paying for something now will deliver a real benefit down the road.
PAUL SNYDERMAN, CHIEF RESEARCH OFFICER, IPSOS HEALTH:
We have yet to address the question of perceived risk. Has anyone read the average package insert detailing all the potential
risks of taking a prescribed drug? It is a disincentive to adherence because of how vaguely these risk profiles relate at
the level of the individual patient—does this apply to me or not? With all the negativity in the insert, can we blame those who conclude that, regardless of what the physician says, the safest
thing is not to take the drug?