AlignMap

Beyond Compliance, Adherence, & Concordance – Supporting The Patient’s Implementation Of Optimal Treatment

AlignMap header image 2
← →

Asheville Patient Compliance Project Expands

April 9th, 2007 at 11:08 am · Allan Showalter, MD · Alignment, Enhancements · No Comments

Is Pharmacist-Driven Compliance Enhancement Program Being Promoted As Success Too Soon?

Firms gang up on diabetes – Will pay cost of employees’ drugs, consultations
By Bruce Japsen
Chicago Tribune April 8, 2007

Program To Improve Adherence To Diabetic Treatment Comes To Chicago

A feature article in yesterday’s Chicago Tribune approvingly reports on a program in which local employers (1) provide free consultations for diabetics covered by company-sponsored health insurance and (2) eliminate co-payments for their medications in hopes of improved disease management and, consequently, lowered healthcare costs.1

The first three sentences of the article are characteristic of its tone:

After years of raising co-payments and deductibles for prescription pharmaceuticals, some employers are taking an unorthodox approach to lowering health-care costs in an experimental program by — get this — paying for diabetes drugs and consultations. For patients the savings could amount to $2,000 a year. If the program proves successful it could be expanded to include other common diseases and chronic conditions such as asthma, depression or arthritis and extended beyond its one-year pilot phase, according to the Midwest Business Group on Health, a Chicago-based coalition of employers that is coordinating the program.

The program is based on the Asheville, NC model featured in a previous AlignMap post, Pharmacist-Driven Compliance Enhancement Programs. The Tribune story notes that

Results from a model project launched in 1997 by the city of Asheville, N.C., show a 50 percent reduction in sick days and no worker’s compensation claims filed by the diabetes patients in the program between 1997 and 2003.

As was true in Asheville, participants in Chicago will be assigned to pharmacists specifically trained to work with the program’s diabetics. The pharmacists’ task is described in these excerpts from the article:

“The pharmacist’s role is to be an educator and motivator, ensuring the patient follows their physician’s orders and understands how to manage and monitor their diabetes and medications,” Boress said. “Studies have shown that with the treatment, education and motivation provided by this program people can dramatically improve their health while positively impacting employer health-care costs.”
“It’s different than a consultation at the pharmacy counter because all of the meetings are done, face-to-face, by appointment and in private counseling areas … this is not done at the drive-through window,” said Dan Garrett, a pharmacist and senior director of medication adherence programs for the American Pharmacists Association Foundation, which has been involved in similar programs in smaller markets.

Currently, the local program is a one-year pilot coordinated by the Midwest Business Group on Health, with two Chicago-area employers on board.

GlaxoSmithKline PLC provides funds ($1 million over the past five years) to the American Pharmacists Association Foundation to cover portions of the cost of nationwide program administration. The article notes that “drugmakers are not able to influence the outcome of the study, pharmacists and employers involved say.”

Commentary

Accolades
There is much to admire about the Asheville Project and its local startup.2

  • I have, of course, long promoted the importance of aligning the interests of all healthcare stakeholders, including patients, insurers, third-party payers, and clinicians. While this program would only be a step in the right direction, it is a step in the right direction
  • Likewise, I’m a proponent of compliance incentives, including increased healthcare insurance benefits.3
  • Heck, just the fact that the Asheville project is being expanded and examined in a systematic manner is laudable. Historically, exportation of patient compliance programs to geographic areas other than their original sites, regardless of the success of the prototype, has been rare.
  • The program invests in rational approaches to compliance enhancement: individual coaching and reductions in the costs of treatment.

Research Limitations and Other Potential Problems
Because I believe this kind of program holds significant promise, I feel compelled to point out potential problems as well as applaud.

Although the Asheville Project is already viewed a success in the popular press and in many pharmacist-oriented publications and has been in operation since 1997, the set of three studies that supplies the statistics most frequently quoted4 was based on only 85 clients, was limited to patients who volunteered for the study, and did not use a true control group. (These limitations as well as other, less significant problems, were duly noted by the study’s authors.)

A later study by Garrett and Bluml5 included 256 patients over a one year period, was limited to patients who volunteered for the study, and did not use a true control group. As the authors note, “The outcomes analysis was intended from the outset to meet the needs of employers to make decisions on eventual continuation of the program. Industry standard economic data reporting sets are not available for medical and pharmacy claims data. Because of this, we developed a standard template for requests for these data that data claims vendors were not always able to report completely.”

These acknowledged limitations do not mean the program is not effective; they do mean it is not known with certainty if the program is effective.

The gathering of data brings up another point. The Tribune article reports that “Doctors will be given results of the consultations and provide information to a ‘research unit tracking the patients’ medical and cost trends,’ the Midwest Business Group said.” Cynic that I am, I think there may be a physician or two who is unenthusiastic about filling out one more form on a patient, especially one that apparently requests cost data. In addition, at least in my idealized vision of an alignment of healthcare stakeholders, clinicians play a more significant role than the passively cooperative receivers and providers of data.6

The issue of data interpretation I raised in my first post about the Asheville Project is still in question:

In addition to the skills the pharmacists bring to the program, I would also suggest that compliance may have been enhanced by the patient’s buy-in itself. Patients who seized the opportunity to buy into the program, trading that enrollment for free diabetic supplies, may have then become more likely to adhere to treatment, or those who agreed to join the program may have, in effect, constituted a preselected group that was, by the nature of its members, more likely to follow the diabetic protocols.

Bioethical Dilemmas
Bioethical concerns could well be raised if such programs are extended.

In other situations, the case has been made, with some legitimacy and, too often, even more pseudo-drama, that offering incentives, for example, for a patient to take a medication is tantamount to providing a cash inducement for a client to swallow a drug that may have serious side-effects. (For a specific example of this phenomenon and my discussion of it, see Cash For Compliance & Other Ethical Dilemmas)

Indeed, there are those who would argue that even a physician’s recommendation that a certain medication could be useful is implicit coercion and an infringement on the individual rights of the patient.

While it is difficult, I would think, to convincingly equate the elimination of a co-payment with a bribe to take a medication,7 framing the issue another way may better reveal the potential problem:

Is it legitimate to enrich the healthcare coverage of those employees – and only those employees – who follow specific employer-approved healthcare recommendations? (For example, what if the recommendation were that a dock worker with back pain take a narcotic medication or a steroid injection that would allow him to continue to work loading and unloading trucks?)

Or, even more pointedly,

Is it legitimate to deplete the amount or eliminate portions of the healthcare coverage of employees who refuse to or cannot comply with employer-approved healthcare recommendations?

If those scenarios seem unlikely, I invite the reader to check out the proposed West Virginia Medicaid Plan discussed at Contracting For Compliance and make the easy substitution of “Medicaid recipient” for “employee” and “State of West Virginia” for “employer.”

___________________

None of these issues are necessarily unsolvable, but they must first be acknowledged.

I continue to support the Asheville Project and to hope that it proves a major success. I also continue to support a full consideration of the evidence and the extended implications, preferably before declaring Mission Accomplished

Footnotes

__________
  1. Chicago is one of more than 30 employer groups in cities across the country rolling out similar programs this year.↩
  2. I live in the outer margins of what the late night car commercials still call “Greater Chicagoland”↩
  3. See Promoting Compliance With Pharmacy Benefit Incentives↩
  4. (1) Carole W. Cranor, Dale B. Christensenk The Asheville Project: Short-Term Outcomes of a Community Pharmacy Diabetes Care Program J Am Pharm Assoc 43(2):149-159, 2003. (2) Carole W. Cranor, Dale B. Christensen, The Asheville Project: factors associated with outcomes of a community pharmacy diabetes care program. Am Pharm Assoc 43(2): 160-172, 2003. (3) Carole W. Cranor, Dale B. Christensen, The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. Am Pharm Assoc 43(2): 173-184, 2003.↩
  5. Daniel G. Garrett; Benjamin M. Bluml Patient Self-Management Program for Diabetes: First Year Clinical, Humanistic and Economic Outcomes J Am Pharm Assoc. 2005;45(2):130-137↩
  6. My professional bias is hereby acknowledged.↩
  7. Unfortunately, the million dollar investment of GlaxoSmithKline, a manufacturer of medications for diabetics, in the Project does muddy the waters↩

Tags: Alignment · Enhancements