Alignment of Healthcare Stakeholders Becoming More Prominent?

The ideas about alignment of healthcare stakeholders expressed in Aligning incentives: The promise of pay for performance by Dennis Schmuland, M.D., FAAFP are hardly novel but given that they carry the imprimatur of a business that is likely to become a major force in healthcare, thy may well take on more significance than the same notions published in, say, some guy’s blog.

While the article focuses on alignment as a compelling reason to use pay-for-performance programs and high tech software and hardware the value of aligning patients, plans, and providers, even independent of the latest Microsoft gadget, is obvious.

I’ve included two excerpts to provide a taste of the brief article:

Clearly I’m biased about the importance of healthcare alignment. That is exactly the reason I urge you to read about the concept elsewhere as well.

The article can be found at

• Healthcare Alignment
• Health Incentives and Minnesota's Healthcare Alignment Plan
• A Physicianv's Experience With Patients Who Avoid Tests Until It's Too Late
• Patient-MD Alignment
• Systemic Alignment

Taking Our Medicine - The bad economics of switching health-care plans
By Ray Fisman. Slate.com
September 7, 2007

Payment For Preventive Care A Bad Bet For Health Insurance

The notion that significant improvement in treatment implementation is possible only if the interests of all healthcare stakeholders are aligned has been and continues to be AlignMap’s central and recurrent theme. Taking Our Medicine, the September 7, 2007 entry from The Dismal Science, the ongoing economics column at Slate.com, sounds a resonant leitmotiv.

An excerpt from the article indicates its basic premise - that the economic nature of the US health insurance system militates against funding of preventive care, which, in turn, negatively influences compliance with this important segment of treatment by insured patients.

In the long-simmering argument over what’s wrong with American health care, recent polls show that many people blame our market-based system of private health insurance. Private insurance companies are faulted for, among other things, failing to do enough to prevent disease. They have no incentive to do so, argue advocates for reform, ranging from Michael Moore in Sicko to some of the current presidential candidates. And yet if preventive measures today result in savings on treatment tomorrow, then what’s good medicine should also be good business.

Diabetes management is a case in point. If they get help early on in managing blood-sugar levels, diabetics can stave off later medical complications that may result in expensive hospital stays. Yet many of these preventive measures aren’t covered or encouraged by insurers. Instead, patients are forced to haggle over reimbursement for insulin pumps, and most are rationed only four test strips per day to monitor their blood sugar (sometimes enough, but often not). If better access to insulin pumps and blood-sugar monitoring will save money in the long run, why are insurers so miserly with their diabetes customers?

A recent study (not yet published) by researchers from Case Western Reserve and Carnegie Mellon University¹ explains that the culprit in poor diabetes management—and the lack of preventive care in general—may be the very high rate at which Americans switch among insurance plans. It takes about a decade for insurers to recoup their investment in early diabetes treatment, and by then odds are that their customer has moved on to another health plan. Alas, a lot of this turnover may be built in to the way Americans get health insurance. And it’s the doing not of individual patients so much as their employers, who are always on the lookout to switch plans for lower-cost coverage.

The essay goes on to explicate the specifics of the employer-based health insurance system and suggest solutions to the problems of frequent switching between programs.

The situation described in this article is an excellent example of the systemic factors that must be brought into alignment if compliance is to be enhanced on a large scale.

This brief and clearly written examination of the implications of a health insurance system in which insurers cannot count on benefiting from long term coverage of the same individuals is well worth reading and can be found at Taking Our Medicine.


Footnotes

1. A preliminary copy of the referenced study is available at Employer-Based Insurance Markets and Investments in Health [back]

• Patient Compliance Subverted By The Temptation Of Now
• The Times Makes Medication Noncompliance Official
• Patient Action Plans
• AMA Passes New Policy On Adherence To Treatment Plans
• Noncompliance Despite Life Or Death Stakes

The Recommendation

Enhancing Prescription Medicine Adherence: A National Action Plan, the report referenced in my snarky August 1, 2007 post,¹ is available² and worth reading by anyone involved with healthcare.

The Report

While I won’t go into detail about the Report’s content, I will note that the prose is lucid and well organized,³ the ideas are drawn from a wide and diverse group of sources, supportive evidence is provided, and the conclusions are neither grandiosely nor apologetically offered.

The headings of the Report’s 10 PRIORITIES FOR ACTION are excerpted below:

1. Elevate patient adherence as a critical health care issue.

2. Agree on a common adherence terminology that will unite all stakeholders.

3. Create a public/private partnership to mount a unified national education campaign to make patient adherence a national health priority.

4. Establish a multidisciplinary approach to compliance education and management.

5. Immediately implement professional training and increase the funding for professional education on patient medication adherence.

6. Address the barriers to patient adherence for patients with low health literacy.

7. Create the means to share information about best practices in adherence education and management.

8. Develop a curriculum on medication adherence for use in medical schools and allied health care institutions.

9. Seek regulatory changes to remove roadblocks for adherence assistance programs.

10. Increase the federal budget and stimulate rigorous research on medication adherence.

The Potential

The strength of the proposal lies in its promotion of patient compliance as an essential factor in healthcare and, even more significantly, its campaign to unite stakeholders in an unified effort.

Of course, much of my current enthusiasm is generated by the fact that I’ve been singing the alignment of stakeholders hymn for years.

And, there are potential problems as well. While the Report covers many strategies, its sponsor, the National Council on Patient Information and Education, as indicated by the organization’s name itself and its ubiquitous motto, “Educate Before You Medicate,” has historically held patient education to be the touchstone of effective medication prescription and administration. As its web site proudly points out, NCPIE’s historical mission has been assuring patient safety through “enhanced communication.” Given that the plan NCPIE proposes, unsurprisingly enough, places NCPIE at the center of this new alliance of stakeholders, there is the risk that its organizational culture and its bias toward patient education could skew the campaign’s strategies. A similar but lesser concern is that the program will focus predominantly or exclusively on medication compliance rather than adherence to treatment in general because that has been NCPIE’s heritage.⁴

Also, persuading the government to fork over more money, even when the need is clear and the uses of the funds worthwhile, will not be a simple matter.

Perhaps even more difficult will be garnering the buy-in of clinicians, governmental agencies, for-profit and not-for-profit healthcare organizations, employers and other funders of healthcare, pharmaceutical companies, and patients to the same plan.

Nonetheless, Enhancing Prescription Medicine Adherence: A National Action Plan seems the most cogent and potentially workable large scale medication compliance enhancement plan published to date.

Accessing Enhancing Prescription Medicine Adherence: A National Action Plan
The report is available in PDF format at ~NCPIE Report and Action Plan PDF~

A Note Re Yesterday’s AlignMap Post
My post yesterday, News Flash! U.S. Government Discovers Treatment Adherence Not 100% - War On Noncompliance Declared, which referenced this Report (which I hadn’t been able to access at the time), was sardonic, mocking, and critical.

In light of what I’ve written in today’s post, the comments in yesterday’s blog entry - are still valid and still heartfelt.

Specifically, I maintain now as I did yesterday when I wrote the preceding post that (1) healthcare noncompliance is not a new discovery but has been a concern to many of us for a long time, (2) there is nothing I find in my initial reading of this report about the nature of noncompliance and its causes that is new, and (3) to the extent that patient education is the total focus of any new program, that program’s potential success is severely and needlessly limited.

Footnotes

1. See News Flash! U.S. Government Discovers Treatment Adherence Not 100% - War On Noncompliance Declared [back]
2. There is some potential for confusing the the report with its press release. The press release (aka Media Advisory), which is more useful than most examples of its genre, is entitled “America’s Other Drug Problem Poor Medication Adherence” and can be found at Online Press Release re NCPIE Report. The press release is also available as a four page PDF document at PDF of Press Release re NCPIE Report. While it’s not clear from the press release, the 34 page report itself is available on the web site of the National Council on Patient Information and Education, the group that organized the study. On that site, the link to the report (in PDF format) is Enhancing Prescription Medicine Adherence: A National Action Plan, which is the same name found on the title page of the report. [back]
3. The clear writing is unusual enough in papers of this kind to warrant a recommendation for reading [back]
4. I should note that while I have no direct connection with NCPIE, I’ve used their materials extensively over the years and have found them a trustworthy organization providing useful services and materials. [back]

• Another Medication Dose Packaging Plan Promoted
• A Commercial Perspective On Compliance Enhancement
• Contracting For Medication Adherence
• Automated Incentives For Medication Adherence
• Medication Adherence Of ADHD Patients And Frequency Of Office Visits

Health Over Health Care
By Carly Harrington Knoxville News Sentinel
May 9, 2007

High Value Vs Low Cost Healthcare

This article reports on the 10th annual health benefit forum sponsored by HealthCare 21 Business Coalition, “a non-profit, member driven organization committed to improving the quality and cost of healthcare in Tennessee and the surrounding region.”¹

The keynote speaker, David Hom, Vice President Of Strategic Initiatives for Pitney Bowes, described that company’s health-care strategy that focuses on understanding employee needs and designing a health benefits plan that encourages healthy behavior. The central concept of this strategy is is characterized in this excerpt:

Also held to be important were incentives such as lowering premiums for healthy employees and those who participate in such programs as weight loss and smoking-cessation classes, free medications, and eliminating co-pays. Pitney Bowes offers a Health Care University that allows employees the opportunity to earn credits for healthy activities and education as well as an on-site clinic and fitness center.

Commentary

What can I add? Business guys like David Hom get it. His “value-based” approach that sets employee health as a mutually beneficial goal for the employer and employee is precisely congruent with the “no-nonsense” alignment of the interests of the stakeholders in healthcare I promote.

Footnotes

1. See HealthCare 21 Business Coalition web site at http://www.hc21.org/ [back]

• AMA Passes New Policy On Adherence To Treatment Plans
• Connection Between Knowledge and Compliance Unclear
• Patient Adherence Decreases Costs But Difficult To Achieve
• Patient Acceptance Of Monitoring
• Pharmacist-Driven Compliance Enhancement Programs

Life - With Diabetes - Goes On

Since I last wrote about Living With Diabetes,¹ that blog has added more posts to its conveniently categorized “Compliance” section.

As I noted previously, these blog entries provide useful insights into a patient’s perspective on compliance that are not often available to a clinician during a treatment session.

I’m especially taken with an observations on the difference between disagreeing with a treatment recommendation and noncompliance as limned in these excerpts from Patient Gripe - Bariatric Surgery Suggestions

For good measure there are a couple of comments that enthusiastically endorse this notion.

So do I.

I have long promoted, especially in How To (Correctly) Not Take Medications As Prescribed, differentiating between noncompliance (whatever that term means these days) and a communicated and acknowledged non-execution of a specific treatment recommendation.²

While all manner of humanistic, sociological, and ethical principles can be invoked in support of this idea, my primary argument is based on clinical pragmatism:

The opportunity cost (in this case, the potential loss of improvements in the patient’s health that the recommendation would have hypothetically caused) of the patient not following the recommendation is more than compensated by the elimination of (some of) the changes patients unilaterally and surreptitiously make in the treatment plan. Because these deviations from the presumed treatment plan are unknown to the clinician, they are especially likely to lead to mistaken diagnoses and erroneous evaluations of treatment outcomes (e.g., a physician may assume a patient’s infection is resistant to the prescribed medication or that the original diagnosis was wrong because of lack of response when the actual cause was the patient not filling the prescription), which, in turn, lead to delays in or prevention of improvements in the patient’s health, geometric increases in healthcare expenditures, and damage to patient and clinician morale and the patient-clinician relationship.³

Clearly, there are situations in which coerced compliance is justified; e.g., the treatment of deadly, highly communicable diseases and the treatment of patients with serious disorders who are cognitively unable to realistically appraise their condition. In the majority of cases, however, automatically categorizing a patient who refuses a treatment recommendation as noncompliant, with all the connotations that term carries, is, at best nonproductive, and is likely to inhibit - and perhaps destroy - treatment.

The Life With Diabetes posts can be found at Living With Diabetes On Compliance

Footnotes

1. See From The Patient’s Point Of View [back]
2. Yes, “communicated and acknowledged non-execution of a specific treatment recommendation is a particularly awkward construction, but a more felicitous phrase, devoid of loaded words, doesn’t come immediately to mind. [back]
3. See the “Complex, Cascading, Cumulative Costs” Section of Complex, Cascading, Cumulative Costs [back]

• Importance Of Individual Variations Over Time In Diabetes Treatment
• Organizing Data About Factors That Affect Compliance
• Pharmacist-Driven Compliance Enhancement Programs
• Connection Between Knowledge and Compliance Unclear
• LIFE Program Enhances Adherence

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

Firms gang up on diabetes - Will pay cost of employees’ drugs, consultations 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:

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

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:

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. [back]
2. I live in the outer margins of what the late night car commercials still call “Greater Chicagoland” [back]
3. See Promoting Compliance With Pharmacy Benefit Incentives [back]
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. [back]
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 [back]
6. My professional bias is hereby acknowledged. [back]
7. Unfortunately, the million dollar investment of GlaxoSmithKline, a manufacturer of medications for diabetics, in the Project does muddy the waters [back]

• Promoting Compliance With Pharmacy Benefit Incentives
• The How To Use Medication Organizers Introduction and Pillbox Pictorial
• LIFE Program Enhances Adherence
• Drug Courts
• The State of the Art