AlignMap

Adherence: The Silent CV Risk Factor,¹ presented by Dr. Keith C. Ferdinand,  Dr. Lars G. Osterberg,  and Dr. Roger S. Blumenthal, is a solid review of the basics of adherence (although special attention is directed, as the title indicates, to cardiovascular disease, almost all of the principles  are transparently applicable to compliance in general) but also offers insights in areas not typically covered by analogous reviews.

Rather than attempt to characterize these usually neglected points that are discussed in this piece, I will provide a few examples.

For instance, while the presenters trot out the familiar stats to indicate the extent of the problem,

… greater than $100 billion are wasted annually due to nonadherence; 125,000 unnecessary deaths are due to nonadherence; and of all medication related hospital admissions, 33% to 69% are due to poor medication adherence.

… they also include the much less commonly addressed point that practitioners rarely have an organized approach  to compliance:

We did a pre-survey and results demonstrated that nurse practitioners and physicians’ assistants are more likely than physicians to change treatment strategies to improve adherence. However, 74% of health care providers do not have an active adherence program.

Similarly, they do a nice job explalining the adherence versus compliance issue, defining concordance, and distringuishing betweeen adherence, compliance, and pesistence.

… researchers have recently defined adherence and compliance a bit differently, compliance meaning the day-to-day way patients take their medications from drug prescription as prescribed by the physician; persistence meaning the time they are on their medications, and it actually may discontinue before the actual prescription is ended. Adherence has been used to include the overarching term of compliance and persistence in medication-taking behavior. The British terminology actually uses a term called concordance, which implies more of a patient-centered approach in that the prescription is really a contract between the patient and the physician and that both are really responsible for the medication-taking. The National Council on Patient Information and Education has really now adopted the term adherence as the proper term because it really implies a more patient-centered approach.

They also make a interesting point about the specialist (cardiology is discussed but many other specialists would face the same conundrum) who has to be concerned about compliance in a patient who might only be seen by that practitioner once each year.

One of the challenges that we have in cardiology is that in the past, we used to be able to see certain patients more frequently, but now, almost always, Keith, patients need to get referrals from their primary care provider to see us. It is harder as a cardiologist to provide some of that reinforcement that I think the patient needs. And with the proliferation of managed care and everybody trying to cut costs, we have a struggle of trying to make sure we have gotten all the information we can from the visit to the referring physician and the patient. It is a lot harder for chronic diseases for the primary care physician to pay as much attention sometimes about lipid lowering medicine, blood pressure lowering medicine when the patient has come in for acute issue.

That is interesting: preauthorization may help keep costs down but it may actually lead to greater nonadherence.

I have always felt that when we see a specialist, it is always helpful to have some goals set not just from the medication point of view in terms of what the blood pressure and lipids would be, but also what they are doing from a lifestyle point of view. With the system we have now with the preauthorization, it is often a lot harder for us to see a nonacute patient back within a period of a few months. Many times, the best we can do is maybe see him back in a year.

And consider this economic insight:

One of the biggest issues that we are all struggling with and now, of course, we are dealing with the bailout of financial firms here, is the issue of money. Many of the medications that we prescribe to patients that are still on patent may be $2.00 or $3.00 a day, so the issue of needing to save money, and many times, physicians do not think of perhaps a less potent generic alternative. It would be nice to have a 50% LDL reduction in everybody, but if we can give a generic statin that may give us a 35% or 40% reduction and have people work on their lifestyle habits, that may work out just as well if they take the medicine and may work out better.

Over-reliance On Patient Education

The presentation does fall short in a few areas.  The discussion of a chart showing “Reasons For Not Taking Medication,” for example, should have included mention of how this data was collected (patient self-report I surmise) and, if it was by self-report, the possibility that the patient might not have provided accurate information.

My major concern, however, is the overwhelming faith demonstrated in patient education as a compliance enhancer.

… one of the things that I guess we are all trying to do is figure out ways for people to better understand why certain medications are prescribed and try to make these clinical trials that are the basis for the guidelines be more understandable. I have often thought that it would be helpful if the patient got a copy of the notes that we send to the referring physicians, but many times, that is not as easy for our office staff to do. But I think it just points to the fact that to improve adherence and compliance, we need to do a better job of making sure the patient understands why the medicine is prescribed and can relate to the clinical trial data, if there is any, related to blood pressure or cholesterol about why this is important.

While this may be a matter of emphasis, I believe that a teaching presentation such as this should acknowledge that some patients who fully understand the illness, the treatment, and the implications of compliance to their cases will nonetheless fail to adhere to the prescribed regimen unless other steps are taken.

Summary: Worthwhile Review Of Basics Plus Bonuses

That said, I return to my contention that this review is head and shoulders above the usual run of competent offerings and well worth reading, if only for the succinct, helpful summary of the Federal Study of Adherence to Medication in the Elderly (FAME).

In addition, one can earn  CME credits² for completing Adherence: The Silent CV Risk Factor.

1. The presentation is available as slides with transcript or can be viewed in a  slides/video format↩
2. See CME Info↩

From Medco Perspectives: A Prescription for National Healthcare Reform

The David Snow Healthcare Policy Speech: Background

On September 19  2008 at the National Press Club, David Snow, who by most accounts has performed well since being appointed Chairman and CEO of Medco Health Solutions in 2003,  moved beyond the boundaries of corporate healthcare to offer, in the words of his press release,

… a pragmatic blueprint for fixing America’s inefficient health care system that, for the first time, is designed to address the root causes of the problem. Unifying the strengths of both the public and private sectors, Snow’s plan is designed to reduce the nation’s health care expenses by as much as $1 trillion – almost 50 percent of current expenditures – while extending affordable, high-quality care to more Americans.

While this post focuses primarily on a reference within that speech to patient compliance as a major healthcare problem, the context in which that reference occurred is also significant. Because few of the accounts of the speech I have found devote any attention to this background material,  I am providing some basics before addressing the issue of treatment adherence.

Mr. Snow has more than 25 years of experience working in healthcare organizations prior to signing on at his current job. He previously held executive positions at Oxford Health Plans, American International Healthcare, Inc. and US HealthCare, Inc. as well as creating and running Managed Healthcare Systems, Inc. (now renamed AmeriChoice).

His ascension to the leadership of  Medco, described below in the excerpt from Newsweek, is itself of interest:

In March, it [Medco] named David Snow Jr. as its new CEO. In January, Snow bolted the No. 2 job at WellChoice (WC ) operator of Blue Cross & Blue Shield insurance plans in New York. Just weeks before, WellChoice CEO Michael Stocker was diagnosed with prostate cancer. Snow’s move left Stocker and others at WellChoice puzzled. Snow did not explain his move then and declined to explain it now. A Medco spokesman told me Snow left WellChoice when it became clear he was still some years away from realizing his ambition to be a CEO.

His work at Medco has been well compensated.  In 2004, his total compensation, according to Salary.com, was a bit over $9 million.  His 2006 total compensation, calculated by a different formula and reported in Forbes, was $1.9 million. Pharmalot dec;ares Snow “earned a $1.18 million salary last year [2006], along with $1.7 million from a non-equity incentive plan, and stock and options that were valued at $7.2 million at the time these were awarded a year ago. Snow, 52, also received $44,809 in ‘other compensation.’” In any case, Mr. Snow earns a nice living.

At the National Press Club Speech, Snow, according to The  Kaiser Daily Health Policy Report, not only presented his healthcare strategy but also critiqued  the healthcare policy  proposals of both presidential candidates:

… Medco Health Solutions CEO David Snow on Tuesday at the National Press Club in Washington, D.C., said that the McCain health care proposal would “create chaos,” Bloomberg/Bergen Record reports. Snow said, “I’m very frightened of the conversations that try to shift responsibility away from employers to individuals,” adding, “There will be more uninsured.” Snow said that the health care proposal of Democratic presidential nominee Sen. Barack Obama (Ill.) also would pose problems, adding that he is “not a big supporter of either” candidate.

Finally, the tone of Snow’s presentation is, I believe, meaningful.  Consider this excerpt from the same press release:

“Despite the urgent need, experience shows that health care reform must be evolutionary, not revolutionary, to be accepted by the American public,” Snow said. “We must agree upon an end-to-end strategic road map now, so that we can begin the journey to reform in earnest. Our commitment to this road map needs to persevere over an extended period of time to realize this opportunity. The payoff for doing this right is huge; the penalty for failure will burden generations to come.”

Not exactly your standard businessman’s, matter of fact, Chamber of Commerce speech, is it?  Along with the implicit nationalistic evangelism and recruitment to a crusade, those phrases are convey  a certain political panache, not unlike, say, a future candidate’s speech?

I am a tad disappointed I couldn’t find a  “My fellow Americans” sort of cliche in the speaker’s notes or locate a form on the Medco web site for ordering “Vote For Snow” bumper stickers. Consequently, the only support I have for my speculation that this presentation was an audition of sorts for a potential political candidate is my observation that an ambitious, successful, experienced business executive gave a ruffles and flourishes speech before the National Press Club calling the nation to the task of fiscally responsible healthcare reform and criticizing the healthcare proposals of the two major presidential candidates.

Just call it a hunch.

David Snow On Patient Compliance – And Other Issues¹

One reason the context is important is that it may explain David Snow’s predilection for absolute pronouncements in this speech.

He offers, for example, “Three Rules for Reform:”

• First, keep it simple – in business, complex solutions always fail.
• Second, revolutionary reform is rejected by our society; instead, we need incremental, evolutionary change with a deliberate and phased approach.
• Finally, and most importantly, we must define the roles of the private sector and the government. Each has an important but distinctly different responsibility and every time we cross those lines it results in failure – without exception.
  • The government’s function is to promulgate and regulate.
  • The private sector’s function is to operate and innovate.
    [emphasis mine]
    

The final tally: three points, two explicit absolutes (with bonus points for the redundant “without exception”).²

I, for one, find it difficult to believe that someone with 30 years experience in the healthcare industry, a field enamored of needlessly complex responses to problems, has never once been aware of a complex business solution succeeding, if only by random chance. I can certainly call to mind a few strategies that succeeded in spite of their complexity (not to mention inaccurate premises, mediocre execution, and bad timing – being lucky is a wonderful thing).

I suggest, as an alternative explanation, that Mr. Snow may have been speaking figuratively rather than literally – in sound bites.

Keep that in mind when considering the compliance points from the speech.

The crux of the speech resides in the specific policy recommendations:

I have five suggestions.  Each is simple [emphasis mine] and leverages the appropriate roles of the public and private sectors in a manner that, taken as a whole and aggressively pursued in a phased approach, creates an opportunity to reduce current healthcare expenditures by as much as $1 trillion.  They include:

•  Wiring Healthcare
•  Fixing Medicare’s Financial Fundamentals
•  Eliminating Medical Liability and Defensive Medicine
•  Increasing Compliance and Reducing Errors
•  Promoting Healthy Lifestyles

Mr. Snow goes on to elaborate briefly on each of these points. I have excerpted the portion dealing with patient compliance:

Encourage Compliance and Reduce Errors
It has been independently documented that we could save another $177 billion related to improving compliance and reducing errors.

The fact of the matter is that doctors are well paid to offer their advice, but all too often, patients simply don’t follow the instructions. In the case of diabetes, which currently afflicts 5 percent of the population and whose treatment accounts for 15 percent of all drug spending, only 7 percent of diabetic patients are controlling the three primary factors that could mitigate the effects of their disease and allow them to live a healthy and productive life.

As a result, this noncompliance may lead to blindness, renal failure, amputations, increased hospitalization, and other complications that magnify the suffering and the expense related to diabetes.

The burden is not the patients’ alone. Research shows that it currently takes 17 years from the time a medical protocol is proven effective to the time that it becomes a widely used standard of practice by physician. …³

One cannot help but note that no solutions are offered for the “simple” problem of noncompliance. In contrast, Mr. Snow explicitly assigns responsibility for correcting the other four problems to the federal government and gives some direction on how to go about those tasks. Excerpts follow:

Wire Healthcare

This is an area where government leadership through policy could become a catalyst for an immediate positive response by the private market. It’s happened once before. In the 1970s, hospitals billed Medicare using a paper-based system that in its best day was inefficient and expensive. To stimulate change, the government promulgated  payment rules whereby hospitals would be reimbursed only for claims that were submitted electronically. The private sector stepped in with technology solutions and, virtually overnight, electronic claims clearinghouses sprang up and all hospitals began billing electronically. Problem solved.

Fix Medicare

Culturally, we are conditioned to expect and implement heroic methods, even in cases where treatment is futile, and often resulting in unintended negative and painful consequences for the patients and devastating financial consequences for Medicare. This inherently uncomfortable issue forces us to confront our own mortality and requires strong leadership with candid conversation – it can’t be left to doctors, hospitals, or insurers. Government needs to set policy and establish rational rules for the level of care based on medical science – it’s not the private sector’s role to pass judgment on hope. Protocols based on scientific standards would ease the burden on families, physicians and, yes, patients. This is not withholding or rationing essential healthcare – it’s stepping up to the important and necessary reality so that resources are available to those who can be helped.

Address Litigation and Defensive Medicine

Tort reform eliminates ridiculous litigation, averts the waste related to physicians performing unnecessary tests as they practice “defensive” medicine, and could reduce healthcare costs by another $200 billion a year.

Wellness and Prevention

Here’s where we must have inspired and credible political leadership to fill the current void and raise the collective national consciousness.

Most of us can remember how government-led campaigns changed behavior through vivid imagery that etched into our memories messages with impact:  Smokey Bear’s sad reminder that “Only you can prevent forest fires”; the crash-test dummies Vince and Larry, serving as a testimonial for seatbelt safety by suggesting that “You can learn a lot from a dummy”; …

The private sector can never be expected to drive behavioral change, although we’ve seen employers make valiant attempts at implementing programs to lower healthcare costs – efforts that unfortunately are doomed to fall short. These range from positive reinforcement – discounted health club memberships and bonuses for employees who meet certain fitness targets – to surcharges for employees who smoke. Meantime, HMOs and other insurers have adopted low- or no-cost preventative programs for baby wellness visits, routine check-ups, mammographies, and other procedures that are designed to detect issues early instead of simply providing treatment after the fact.  Such initiatives are only likely to succeed if we make wellness a national imperative, something that requires political leadership and personal responsibility. In the end, each of us must take on greater accountability for making positive choices in our lifestyle.

I do think one could make the argument that a parallel strategy to that suggested for enhancing Wellness and Prevention (i.e., “inspired and credible political leadership to fill the current void and raise the collective national consciousness”)  could also be implemented to enhance compliance. Even so, kind of public service announcements and ad campaigns to which Mr. Snow points have not, to my knowledge, shown more than short term gains when applied to patient compliance (e.g., ad campaigns to encourage participation in mammogram screening). And, more to the point, Mr. Snow did not himself suggest that as a compliance solution.

In closing, Mr. Snow observes that while the federal government, individual patients, clinicians, and hospitals have either directly caused this set of problems or failed to take advantage of opportunities to correct them, there are – thank goodness – some organizations making heroic efforts to save us from ourselves.

After earlier bemoaning the unfair demonizing of HMOs, he approvingly notes that

HMOs and other insurers have adopted low- or no-cost preventative programs for baby wellness visits, routine check-ups, mammographies, and other procedures that are designed to detect issues early instead of simply providing treatment after the fact.

And, he modestly allows that “At Medco, we’re doing our part,” and goes on to list the specific ways in which Medco is indeed doing its part, including, with respect to adherence,

Leveraging the power of information to prevent errors and drive greater compliance, we’re a founding member of one of country’s largest organizations to process electronic prescriptions, creating the equivalent of a superhighway that shuttles information between the prescriber, payer, and pharmacy.

I suppose I should have expected the commercial; still, it hardly lends credibility to the remainder of the talk and it tends to polarize stakeholders in healthcare. As a physician who didn’t automatically follow every idiotic protocol shoved at me⁴ and as a sporadically noncompliant patient, I’m a tad miffed about the tenuous proposition that, in contrast to the sins of my fellow clinicians and patients, HMOs and Medco are “doing their part” to increase the effectiveness and efficiency of healthcare.

Conclusions

The good news is that David Snow wants to put adherence to treatment on the national agenda, albeit as part of a group of healthcare issues that inflate the cost of medical care. I may have mentioned once or twice my conviction that patient compliance should be a national healthcare priority.

And, some of his points are so on target (i.e., I agree with them) that they do seem to be no-brainers. For example, tort reform⁵ seems an area in which it is possible for government to act quickly and decisively to effect a sweeping change that could save huge amounts of money, in this case by eliminating the necessity to practice defensive-expensive medicine.

On the other hand, the idea that the Feds can, as Mr Snow suggests, shift public opinion and clinical practice sufficiently to rescue Medicare by curtaining care for those for whom there is little medical hope⁶ seems a mathematically valid concept formulated in an ivory tower than a politically pragmatic program. Perhaps it’s a negotiating point – or one of those ideas floated as a trial balloon early in a campaign.

Because, however, I am familiar with and have thought much about treatment adherence, I especially object to the notion that there is anything “simple” about noncompliance other than the fact that it is, indeed, a prominent and very expensive problem.

Providing a few of the many available statistics that indicate the extent and cost of noncompliance is hardly a step toward a solution. If that were so, every review of patient compliance and every web site on the subject (including this one) would have eradicated the scourge years ago.

I agree that noncompliance is a problem. The thrust of this speech is that straightforward solutions exist when I’m not convinced an accurate model or conceptualization of the problem exists.

Returning readers may recall an earlier post which dealt with the claim that a prosthetic tooth capable of releasing a controlled dose of medication at regular intervals would, in the words of its press release, “mean, finally, an end to the 2500 year-old patient compliance conundrum.”

Marshall Molar, Medication Modulator

My vision of the tooth hailed as the solution to patient noncompliance

The conclusion to that post included this admonition:

IntelliDrug [the drug-dispensing tooth] seems a legitimate, scientific project that could have an impact in some cases in which medication noncompliance is too dangerous or too costly to risk and the patient is cooperative.

Transforming an expensive potential tactic to improve adherence among a relatively small group of individuals into “an end to the 2500 year-old patient compliance conundrum” makes the project seem a joke and leads to mistrust of any future claims of effectiveness, however reasonable they might otherwise be.

My recommended solution to this problem follows:

Don’t make ridiculous claims for a
compliance-enhancing device or program

David Snow doesn’t claim he can put “an end to the 2500 year-old patient compliance conundrum,”  but in his National Press Club speech he does implicitly claim that noncompliance (or at least the cost of noncompliance) can be simply and significantly improved.  My contention is that this has a remarkable resemblance to a ridiculous claim and that no such simple solution is possible. In any case, none is offered in the National Press Club talk.

If there is a solution, Mr. Snow should spell it out.

Alternatively, I am available for appointment in Mr. Snow’s adminstration to a cabinet level position – say, Grand Exalted and Beloved Vizer of Healthcare Alignment – from which I could promulgate any treatment adherence policy necessary.

If nominated, …


Footnotes

1. Mr Snow’s complete presentation is available at Medco Perspectives↩
2. The absence of an “always,” “never,” “none,”   “without exception,” or similar absolute qualifier in the second point causes one to wonder if Mr. Snow is less confident of its validity.↩
3. Note that patient compliance with treatment recommendations and clinician compliance with medical protocols are conjoined. While both are legitimate concerns, combining them seems more complex and confusing than helpful. Consequently, this post focuses only on patient compliance.↩
4. For the record, not every protocol is idiotic. And, I did follow the idiotic ones that only robbed me of my time and effort but didn’t seem to hurt anyone↩
5. I suspect is is my occupational biases that prompt me to immediately think of tort reform as an example.↩
6. Snow phrases it as “Government needs to set policy and establish rational rules for the level of care based on medical science – it’s not the private sector’s role to pass judgment on hope.”↩

The Frightening – And Typical – Scenario

Benjamen Brewer, MD, commenting in the 23 July 2008 Wall Street Journal on the effect the current economic problems have on his patients, describes this vignette from his practice:

A patient quit smoking so he could afford gas for the 40 mile commute to work in a packaging plant. He has been living paycheck to paycheck for years and his rent just went up. I was glad that something finally motivated him to stop smoking.

The bad news was that he came to the office with severe pneumonia two days after refusing to let an E.R. doctor admit him to the hospital. My patient was afraid of the expense and all the time he would go without pay from work.

To make matters worse, he didn’t fill the antibiotic prescription he was given either. The $50 co-payment was unaffordable, he said. This is a case when an insurer would have been better off picking up the antibiotic tab to avoid a larger expense. But there’s no easy way for a doctor to override a plan’s co-pay or to let an insurer know its rules are about to make something very expensive happen.

When the patient came to see me, his condition had deteriorated. I persuaded him to let me admit him to the local hospital. He was in such bad shape that he was soon transferred to the ICU of a large medical center. His care will end up costing tens of thousands of dollars.

Commentary

I suspect there are few physicians in clinical practice who could not relate similar stories these days. In addition to its poignancy, however, this episode is also instructive. Patient compliance rarely seems to hinge on a few dollars but our health system operates as a fiscally leveraged system in which huge costs and fees are pragmatically payable only through insurance and other third party payer plans. The loss of a job or a health benefit has consequences beyond a decrease in income or the dollar equivalent of a health benefit. Without insurance, the individual is vulnerable to costs that one can neither control or pay. One result is that financially dependent compliance is remarkably brittle. We should not be surprised that a downturn in the economy has a tremendously magnified negative impact on compliance.

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↩

Thoughtful Commentary On Core Issues

Source: Dealing with non-compliance
The Pharmaceutical Journal Vol 263 No 7074 p922-923, December 4, 1999 Forum

While the majority of AlignMap posts deal with research, the topic today is an editorial emanating from a Drug and Therapeutics Bulletin seminar on “How to look after patients who fail to care for themselves.”

Although this seminar was held in 1999, its content, the economic, ethical, and clinical aspects of treating noncompliant patients, remains pertinent today. This brief (less than 2000 words) article consists entirely of a series of comments from seminar participants that are insightful, thoughtful, and sometimes provocative and is well worth reading.

This editorial can be found at ~ Dealing with non-compliance ~

Controlling Prescription Drug Expenditures:
A Report of Success
David P. Miller, MD; Curt D. Furberg, MD, PhD; Ronald H. Small, MBA; Franklyn M. Millman, MD; Walter T. Ambrosius, PhD; Julia S. Harshbarger, PharmD; and Christopher A. Ohl, MD
Am J Manag Care. 2007;13:473-480

Using Multiple Clinical Administrative Strategies To Control Pharmaceutical Costs

To hold the line on prescription medication costs without decreasing the necessary use of drugs ordered for treatment of chronic conditions, the health plan covering the 11,000 employees of Wake Forest University Health Sciences and North Carolina Baptist Hospital instituted four administrative level interventions, none of which resulted in higher out-of-pocket charges to individual patients, even if they were, as a result, shifted to a more expensive medication.

The four policies, their fiscal impact, and their effect on clinical utilization are summarized in this excerpt from the article:

Commentary

This article serendipitously came to my attention shortly after I published the previous entry in this blog, Another Case Of Cash For Compliance, which focused on monetary incentives and disincentives, including cost-sharing,¹ implemented to improve healthcare habits and cut costs.

The decision of this organization to eschew shifting some or all of the costs of more expensive drugs to patients to discourage their use made this article a striking counterpoint to the accounts of plans opting for cost-sharing.

While the results for the Wake Forest University Health Sciences and North Carolina Baptist Hospital health plan have been encouraging thus far, especially given that prescription medication costs have increased between 8% and 15% annually in this country since the year 2000, caveats are in order.

Most importantly, the study, as the authors note, only looked at one clinical parameter, the utilization of chronic medications; the effect of these interventions on other clinical outcomes (e.g., hospitalization rate) must also be determined.

Moreover, the clinical offerings and the pricing structure of the pharmaceutical industry have been and are likely to continue to be in flux (a factor also acknowledged in the article). Today’s successful price-cutting tactic can be rendered ineffective or even counterproductive by a policy shift at one of more of the medication manufacturers.

For example, pill splitting, used in this study to “yield substantial cost savings,” could be eliminated overnight by a simple change in the nonobligatory one pill, one price policy (i.e., a 25 mg dose and a 50 mg dose of a medication is typically sold for the some price, allowing a patient to split one 50 mg pill into two 25 mg doses at a saving of 50%) of many pharmaceutical producers which, as I’ve pointed out in a previous post, Intentional Noncompliance With Treatment, already consider the tactic subversive and seem well along toward the rationalization that it could be dangerous to patients.

And, of course, clinical discoveries can have analogous results, although cataclysmic changes may be less likely to occur without warning.

Nonetheless, the findings of this study support the notion that health plans willing to continually track, evaluate, and reassess pertinent changes in the clinical and business spheres of healthcare and adjust their own benefit structure accordingly can make impressive progress toward the goal of affordable healthcare.

Footnotes

1. Previous posts on cost-sharing:
   Cost-sharing and Adherence To Prescribed Medication
   Healthcare Cost-sharing And Medication Compliance
   More On Cost-sharing And Medication Compliance

   ↩

After publishing two posts dealing with cost-sharing (More On Cost-sharing And Medication Compliance and Healthcare Cost-sharing And Medication Compliance) earlier this week, I realized I had other articles on this topic stashed for potential use in future blog entries.

Because I can’t predict when – or if – those articles will make it online on this site and because of the importance of the effects of healthcare cost-sharing on patient compliance as well as the current interest in the topic, today’s post references some of this material for the interested reader.

The Integrated Benefits Institute Report
The Integrated Benefits Institute (IBI) has issued the a report, A Broader Reach for Pharmacy Plan Design, that, according to the press release, “finds pharmaceutical cost shifting leads to increased disability and lost productivity.” Funded by IBI, the full report is available to IBI members,¹ but others can access the Executive Summary.

The American Journal of Managed Care Special Issue
In June, the American Journal of Managed Care published a special issue devoted to medication cost-sharing that included, among others, these titles:

• “Fiscally Responsible, Clinically Sensitive” Cost Sharing: Contain Costs While Preserving Quality
• Effect of Copayments on Drug Use in the Presence of Annual Payment Limits
• Effect of a Medication Copayment Increase in Veterans With Schizophrenia
• Relationship Between Generic and Preferred-brand Prescription Copayment Differentials and Generic Fill Rate
• Consumer Response to Dual Incentives Under Multitiered Prescription Drug Formularies

The complete articles are available in PDF format online at The American Journal of Managed Care (June 2007 Issue, Part 2): Prescription Drug Cost Sharing

Commentary

Both the Integrated Benefits Institute and the American Journal of Managed Care have a specific point of view that may influence their take on this topic. Of late, however, I have found it difficult to find research that it free of potential influence. These days, I am grateful when the researcher’s point of view and potential biases are at least clearly presented.

Footnotes

1. The full report is also offered to media; consequently, I have requested a copy. If that request is granted, I’ll review the report on this blog.↩