The following guest post — part of Disruptive Women’s drug adherence series — is written by Valerie Fleishman, Executive Director, New England Healthcare Institute.
Patient adherence represents a rare “win-win” in health care, so it’s no surprise that all sectors have been busy seeking potential solutions. Technology companies have developed reminder gadgets, employers have redesigned benefit plans to remove cost barriers to chronic disease medications, pharmaceutical companies have developed combination drugs to simplify regimens, and providers have begun implementing new patient education and counseling techniques. However, efforts to date have remained largely sector specific and silo-ed. An earlier post by Janet Wright correctly pointed out that poor adherence is not the fault of patients, but rather the fault of the entire health care system. Ideally, we need to move beyond silo-ed efforts and develop a system-wide approach to the problem.
Recognizing that, the New England Healthcare Institute (NEHI) launched a multi-stakeholder initiative earlier this year to identify system-wide solutions to poor adherence. Several of these solutions have been mentioned in this series such as improved care coordination and the use of health information technology. However, I would like to highlight a fundamental system-wide change that has not yet been discussed in great detail, and was one of the critical findings from NEHI’s multi-sector expert roundtable and issue brief: payment reform.
It is important to keep in mind that patient medication adherence is ultimately a quality issue. As NEHI’s research shows, the link between medication adherence and improved health outcomes is clear. Studies of chronic disease patients have shown that adherent patients have significantly lower hospitalization rates than nonadherent patients. Unfortunately, the current payment model is not designed to reward providers for patient outcomes – of which medication adherence may qualify as either a means toward that end or an endpoint itself. Either way, using payment reform to move away from rewarding volume of services and towards rewarding good health outcomes would go a long way to improving medication adherence and patient outcomes.
Performance-based reimbursements, global service payments, and Accountable Care Organizations are all being discussed as ways to reform our payment and delivery system. Performance-based reimbursements would reward providers for helping patients achieve measurable, positive health outcomes. Global service payments would give providers a lump sum to manage a group of patients as they see fit – with the expectation that the payment is used to achieve the best possible outcomes. Accountable Care Organizations are collaboratives within which a hospital, primary care physicians, specialists and other providers accept shared responsibility for the cost and quality of the care provided to a group of patients.
With the ultimate goal of better patient outcomes, all three of these models could provide the needed incentives and resources for providers to invest in interventions that would help them monitor and improve adherence. For example:
- Providers would have incentives to review and act on patient adherence data such as claims or pharmacy records, which could be used to identify non-adherent patients so that providers could intervene as appropriate.
- Physician practices would have additional resources needed to invest in longer visits with patients. Moving beyond the 15 minute model would allow physicians and other providers within the practice to engage in activities such as medication reconciliation, motivational interviewing and patient education.
- Payment reform to promote adherence and improved health outcomes could be extended directly to non-physicians as well. We have an enormously valuable and untapped resource in our community pharmacists, and yet they are not reimbursed for patient medication counseling beyond limited medication therapy management programs. Creating the appropriate reimbursement incentives could encourage community pharmacists to provide additional services and to work collaboratively with physician practices around medication reconciliation and adherence.
- Clinical pharmacists could be hired by physicians to assist their practices with medication related needs. Given the skill set that clinical pharmacists have in pharmacology and medication use, they could be utilized on a regular basis to care for patients struggling with complex medication regimens.
- Providers would have incentives to better coordinate patient care, particularly during times of care transitions such as hospitalizations. Under an Accountable Care Organization model, providers would be accountable for ensuring that medication lists are reconciled before patients leave the hospital, that patients understand post-discharge care instructions and that the appropriate follow-up is made to ensure that patients have filled their prescriptions and are educated about taking their medicines appropriately.
Payment reform is an essential first step in taking a system-wide approach to medication adherence. It is critical that we align incentives to focus on and reward better patient outcomes. Without the appropriate payment incentives, it will be exceedingly difficult, if not impossible, for our health care providers to make any meaningful dent in the widespread problem of poor adherence.