Improving Adherence to Chronic Medications: The Physicians Role and How 340b Can Help

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Augusta Rose
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1 Improving Adherence to Chronic Medications: The Physicians Role and How 340b Can Help William Shrank MD MSHS Division of Pharmacoepidemiology & Pharmacoeconomics Harvard Medical School

2 Agenda The Problem of Non-Adherence The Many Reasons for Non-Adherence The Role of Cost A Challenging, Complex Environment for Physicians and Patients What Doctors Can Do to Help Patients Our Adherence Intervention in NYC The Role of 340b Programs to Assist Physicians with Adherence

3 Non-Adherence is Common Across Chronic Conditions 90% 80% 70% 80% 78% 78% 73% 73% 71% 70% 60% 50% 55% 51% 40% 30% 20% 10% 0% Cancer Psych. Illness Glaucoma Diabetes mellitus HTN C V Epilepsy Asthma COPD Mean Medication Adherence Rate Claxton, Clin Ther, 2001

4 Adherence to Essential Chronic Medications is Poor: 50-70% Coronary Artery Disease 45% of patients are fully adherent with beta-blockers in the 1 year after an acute MI. (Kramer, AHJ. 2006) 50% of patients are adherent with their prescribed statin. (Jackevicius, JAMA. 2002) Less than 20% use all four recommended agents. Antihypertensives 50% (Rudd, Card Rev. 2004) Lipid Lowering mean PDC was 79% in the first 3 months, 56% in the second quarter, and 42% after 120 months (Benner, JAMA. 2002) World Health Organization: about 50% adherence to essential chronic medications

5 With Massive Public Health Consequences 125,000 deaths per year in U.S. 1 11% of hospitalizations 2 Total cost estimates range from $100 billion 3 to $300 billion 4, including both direct and indirect costs. 1 Haynes RB. Compliance in Healthcare, 1979; Blackwell B. N Engl J Med, Caro JJ, CMAJ Munger, Liu, Wertheimer, Whitcup, Berg, Ickovics, Burney, Biondi-zoccai 4 DiMatteo, Med Care, 2004.

6 In 2003 WHO identified nonadherence as a leading cause of preventable morbidity, mortality and cost WHO report Lessons Learned 1. Patients need to be supported, not blamed 2. The consequences of poor adherence to long-term therapies are poor health outcomes and increased health care costs 3. Improving adherence also enhances patient safety 4. Adherence is an important modifier of health system effectiveness 5. Improving adherence might be the best investment for tackling chronic conditions effectively 6. Health systems must evolve to meet new challenges 7. A multidisciplinary approach towards adherence is needed

7 Factors Associated with Non- Adherence Patient characteristics Demographic Clinical Health services use Prior medication adherence Social support Provider characteristics/ relationship Specialty Patient assessment of relationship Regimen characteristics Out of pocket cost Effectiveness Tolerability Frequency Packaging Complexity Health system characteristics Type of health insurance Pharmacy benefit design

8 Patient Reported Reasons for Non-Adherence Unconvinced of need for therapy Never needed it Need went away (cured) Competing health priorities Don t know indication Unconvinced of effectiveness Poor understanding of what medication does Experienced/feared side effect Difficulty with administration Routine Route (needles, inhaler) Administrative challenges Transportation to the pharmacy Understanding prior authorization Health Literacy Issues Unable to read label Out of pocket cost Of subject medication Of other medications

9 Cost is a Major Factor for Many Patients Meta-analysis: each 10% increase in cost sharing, prescription drug spending decreases by 2% to 6% (Goldman, JAMA 2007) Doubling copayments reduced use of chronic meds by about 1/3. (Joyce, JAMA 2005) Patients who restrict med use due to cost have 50% increased odds of angina, MI, stroke (Piette, Med Care 2004) Introducing cost-sharing for Rx in low-income patients in Canada led to: (Tamblyn, JAMA 2003) -- 14% reduction in essential medication use -- Doubling of adverse events from non-adherence and ER visits

10 The Poorest are Charged Most We evaluated prices for the same drug at pharmacies across the state in Florida Found great variability Prices were highest in poor neighborhoods Less chains in poor neighborhoods Gellad, Shrank under review

11 A Challenge for Patients and Physicians Hard to identify the right drug for the right price

12 Doctors Unaware of Formularies and Patients Out-Of-Pocket Costs Physician Familiar with Patient s: Familiar Most or All of the Time Familiar Some of the Time Familiar Seldom or Never Insurer 47% 24% 29% Formulary 16% 25% 59% Out-of-Pocket Costs 10% 20% 70% Shrank et al. AJMC, 2005

13 And Docs Don t Feel Accountable Physicians Pharmacists % of Physicians Strongly Disagree Somewhat Disagree Neither Somewhat Agree Strongly Agree Shrank et al. AJMC, 2005

14 Patients also Unaware And They Don t Talk to Their Doctors About Costs Never Sometimes Always No Copay Single Copay Multi Copay No Rx. coverage Shrank et al, Journal General Internal Medicine. 2006

15 Does it Matter if Doctors and Patients Are Aware and Communicate About Costs? Is adherence at risk? Data Source: Anthem pharmacy claims Patients continuously enrolled in 3-tier plans Identified patients who initiated any of 6 classes of chronic medications Measured adherence in the following year Controlled for income, age, gender, chronic diseases Shrank WH, et al. Archives of Internal Medicine. 2006

16 Prescribing in Compliance with Formularies Improves Adherence Proportion of Days Covered Shrank WH, et al. Archives of Internal Medicine

17 Which Patients Receive Generics? Treated by generalists rather than specialists Taking more medications Using mail-order pharmacies Charged higher copayments for branded medications Those who live in WEALTHIER neighborhoods Shrank et al, JGIM 2007

18 Patient beliefs about generics Hypocrisy? FIGURE 2. Differences in Individual Preferences for Generic Medications and Perceptions about Generics for Society Even more challenging for Physicians Percent Agree agree disagree 10 0 I would rather take generic drugs Americans should use more generic drugs Shrank, Fischer, Choudhry, under review

19 To Sum up Complexity Doctors and patients unaware of out-ofpocket costs for medications Doctors and patients not communicating Patients, and maybe doctors, have concerns about cost-effective medications A complex system that adversely affects adherence. Those most vulnerable may be at greatest risk.

20 What Can Doctors Do? Ask about medication adherence More patient education about medication Indications/reasons for the medication Directions Side effects/warning Think Generic first Explicit communication about costs Awareness of resources available for patients NCQA is adding adherence to chronic medications as a quality indicator may be a pay for performance metric someday soon

21 Interventions to Improve Adherence: What Does the Evidence Say? Multi-factorial Education about medication Reduce cognitive complexity Simplify regimens Reduce costs when a barrier Social support Communicate with physicians Increased contact with patient and doctors about the medication will improve adherence

22 How 340b Programs Can Help Reduced Costs for Patients Trying to identify a formulary of best-buy drugs to encourage more cost-effective prescribing Development of a database of medication use that can be used to track adherence Can be used to communicate with patients or providers A sense of a system where patients will (hopefully) feel more comfortable communicating needs and barriers

23 The NYCRx Cares Adherence Intervention Use 340b data to identify with hypertension or diabetes who are non-adherent Contacted by community health workers Open-ended script to identify any of 12 barriers to adherence Nurse back-up for more gravitas Stimulate communication with physicians Empower patients, provide them with more knowledge We will measure the effects on medication use

24 Community Health Worker Algorithm to Identify Reasons for Non- Adherence

25 What 340b Can Do to Help Your Patients Assist them with medication costs Give you data about medication use Enhance your communication with patients about medications Provide your patients with more complete system of care

26 Improving Adherence to Chronic Medications: The Physicians Role and How 340b Can Help William Shrank MD MSHS Division of Pharmacoepidemiology & Pharmacoeconomics Harvard Medical School

SURVEY ABOUT YOUR PRESCRIPTION CHOICES

SURVEY ABOUT YOUR PRESCRIPTION CHOICES Editor s Note: This online data supplement contains supplemental material that was not included with the published article by William Shrank and colleagues, Patients' Perceptions of Generic Medications,