Addressing the Challenge of Medica3on Adherence. Jan Berger MD, MJ President and CEO Health Intelligence Partners

Transcription

1 Addressing the Challenge of Medica3on Adherence Jan Berger MD, MJ President and CEO Health Intelligence Partners

2 Drugs Have Become the Mainstay of Healthcare Treatment

3 America s Other Drug Problem Non-adherence has Reached Crisis Proportions Adherence among pa3ents with chronic condi3ons averages only 50% Nearly 1/3 of pa3ents don t fill the prescrip3ons they are given Nearly 3 in 10 stop taking a medica3on before their supply runs out Nearly 1/4 take less than the recommended dose Poor medication adherence costs an estimated $310B annually in total direct and indirect health care costs Source: National Council on Patient Information and Education, November, 2009.

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5 The Problem is Not New Keep a watch on the faults of the patients, which often make them lie about the taking of things prescribed. For through not taking Disagreeable drinks, purgative or other, they sometimes Die. - Hippocrates Drugs don t work in patients that don t take them. C. Evere( Koop, M.D. 5

6 There is no impending pharmaceu3cal discovery, surgical innova3on, or governmental policy change with greater poten3al for improving the health of pa3ents and the efficacy of the healthcare system than simply increasing the percentage of treatment plans that pa3ents carry out as prescribed. Increasing the effec3veness of adherence interven3ons may have a far greater impact on health of the popula3on than any other improvement in specific medical treatment World Health Organiza3on 2002

7 Health Reform and the Issue of Medica6on Adherence Payment Reform New Provider Models Reduc3on of Out of Pocket Cost Barriers Care Coordina3on Health Informa3on Technology

8 Defini3on of Adherence Taking a medica3on in the manner and for the length of 3me agreed upon between the healthcare consumer and their healthcare provider

9 All Non Adherence is Not The Same Non- Inten3onal- Most commonly a passive ac3on Inten3onal- An ac3ve decision on the part of the pa3ent Primary- Prescrip3on given but the pa3ent never fills the medica3on Secondary- The pa3ent has filled the medica3on at least one 3me

10 Almost 25% of pa3ents don t fill their first prescrip3on Percent Filled Filled by Therapy by Therapy Nutritional Products Genitourinary Products Cardiovascular Agents Central nervous System Drugs Gastrointestinal Agents Respiratory Agents Topical Products Neuromuscular Drugs Endocrine & Metabolic Drugs Analgesics & Anesthetics Anti-Infective Agents Hematological Agents Antineoplastic Agents SOURCE: Fischer, Choudhry, et al Am J Med 2011; in press

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12 Why Does Adherence Ma\er? 25% 100,000 $310B Percentage of coronary artery patients discontinuing drug therapy after 6 months Number of deaths annually due to poor medication adherence; on par with those caused by stroke Annual cost of poor adherence

13 Rx Adherence Vs. Medical Spend: Average expenditures per year $10,000 $9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $55 $8,812 Diabetes $165 $285 $404 $6,959 $6,237 $5,887 Rx $ Medical $ $763 $3,808 $1,000 $0 1 19% 20 39% 40 59% 60 79% % Compliance levels (% days supply/1 year) Increased drug spend and adherence results in an overall decrease in medical expenditures for diabetes. Source: M.C. Sokol, K.A. McGuigan, R.R. Verbrugge, R.S. Epstein, "Impact of Medica3on Adherence on Hospitaliza3on Risk and Healthcare Cost," Medical Care 2005;43: ) 13

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15 Survey Aeer Hospital Discharge Reveals Medica3on Adherence is the #1 Issue Resources Required for Pa9ents in the 24 to 72 Hours Post Discharge Need transporta6on 11% No follow up with provider 11% Haven't filled Rx 31% Needs same day follow up with care manager 13% Financial barriers to care 15% Need help around the house 19% N = 1,400 Source: Silverlink Communications, Inc. 15

16 A Complex Challenge: Barriers to Adherence While it may seem to be a simple issue, many factors contribute to adherence problems For outcomes to be improved, many factors must be addressed Source: Adherence to Long- term Therapies Evidence for ac3on, World Health Organiza3on

17 Barriers to Adherence: No Magic Bullet Pa6ent Level Physician Level System Level Understanding how to use medica3on Understanding illness & importance of the medica3on Affordability / coverage Complexity Side effects Family support Understanding drug costs Communica3ons about drug costs Knowledge of drug costs Communica3ons about safe and appropriate use Knowledge about pa3ent adherence Access / coverage Complexity of formularies Administra3ve barriers Prior authoriza3on Barriers to access to care Economy Physician / pa3ent rela3onship Health IT Communica3ons about drug costs 17

18 Survey Reveals Challenges for Pa3ents on Prescrip3on Medica3on for Chronic Illnesses 40% say they haven't followed doctor's instruc3ons or have skipped taking their meds at least once in the past year More than a quarter said they've stopped taking medica3ons altogether or never even filled a prescrip3on 25% of respondents said taking medica3on makes them feel old 21% said they worry when they take meds, and 10% said it reminds them of their illness and makes them feel sad Survey conducted by Healthprize n=>1,000 18

19 Different Patients Cite Different Reasons for Low Adherence Percent of respondents citing reasons for not adhering to drug regimens Active choice not to adhere Other Don t know how to use drug Can t get Rx filled, picked up, or delivered Don t think I need the drug The drug costs too much Don t want the side effects 24 Sometimes forget to use or refill The Hidden Epidemic: Finding a Cure for Unfilled Prescriptions and Missed Doses, The Boston Consulting Group (BCG), December ,000 patients surveyed.

20 Addi3onal Insights on What Gets in the Way Barriers to Medica6on Adherence Medicare Popula6on I am convinced of the importance of my prescrip3on medica3ons 84% 13% 3% I feel financially burdened by my out- of- pocket expenses for my prescrip3on medica3on 40% 43% 17% My medica3on will do more harm than good 11% 48% 41% 0% 20% 40% 60% 80% 100% N = 5,271 Source: 20 Silverlink Communica3ons, Inc. Agree Neutral Disagree

21 Most patients don t realize what they don t do Quick Take Rx Adherence Hits The Ignorance Wall,

22 Women of All Ages Struggle More than Men to Follow Doctor's Orders 32% of women said they've quit taking medica3ons or didn't fill a prescrip3on, compared with 20% of men 20% of women also said they're more likely to follow a prescrip3on if it's for a pet rather than for themselves 22 People of both genders report that they don't always trust their doctor's judgment

23 The Biggest Non- adherence Culprits are Millennials 56% of millennial reported stopping their medica3ons altogether or had never filled a prescrip3on, compared to 16% of people ages 65 and older 23% of all survey respondents said they don't always trust their physicians or the medica3ons they prescribe 23

24 The Provider- Pa3ent Disconnect 83% of Pa3ents would not tell their doctor that they did not take their medica3ons 74% of doctors believe that their pa3ents are adherent to their medica3ons Goldberg et al, Social Science Medicine 1998 Lepane, AJMC 2007

25 What do we know about how to intervene to improve adherence? 25

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27 Beliefs Don t Predict Behavior When asked 90% of pa3ents stated that taking their medica3ons was important to their health At the end of one year over 50% of pa3ents stopped taking their medica3ons So what is the disconnect?

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29 Money Ma\ers But how much?

30 Physicians Are Rarely Aware Of Pa3ents 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,

31 Pa3ents Unaware of Costs of Medica3on at the Point of Prescribing % of Pa6ents Never Some3mes Most of the Time Always Shrank, AJMC

32 Systema3c Review of The Effect of Copayments on Adherence $ Increased cost- sharing associated with lower rates of drug use, worse adherence among exis3ng users, and more frequent discon6nua6on of therapy For every 10% increase in cost sharing, drug use decreases by 2-6% For pa3ents with CHF, lipid disorders, diabetes, and schizophrenia, higher copayments are associated with increased use of medical services Goldman DP, et al JAMA

33 Cost Alone Does Not Solve The Problem Studies have shown that plan design changes that reduce a patients out of pocket expenses for medications without any other interventions increases medication adherence by 3-11%. Adding personalized communications and coaching can more than double these rates with increases of 20-25%. Communica3on 33 Dollars

34 Communica3ons: Personalize the Message Not a Best Prac6ce! October 13, 2010 Dear Resident(s), WELCOME to BARRON PARK!*!*! We hope that you will find the following items in our Gree3ng Packet useful. All residents receive the Barron Park Associa3on Newsle\er in Spring, but you must subscribe to receive the other issues quarterly. A recent issue is included for you to sample, with a separate membership form to encourage you to subscribe. The Weekly s Resource Guide Info (once a year) will come to you, along with the Weekly, by mail. The Neighborhood Watch material is something you re probably already familiar with. The Neighborhood Watch program is organized by local neighborhood organiza3ons. 34

35 Communica3ons: Make the Message Understandable Health Literacy is cri6cal October 13, 2010 USA care is reaching out to make sure that you are adherent to the health care that your physician had prescribed for you in order to maximize your health and manage your diabetes. Doctors recommend that you see an ophthalmologist and receive a slit lamp eye exam annually. In addi3on, you should receive an Hemoglobin A1c semi annually. Our records show that an appointment is required with your ophthalmologist for an eye exam and endocrinologist or primary care physician for your hemoglobin A1C. Remember, it is the 3me of year to discuss your influenza vaccine in order to protect yourself. 35

36 Physician- Pa3ent Communica3on About New Medica3ons Physicians stated the medication name for 74% of new prescriptions Explained the indication 87% of time Adverse effects addressed for 35% of medications Dura3on of therapy 34% Explicit instruc3ons about the number of tablets to take 55% and frequency or 3ming of dosing 58% Tarn D. Archives of Internal Medicine Patients frequently do not remember their conversations with doctors Fletcher SW, Journal of Community Health

37 Many Pa3ents Cannot Understand Labels IOM finds that almost half patients have low-health literacy In an evaluation of 395 patients shown 5 medication labels Correct understanding ranged from 67.1% to 91.1% Low literacy patients did worse and were less able to understand all 5 label instructions Only 34.7% could demonstrate the number of pills to be taken daily Davis T, Annals of Internal Medicine

38 Can Wri\en Material Fill The Void? What is The Label? Container Label Consumer Medica6on Informa6on (CMI) Package Insert Medica6on Guide 38

39 Implica3ons of Therapeu3c Complexity on Medica3on Adherence Evidence that complex dosing schedules nega3vely impact adherence But medica3on complexity also involves number of: Pharmacies Visits to the pharmacy Prescribers Purpose of this study was to: Define the magnitude of treatment complexity Determine the impact of complexity, refill synchronicity, and a pharmacy home on medica3on adherence Es3mate the poten3al impact of simpler medica3on regimens on adherence, health outcomes and health care u3liza3on 39

40 Complexity Levels Can Predict Pa3ents Adherence STATINS ACE/ARB Adherence is greater when pa3ents: Synchronize refills Fill all their prescrip3ons at a single pharmacy ADHERENCE COMPLEXITY SCORE A simple predic6on rule may help us design interven6ons to reduce complexity and improve adherence. 40

41 Social Support: Leveraging Caregiver / Buddy System to Drive Adherence Filling Pill Boxes Reading Labels Paying for Medications Providing Transporta6on Picking Up Prescrip6ons Providing Encouragement & Reassurance AJMC, December 2012; vol. 18 no. 12 c461- c467 41

42 Technology: Using Text Messaging to Support Medica3on Adherence Interactive Messaging One-Way Reminders Stay Healthy! Be sure to refill your medicine on 3me. If you re having trouble taking your meds or refilling on 3me, chat w/your Dr. Series of mul3ple educa3onal text messages and adherence reminders Don t miss or skip on those meds! Are you on track with your refills? Reply REFILL Yes or REFILL No Know your numbers! Regular A1C & Cholesterol tests can help avoid harm to kidneys, eyes, heart & feet. Visit USACare.com One- way or two- way, interac3ve messages sent weekly Keep your A1C near normal, 7.0% or less can add 5 yrs to your life. Aim for a Cholesterol of 100. Ea3ng & taking your meds at about the same 3me each day helps you keep your blood sugar at the right level. Interac3ve prescrip3on refill survey several weeks into the program. 42

43 Case Study: Adherence Focused on people who were more than 21 days past due for a 100- day refill 85% be\er refill rate among those listening to the message Medicare Membership Success Rate 40% 30% 20% 21% 39% Key Barriers to Sta6n Adherence Convenience 15% Cost 11% Did Not Know To Refill 37% 10% Physician Instruc3ons 15% 0% Did Not Hear Message Heard Message Side Effects 22% Targeted members with diabetes and/or heart disease 71% of targeted members heard the message Conducted a barrier survey during call and provided results back to client 13% of those with side effects eventually refilled 42% of those with convenience issues eventually refilled 43

44 What Employers Can Do Make it a corporate focus Data ma\ers Align incen3ves Benefit design Vendor based adherence summit

45 Aggregate- Integrate- Analyze

46 Aligned Incen3ves

47 Value-Based Benefit Design Approaches Therapeutic class-based Copay waiver for generics within high-value therapeutic classes (i.e., high blood pressure) Move all generic and brand drugs within a therapeutic class to a lower tier Risk-based Copay incentives for high-risk consumers taking high-value drugs according to evidence-based medicine Compliance-based Copay incentives for consumers who are compliant with health management model (i.e., HRQ, biometric; medication adherence) 47

48 The Vendor Summit

49 Medica3on non- adherence is a serious healthcare problem that has high clinical and financial implica3ons to pa3ents and payers The are a number of reasons that pa3ents are non- adherent to their medica3ons There are a number of solu3ons that are available to minimize the risk member non- adherence In order to maximize medica3on adherence solu3ons need to be personalized and mul3 faceted Final Thoughts 49 49