AHIP Coverage (November/December 2008)
What the Doctor Ordered
Health plans take steps to ensure members adhere to their medication regimens.
By Glenda Fauntleroy
Medication adherence has become a major health care crisis in the United States. It has also proven to be an obstacle many health plans across the country are committed to tackling head on.
When patients fail to take medications as prescribed by their health care providers, the outcome is a costly one—both in terms of patient health and the overall cost of care. A review published in the August 2005 issue of the New England Journal of Medicine reported that of all medication-related hospital admissions in the United States, 33 percent to 69 percent are due to poor medication adherence. These admissions cost about $100 billion a year.
“We’ve found that if you’re taking your medication according to the way your doctor has ordered at least 80 percent of the time, you are far less likely to have a condition-related hospitalization,” says Karen J. Bray, M.D., vice president of clinical care services at Optima Health in Virginia Beach, Virginia. “People who drop below 80 percent are far more likely to have hospitalizations.”
In a concerted effort to improve the health of Medicare beneficiaries with high utilization by better managing their medications and reducing medication errors, the Centers for Medicare & Medicaid Services (CMS) in 2006 began to require all Medicare Part D plans and stand-alone prescription drug plans to implement a Medication Therapy Management Program for enrollees who meet certain criteria.
Targeted members are Medicare beneficiaries who have multiple chronic diseases, are taking multiple Part D drugs, and are likely to incur annual costs of at least $4,000 for all covered Part D drugs.
Existing successful “drug therapy management program” models helped inform the design of Medicare’s Medication Therapy Management Program. Though the programs offered by commercial, Medicaid, and Medicare plans are referred to by different names, all commonly aim to help members optimize therapeutic outcomes, improve medication adherence, reduce adverse events, and, by doing so, avoid costly medical care, become healthier, and have a better quality of life.
The chief obstacle to addressing medication adherence—for commercial plans, as well as Medicare plans—was to first uncover exactly why patients were not following their doctors’ orders.
Barriers to Adherence
Research on adherence has typically focused on the barriers patients face in taking their medications. The same 2005 New England Journal of Medicine review concluded that “common barriers to adherence are under the patient’s control, so that attention to them is a necessary and important step in improving adherence.” The review cited that typical reasons given by patients for not taking their medications included: forgetfulness (30 percent), other priorities (16 percent), a decision to omit doses (11 percent), lack of information (9 percent), and emotional factors (7 percent).
Bray confirms that forgetfulness is a common cause. “A main reason for non-adherence is that patients simply forget to take their medications when they are taking more than one,” says Bray.
And according to an estimate by the Institute of Medicine, nearly one-third of adults are, in fact, taking five or more different medications.
“At Optima, we’ve discovered that the more medications a patient has to take regularly, and the more chronic conditions they have, makes it less likely they are going to adhere to their medications as prescribed,” adds Bray.
Optima Health reaches more than 350,000 members throughout Virginia, and Bray says its in-house case management nurses and health coaches connect one-on-one with about 14 percent of the members, amounting to about 51,000 members actively participating in its disease management program.
“Our case managers help patients organize their lives to try to help them remember their medications,” she says. “For instance, we tell people the best way to take a chronic medication is to work it into your schedule somehow. We say, ‘If you have to take a medication in the morning, put it by your toothbrush.’” CIGNA HealthCare’s Thom Stambaugh agrees that finding each patient’s reason for non-adherence is crucial.
“The most important thing is to understand that each individual has [his or her] own specific barriers to medication adherence,” says Stambaugh, chief pharmacy officer at Hartford, Connecticutbased CIGNA. “We can then help them understand what their specific barriers are and give them solutions to the barriers.”
While health plans want to make sure all members are adhering to medication regimens, most target patients with chronic conditions, such as diabetes, hypertension, cardiovascular disease, and asthma. Stambaugh says medication adherence for these patients is paramount for their continued health. “At CIGNA, we’re very focused on medications where we know adherence directly impacts the outcomes people will have,” he says.
The same is true at St. Paul, Minnesota-based Blue Cross Blue Shield of Minnesota, where Beth Webb, RN, director of clinical design and performance, agrees it is important to closely focus on the chronically ill.
“We also tend to monitor more closely members with those conditions because we know from a medical standpoint that these are the individuals who have the most problems with adherence,” says Webb.
Blue Cross Blue Shield of Minnesota has created a concept it calls Whole Person Health Support that is aimed to meet each member on his or her own terms. By analyzing a mix of data from multiple sources, Whole Person Health Support creates a composite picture of its members’ health needs and then can customize support tools that are most likely to help members succeed in getting healthier.
Webb says the plan’s team of more than 80 dedicated nurses is key to the Whole Person Health Support concept.
She explains that non-adherence is often the result of miscommunication or poor communication between providers and members. Members “often just don’t understand when and what they are supposed to take,” she says. “That’s when having a relationship with one of our dedicated nurses is beneficial so they can help explain the medication in a bit more detail.”
Nurses also provide information and help members prepare to have productive conversations with providers about their medications.
Partnering With Physicians
Health plans with Drug Therapy Management programs also depend on their pharmacy divisions to track their members’ medication refill habits. And because pharmacy divisions track the second step after a patient leaves the doctor’s office, partnerships with physicians are key for success.
CIGNA developed its program around a realization that once a member leaves a physician’s office, that physician has no way of knowing whether the member filled the prescription or took the medications as instructed. Accordingly, CIGNA Pharmacy Management (CPM) identifies members who have not filled prescriptions in keeping with national clinical guidelines for their conditions and sends reports to the member’s physician. The reports graphically represent for the physician the last six months of medication therapy for the member, making it easy to identify and follow up with individuals whose refill patterns indicate an adherence problem.
“We hear time and time again from physicians, ‘This is great information. I prescribed the medications and wasn’t aware the patient wasn’t taking them,’” says Stambaugh. “The physicians ask us what else we can do to help them reinforce the message to the patient on how important it is to take their medications.”
In January of this year, CPM also began mailing similar reports directly to members who show new or repeat gaps in care.
“When we find these individuals, we reach out to them as well as to their physician,” adds Stambaugh. “And these reports can be sent to patients on a monthly basis.”
He adds that the partnership between CPM and its physicians is a two-way street. The plan wants to make sure the monthly reports are also entered into the patients’ medical records so physicians can have an open, face-to-face discussion about the patient’s refill patterns at the next office visit.
The results of this type of intervention have proven successful for the plan. For instance, 31 percent of the members in CIGNA’s Diabetes Outcome Improvement Program reduced their blood glucose, resulting in a 13 percent decline in emergency room visits, 18 percent dip in hospitalizations, and a 24 percent reduction in medical costs for members in the program.
When Cost is the Barrier
According to a September fact sheet issued by the Kaiser Family Foundation, spending in the United States for prescription drugs was $216.7 billion in 2006—more than five times the $40.3 billion spent in 1990. Although health plans continue to bear the greatest share of growing prescription drug spending, plan sponsors also are passing more cost along to members in the form of higher copayments for preferred drugs (those included on a formulary or preferred drug list, such as a brand name drug without a generic substitute). The Kaiser Family Foundation reports a 67 percent increase, from an average of $15 in 2000 to $25 in 2007.
With these escalating costs of prescription drugs, another common barrier to medication adherence is a simple case of dollars and cents. Many patients can’t afford rising drug copayments and have to make a choice between filling a prescription and paying other household bills. Experts say seniors especially are feeling the pinch.
“We learned from our seniors that one of their obstacles to adherence was linked to cost,” says Vanita Pindolia, Pharm.D., director of pharmacy care management at Detroit-based Health Alliance Plan. “They have a limited budget and are eager for assistance to make their medications more affordable.”
Health Alliance Plan provides health insurance to more than 500,000 members in Southeast Michigan, and launched its initial Drug Therapy Management Program for asthma in 2005. Since the inception of the asthma program, HAP Pharmacy Care Management has begun four additional Drug Management Programs, including a Medication Therapy Management Program designated for Medicare beneficiaries that encompasses more than 20 diseases.
“For the Medication Therapy Management Program, we do electronic queries monthly to see whether our seniors have been diagnosed for three of 21 selected diseases that commonly affect seniors, such as arthritis, coronary artery disease, heart failure, and diabetes,” says Pindolia. “Also, if they fill at least four prescription medications and if they are likely to incur a large annual prescription spend, they are enrolled in our senior management program.”
“Our program has in-house clinical pharmacists who engage with patients to determine their health care needs and integrate this information with the physician’s health care goals to develop and implement a new medication plan in collaboration with the patient’s physicians. By incorporating the patient’s needs into the new medication plan, the patient is more likely to adhere to the prescribed regimen,” she continues.
HAP’s Pharmacy Care Management relies on many methods to increase drug affordability for its members, including generic drug substitution, generic alternatives to brand drugs, lower cost brand alternatives, tablet splitting, and over-the-counter alternatives.
Philadelphia-based Independence Blue Cross (IBC) is another health plan that has found a way to address its members’ cost barrier to medications.
Since July, its Rx for Better Health program has waived copayments and coinsurance on 75 generic drugs that are used to treat common chronic conditions, such as high blood pressure, high cholesterol, diabetes, depression, acid reflux, and heart failure. The generic drugs for which IBC waived copayments were chosen because they are used to treat illnesses for which studies have indicated there is a huge opportunity for improved health among patients.
Rx for Better Health educates members on the benefits of following prescribed treatment plans for their illnesses and on the benefits of generic prescription drugs. The program builds on the success and popularity of No Pay Copay, the generic education program that waived copayments for IBC members on all generic prescriptions for all of 2007.
“In January of 2007, we began a major investment in our members,” says Paul Urick, senior vice president of Future- Scripts, IBC’s pharmacy benefit manager that administers the program. “We realized one of the most valuable things we could do to help them over the long term was to waive copays on all generics for the entire year to encourage members to better adhere to their prescribed medications.”
Urick added that a survey of their membership indicated that once members make the switch to generic, 87 percent will stay with the generic, helping them save money while adhering to the prescribed drug regimen.
He says IBC waived more than $50 million in copayments for its members in 2007 under the No Pay Copay program. Results have shown the program has been a success. For example, in a recent study of IBC members who take antidepressants and had been targeted with intervention outreach due to a gap in medication adherence, the plan saw a 37 percent improvement in adherence from 2007 to 2008.
According to Urick, IBC members will continue to receive the educational benefits and cost savings of these waiver programs in the future, as members have responded they will continue using generics. Once they have switched to a generic, they will always pay the lowest copayment on their plan, even after the waiver program is no longer in effect.
“People are really receptive to any education that is going to better their health and save them money,” adds Urick. “Rx for Better Health comes at a welcome time, when our members have faced a higher cost of living than ever before. We look forward to our members staying out of the hospital and emergency room by remaining adherent to their generic drugs.”
Glenda Fauntleroy is a freelance health writer and editor based in Carmel, Indiana.
Sidebar
Making the Switch
Asthma patients across the country are beginning to adjust to a change in their asthma medication, and health care professionals are making concerted efforts to ensure the adjustment is a smooth one.
To treat their condition, many asthma patients depend on albuterol, a quick-relief medication that is used to open up the airways so it’s easier to breathe. Albuterol is administered through inhalers that use a type of a propellant—chlorofluorocarbon (CfC)—that helps the medication reach the lungs. And it’s the propellant that has sparked the need for patients to make a switch.
CfCs were found to be among the substances that damage the earth’s ozone layer and led the united states to enter into the Clean Air Act, an international treaty that prohibits CfC-propelled albuterol inhalers from being produced or sold in the united states after Dec. 31, 2008.
With the treaty in place, the food and Drug Administration (fDA) banned the CfC-propelled inhalers and has turned to new, environmentally friendly albuterol inhalers that use a hydrofluoralkane (HfA) propellant—and with the new inhalers comes the challenge of transitioning the more than 16 million adults and 6 million children living with asthma to the latest device.
Albuterol is one of the top 10 prescribed medications in the country with about 52 million prescriptions written every year. A chief concern is that many asthma patients still rely on CfC-propelled albuterol inhalers and won’t refill their prescriptions until they’re having an emergent asthma attack—at a time when they will be totally unfamiliar with the new inhalers.
“Making sure asthma patients are aware of these new inhalers is essential to improving patient outcomes,” says Jim Glauber, MD, senior medical director at Neighborhood Health Plan in Boston and a practicing pediatric asthma specialist at Harvard Vanguard Medical Associates.
Glauber adds that health plan officials know that the patients who adjust well to the new HfA albuterol inhalers are more likely to adhere to their medication regimen and continue managing their asthma properly.
New Devices, New Concerns
The FDA has approved four HfA-propelled albuterol inhalers to replace CfC inhalers, and the agency began issuing public health advisories this May to alert patients, caregivers, and health care professionals about their entrance into the market. the new HfA-propelled inhalers, however, are not without controversy. the FDA advisories cautioned for patients that although the HfA-propelled inhalers deliver the same albuterol medicine, many important differences exist between the old and new devices.
For starters, according to the advisories, the spray from HfA-propelled albuterol inhalers “taste and feel different” than the CfC-propelled albuterol inhalers. The force of the spray of an HfA-propelled inhaler may feel softer and less forceful. The new inhalers also require special priming and cleaning care because the dispensers have a tendency to clog.
Glauber says clogging may cause patients to administer less medication than prescribed.
“Because of the issue with clogging and priming, patients might perceive they are getting less clinical effect from the new inhalers and say to themselves either ‘I must need a refill’ or ‘this new albuterol isn’t working as well as the old stuff I had,’” Glauber says. “And part of the problem is that many physicians are not aware of these issues with the new inhalers, so they’re not talking to their patients about them.”
A Time for Outreach
Because many health care providers are not yet aware of the differences in the new HfA inhalers, Neighborhood Health Plan, like many other plans, is coordinating outreach to educate its 17,000 members with asthma, as well as their physicians, to get ready for the transition.
Glauber says that Neighborhood had to first tackle the fact that the new HfA-propelled inhalers are all brand names—meaning patients have to say goodbye to their generic albuterol, and with it the generic pricing. Health care providers worry that many asthma patients will face a financial obstacle when they first fill a prescription for the new inhalers.
“Because the new HfA inhalers are all brand names, there isn’t a generic for them yet,” Glauber says. “so for a lot of patients who have tiered pharmacy benefits, they’ll be going from a tier 1 generic copay to a branded copay.”
Depending on a patient’s coverage, Glauber says copayments could be as much as twice what patients are accustomed to paying.
Officials at Neighborhood Health Plan took steps to prevent its members from absorbing the cost increase stress.
“We made the decision to keep all our albuterol products at a tier 1 copayment, including the HfA products, because we didn’t want our members to be impacted that way,” he says.
Neighborhood Health Plan is now identifying its members who have had recent prescriptions filled for generic albuterol to warn them that they will soon need to contact their doctor for a new prescription for the HfA inhalers.
“We’re letting them know they cannot refill the old prescriptions after Jan. 1, [2009],” says Glauber.
Neighborhood Health Plan is including educational material about the new inhalers in its newsletter to members with persistent asthma, which also includes facts on its asthma disease management program. One handout, “understanding the Changes in Your Quick relief Asthma Inhaler” tells patients what to expect from the new inhalers and, especially, how to correctly prime and clean them.
According to Glauber, Neighborhood Health Plan is also taking steps to limit the number of members who may “fall through the cracks” and are often left out of patient education from the health care community. to reach their asthma patients with limited literacy or English-language skills, the plan has developed a pictorial guide to illustrate how patients can self-manage their condition and how to use the new HfA-propelled albuterol inhalers.
Neighborhood has already posted materials for health care providers on its Web site where physicians can download an asthma self-management toolkit for their patients. the plan will also mail copies of the toolkit to medical directors at their participating health centers. –G.F.
