Perspectives

Health Care Current: March 15, 2016

Improving medication adherence: It’s personal

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory and legislative changes.

Improving medication adherence: It’s personal

Taking one’s medicine seems like such a simple thing. But, for many, it often isn’t that simple.

For the last 10 years or so, I have had the luxury of not taking any regular medicine – just the occasional ibuprofen or allergy medication as needed. More recently, I’ve started taking medicines that, while they are supposed to help me, often are accompanied by side effects. Coincidentally, I have been working on a research paper on medication adherence, so I’ve been watching my own behavior closely.

I have the “remembering” part of the adherence task down pat: I have a system in the morning over breakfast and in the evening before bed where I’ve tied taking pills to other, well-established personal habits, like brushing my teeth.

I also have carefully read the information about the medications and what they are for and understand the potential side effects. And I’m blessed to have minimal cost sharing for these drugs.

But, I still feel deeply conflicted about having to take medicine at all, especially now that I have no symptoms of illness. It has made me have a much better appreciation for all the “non-adherent” people out there with hypertension or high cholesterol.

Some of my frustrations about medication adherence were echoed in findings from our recent study, Improving medication adherence: Tailored approaches may boost potential for success, which leveraged the Deloitte Center for Health Solutions 2015 Survey of US Health Care Consumers. We found that adherence is related to consumers’ attitudes about the health care system, wellness, and engagement with digital tools. Specifically, our study reveals that people who are more positive about incentives are more likely to report greater adherence. Lower rates of reported adherence are associated with individuals’ demographic and socioeconomic characteristics, which is consistent with industry literature.

We also found that more than half of consumers (54 percent) are interested in using digital tools and mobile technology that provide alerts and reminders to take their medication. Although current use of these tools is only 13 percent among the surveyed individuals who had a prescription in 2015, many people who used the tools say they are very or somewhat interested in receiving this type of information. Among the larger group of people who had not tried these tools, 42 percent of the respondents say they are very or somewhat interested in receiving this type of information.

This issue matters.

According to the US Centers for Disease Control and Prevention (CDC):

  • Non-adherence causes ~30 to 50 percent of treatment failures and 125,000 deaths annually 
  • Non-adherence to statins increases relative risk for mortality (~12 percent to 25 percent) 
  • Non-adherence to cardio-protective medications increases risk of cardiovascular hospitalizations (10 to 40 percent) and mortality (50 to 80 percent) 
  • Poor adherence to heart failure medications increases the number of cardiovascular-related emergency department (ED) visits1

Estimated US costs of non-adherence range from $105.8 billion for adults diagnosed with diabetes, hypertension, or dyslipidemia in 20102 to $290 billion for all patients in 2012.3

Many purchasers of health care recognize the benefits of better adherence. Health systems and health plans are emphasizing better medication adherence through value-based care (VBC) and related quality initiatives. Many of the quality measures in the US Centers for Medicare and Medicaid Services (CMS) value-based purchasing programs are influenced by medication adherence, and some measures capture adherence directly. For example, control of hypertension and blood sugar – quality measures for accountable care organizations (ACOs) and Medicare Advantage plans – improves with higher levels of medication adherence. CMS also directly measures and rewards medication adherence for three conditions under Medicare health plans that cover both Part C and Part D benefits and standalone Part D plans.

So what should health systems and health plans do to succeed on these measures? And what can life sciences companies do to help?

One strategy to improve medication adherence may be to tailor it to a consumer’s economic, information, and incentive issues. For example, if a person’s reason for non-adherence is financial, one potential solution is providing access to a discount coupon or best-price drugs, information about generic options, or mail order savings. If the issue is side effects or skepticism about a medication’s benefits, scheduling a clinician consultation might be a good approach. Finally, if the issue is forgetfulness, the patient may benefit from a reminder app.

Other strategies around personalizing the approach to improving adherence might lie in lessons from behavioral economics. Non-traditional approaches, such as “nudging” patients toward adherence in a personalized way, may also help support adherence.

Personalized approaches will also need to recognize that adherence issues are often related to a patient not wanting to be reminded of their disease or condition, which certainly rings true in my case. The field of cognitive behavioral therapy might hold some potential for changing how one thinks about this issue and may hold some potential for breaking through strategies.

I think all of these ideas are worth more research. Perhaps if we take some of our best technologies and analytics to target solutions, we can see what works and eventually solve the adherence problem.

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Sources:
Centers for Disease Control and Prevention. (2013). Medication Adherence. CDC Noon Conference: March 27, 2013. http://www.cdc.gov/primarycare/materials/medication/docs/medication-adherence-01ccd.pdf, (p. 13).
2 Kamyar Nasseh, P., Sharon Glave Frazee, P. M., Jay Visaria, P. M., Anna Vlahiotis, M., & and Yuhong Tian, P. (2012). Cost of Medication Nonadherence Associated With Diabetes, Hypertension, and Dyslipidemia. American Journal of Managed Care, e41-e47. Retrieved from http://www.ajmc.com/journals/ajpb/2012/ajpb_marapr2012/cost-of-medication-nonadherence-associated-with-diabetes-hypertension-and-dyslipidemia#sthash.1RT5ntOl.dpuf
3 Hagland, M. (2013). CVS Caremark Report: Medication Non-Adherence in US Costs Up to $290 Billion Annually. Healthcare Informatics, http://www.healthcare-informatics.com/news-item/cvs-caremark-report-medication-non-adherence-us-costs-290-billion-annually.

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My Take

By Sarah Thomas, Director of Research, Deloitte Center for Health Solutions, Deloitte LLP

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CMS Part B demonstration would test new ways to pay for drugs

CMS proposed a new five-year experiment to lower Medicare Part B spending last week. In 2015, Part B drugs – drugs administered in a physician’s office or a hospital outpatient setting – cost the program about $20 billion. The CMS Innovation Center will lead this new experiment, which aims to incorporate aspects of value-based payment for these drugs.

Under this program, CMS would shift payment away from the current reimbursement formula, which pays the average sales price (ASP) plus six percent. Many experts say that this formula encourages physicians to prescribe higher price drugs and does not have enough emphasis on higher quality and lower cost. Starting later this year, CMS would test a new formula – ASP + 2.5 percent + $16.80 per drug per day – to determine if creates better incentives.

CMS also plans to implement one or more of five additional policy changes in the second phase of the model. Components of the experiment include:

The US Department of Health and Human Services (HHS) published a report on prescription drug spending in Medicare Part B the same day of the proposal. Medicare spent $18.4 billion on Part B drugs in 2014, double the amount spent in 2005. More than half of that went to physicians’ offices, and one-third to hospital outpatient departments.

Reaction: The pharmaceutical industry and clinical oncologists have criticized the CMS proposal, saying that the model could put patients at risk. The groups also said that CMS did not engage patient or provider stakeholders when developing the proposal. America’s Health Insurance Plans (AHIP) supports the new model and applauds CMS’s attempt to address rising drug costs and realign current incentives.

Prior to the ACA and its creation of the Innovation Center, a payment change of this magnitude would have been made through legislation. But, through the CMS Innovation Center, pilot programs and experiments can now be tested and scaled up if they demonstrate success. This is the first Innovation Center program that focuses only on drug spending in Medicare Part B.

(Source: HHS ASPE, “Medicare Part B Drugs: Pricing and Incentives,” March 8, 2016)

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Implementation & Adoption

Most physicians still paid through fee-for-service arrangements

A recent Health Affairs study found that despite efforts to stem cost growth by moving toward value-based payments, most physician office visits continue to be paid fee-for-service. Researchers evaluated data collected from supplemental physician surveys as part of the annual Medical Expenditure Panel Survey between 1996 and 2013; they found that 94.7 percent of all physician visits were paid for using fee-for-service payment methods in 2013. Moreover, fee-for-service payments are increasing, as this is up from 93.4 percent in 2007. In 2013, the other 5.3 percent of payments were paid under capitation arrangements, where a physician receives a fixed monthly payment per patient.

The study also found:

This study suggests that more work needs to be done to move physicians toward VBC arrangements. The study comes shortly after HHS announced it had reached its goal to tie 30 percent of Medicare payments to alternative payment models (APMs) by 2016. The study results are from 2013, so future research will need to identify if the pace toward VBC adoption has sped up since then.

Related: A recent Healthcare Information and Management Systems Society (HIMSS) report details some of the challenges health systems face when transitioning to VBC reimbursement models. The report uses data from the organization’s 2016 Cost Accounting Survey and highlights that only 3 percent of respondents said their organization was “highly prepared” to move away from payment models based on fee-for-service. HIMSS also identifies the top three needs for organizations transitioning to value-based payment:

  • Tools to track and evaluate quality of care
  • Better communication between disparate providers
  • Consistent quality definitions by disease type

(Source: Samuel H. Zuvekas and Joel W. Cohen, Health Affairs, “Fee-For-Service, While Much Maligned, Remains The Dominant Payment Method For Physician Visits,” March 2016)

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One-third of beneficiaries aligned to a Pioneer ACO turned over during three performance years

Nearly one-third of beneficiaries aligned with one Pioneer ACO in 2012 were no longer connected to the ACO by 2014. Reasons included physician turnover and care delivery changes. This is a finding from a recent Health Affairs study that showed results of an analysis of assignment data from one of the largest Pioneer ACOs with more than 82,000 beneficiaries between 2012 and 2014.

The ACO had more than 42,050 beneficiaries aligned to it in 2012, the first year of the program. However, while new beneficiaries were aligned to the ACO during each program year, it had substantial year-to-year turnover. Only 45 percent of beneficiaries aligned with the ACO in 2014 were aligned to the ACO in 2012, and 32 percent of the beneficiaries who were aligned with the ACO in 2012 were no longer associated with it by 2014.

Beneficiaries whose primary care physicians (PCPs) left the ACO were nine times more likely to leave the ACO the following year. But, care delivery strategies may help offset this trend. For example, beneficiaries who were actively engaged in the ACO’s care management program were one-third less likely to leave the ACO the next year compared with those who were not in the program.

Analysis: Strategies that encourage patients to align themselves to the ACO, whether via an opt-in or opt-out model, might reduce turnover. ACOs operate in the traditional Medicare program, where beneficiaries are not locked into a network of providers – they may seek care at any organization participating in Medicare.

The Pioneer ACO program expires at the end 2016. As explained in Medicare accountable care organizations: Balancing risk and opportunity, the Next Generation ACO program, which was meant to essentially replace the Pioneer program, began in January 2016 with 22 organizations. It attempts to address some of the issues that early ACO adopters have had with the Medicare ACO model. For example, the Next Generation ACO program built in reward payments for beneficiaries who continue to get care from that organization.

(Source: John Hsu, Health Affairs, “Patient Population Loss At A Large Pioneer Accountable Care Organization And Implications For Refining The Program,” March 2016)

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Independent committee outlines 10 goals for improving use of biomarker tests

A recent report by the National Academies of Sciences, Engineering, and Medicine found that biomarker tests for molecularly targeted therapies are not being incorporated appropriately into clinical practice. This is mostly because few standards for regulatory, reimbursement, and treatment decisions exist.

Biomarker tests use people’s unique genetic makeup to exploit therapies that focus on molecular variation. Biomarker tests can also identify whether treatments may cause harm or be ineffective for some individuals. However, inaccurate tests may cause harm to patients. The researchers outline 10 goals to advance the practice of biomarker tests for targeted therapies while protecting patients.

(Source: Laurene A. Graig, Jonathan K. Phillips, and Harold L. Moses, “Biomarker Tests for Molecularly Targeted Therapies: Key to Unlocking Precision Medicine,” 2016)

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Mental health bill aims to improve access to services and protect patient privacy

Last week, the Senate Health, Education, Labor, and Pensions (HELP) Committee released a draft bipartisan mental health bill. The Mental Health Reform Act aims to support coordination between agencies that target mental health, look at state funding, improve mental health practices, and increase access to mental health care. It includes measures to address workforce shortages and care access issues.

The bill would:

  • Create a chief medical officer position at the Substance Abuse and Mental Health Services Administration (SAMHSA)
  • Establish an inter-departmental committee to coordinate services relating to serious mental illnesses
  • Ensure the National Suicide Prevention Lifeline is available 24/7 and that veterans are connected to a prevention specialist
  • Educate mental health providers on privacy issues to protect patients and their families

Many aspects of the bill mirror legislation developed by Senators Christopher Murphy and Bill Cassidy to improve the mental health system. The bill will help federal programs and policies include scientifically proven approaches to enhance patient care.

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On the Hill & In the Courts

Senate lawmakers concerned about several policy proposals for Medicare Advantage

Last week, Senate leaders sent a letter to CMS Acting Administrator, Andy Slavitt, saying they were concerned with several of the changes CMS proposed in its recent Medicare Advantage guidance (see the February 23, 2016 Health Care Current).

The lawmakers’ concerns are primarily in three areas:

Related: The letter came one day after CMS announced it was changing a policy around sanctions in the Medicare Advantage program. CMS has, in the past, reduced star ratings for health plans with sanctioned contracts to 2.5 stars. Many health plans said that this policy harmed plans with higher star ratings more than ones with lower star ratings because a plan that started with 4 stars would see a 1.5-star drop while a plan with 3 stars would only drop 0.5 stars to a 2.5 star rating. CMS said that going forward, it is suspending this policy and will revise the policy in the 2018 call letter.

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Senate passes legislation to combat opioid and heroin abuse epidemic

Last week, Senate lawmakers passed (94-1) legislation to curb the abuse of opioids such as prescription painkillers and heroin across the country. The Comprehensive Addiction and Recovery Act (CARA) includes a number of provisions to improve addiction recovery services and prevention efforts. It would enhance education efforts around opioid abuse, increase availability of a drug that can save the life of individuals who are overdosing, expand prescription drug monitoring programs, and target education programs to incarcerated individuals (see more in the March 8, 2016 Health Care Current).

The version of CARA that passed the Senate did not include a $600 million provision to fund the treatment and prevention programs. Many lawmakers, including Senate Majority Leader Mitch McConnell, instead said that lawmakers should direct approximately $400 million in last year’s omnibus spending bill to CARA efforts. The bill now moves to the House, where companion legislation awaits a hearing by the Judiciary Committee.

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CDC draft proposal aims to limit painkiller prescribing and curb opioid abuse drawing from state success

The CDC recently published draft guidance for prescribing opioids for chronic pain, seeking to curb opioid abuse and the growing death toll from prescription painkillers. The proposal is based on states’ success with opioid legislation. It recommends that primary care doctors:

CDC drew many of these ideas from state policies. For example, Massachusetts Governor Charlie Baker proposed a similar three-day limit for medication supply in October, and Vermont Governor Peter Shumlin adopted a similar measure in Vermont last month. Governor Shumlin said that all governors should limit the number of opioid pills doctors prescribe to patients taking them for the first time following a non-traumatic injury, minor surgery, or dental procedure. In 2007, Washington state passed legislation to limit prescriptions to no more than the equivalent of 120 milligrams of morphine per day. The state was sued and the opioid dose limit was dropped in 2010. However, opioid overdose deaths declined when the policy was in effect. After peaking in 2009 with more than 500 deaths, the annual number of deaths linked to opioid overdose dropped to about 300 in 2014. The number of prescriptions and the number of workdays lost to injury declined by nearly a third.

Related: Other states are also investigating prescription drug overdoses and illicit drug use. The Michigan Department of Health and Human Services recently found that drug overdoses caused 1,745 deaths in 2014, a 14 percent increase over 2013. Adults age 35 to 44 years old were the age group most likely to die because of opioids (12 for every 100,000 people). Congress is monitoring this issue closely, and the Senate just recently passed CARA to try and curb opioid abuse in the US (see story above).

(Source: Christine Vestal “States, CDC Seek Limits on Painkiller Prescribing,” The Pew Charitable Trusts, March 2016)

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Around the Country

Report card: Cost ratings and quality performance of California providers

A new report card looks at the quality of physician organizations (medical groups) providing services to about 9 million Californians in commercial HMOs and point of service (POS) products. Using data from 2014 medical charts, billing records, and prescription drug usage, the Integrated Healthcare Association (IHA) used 19 quality measures and compares cost data to assign a four-star rating to each medical group. The rating covers evidence-based care, patient experience, and total cost of care.

Publicly reporting clinical quality measures alongside patient experience ratings and cost information could represent a significant development as the health care system continues to explore ways to pay for value. This report card is the largest statewide, multi-payer report to provide side-by-side comparisons of physician group performance across care quality measures, patient experience ratings, and health care costs. It provides consumers with transparent quality and cost information to consider when selecting a physician organization. Health plans also can evaluate the performance of their contracted partners, and physician organizations can see how they compare with one another and, ideally, compete on quality and cost. The report card also demonstrates how widely costs vary across the state and between provider groups.

In California, most commercial HMOs pay physician organizations a fixed per member, per month amount – or a capitated rate – to cover all health services and visits for each patient member. Findings from another IHA report found that California HMOs have achieved high quality scores without using more resources relative to other preferred physician organizations.

Background: The IHA report card uses cost data for patients from ten California health plans covering roughly 94 percent of the commercial HMO/POS population in California. The cost measure is risk-adjusted to account for the differences in patients’ health status and adjusted for geography to account for price differences. The medical groups participate in the IHA pay-for-performance program, which uses a common set of quality measures, health plan incentive payments to physician groups, public reporting of results, and public recognition awards to improve patient care.

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Low-tech solutions to obesity and heart disease could lead to good results

The epidemic of obesity in America is leading to increased rates of heart disease and other preventable diseases. Recent research presented at the American Heart Association’s Epidemiology/Lifestyle 2016 sessions demonstrates how food pricing can improve health and potentially reduce risk and deaths from cardiovascular disease.

Researchers from the UK and Tufts University developed a tool called the US IMPACT Food Policy Model that included projections of US demographics and cardiovascular death rates to 2030. They combined that data with current and projected fruit and vegetable intake figures. The model simulated the effects of different policies on eating habits. It demonstrated that a 10 percent drop in the price of fruit and vegetables could save millions of lives by reducing death from heart disease by 1.2 percent within five years and nearly 2 percent within the next two decades. Findings also showed that deaths from heart disease could drop by almost 0.1 percent within five years of a price increase of 10 percent on sugary drinks. The two strategies combined could prevent 515,000 deaths from heart disease and prevent nearly 675,000 heart attacks, strokes, and other events. Promoting small increases in fruit and vegetable consumption through food assistance programs could also have a significant impact.

Although many states and cities have attempted taxes on sugary drinks with little success, there have been a few exceptions. Last year, the Navajo Nation eliminated sales taxes on fruits and vegetables, while increasing them on sodas and other low nutrient food. The revenue is being spent on education campaigns to promote healthy diet. One recent study on Mexico’s sales tax on sugary drinks showed a decrease in sales.

Analysis: Despite increased health education campaigns on eating healthy and the negative health effects of obesity, the number of overweight and obese Americans has greatly increased in the last 30 years. Rising obesity rates have contributed to growing rates of heart disease, diabetes, cancer, arthritis, and other chronic health conditions. Many stakeholders are looking to breakthrough technologies that are disrupting the health care system, such as increasingly sophisticated biosensing wearables and other remote monitoring devices, to help people eat healthier and exercise more in part through increased awareness and tracking. However, this recent research shows that there are lower tech strategies, such as subsidizing fruits and vegetables at the farm or wholesaler level, and other price-related initiatives, such as grocery store bonus cards, that could improve health.

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Breaking Boundaries

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