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Posts tagged with "medication adherence"

Changes to Health Delivery System Key to Reducing Care Costs

With all the talk this week about Obamacare and whether or not the Supreme Court will declare the law constitutional, partially unconstitutional, or take no stand, the law will not have a measurable impact on the cost of health care delivery to patients until significant changes take place in the way the delivery system works.

There are several reasons why the cost of care has risen so radically, and there are measures that can be taken to reduce some of these costs, simply by changing patient and provider behaviors in areas such as medication adherence, fast access to care and preventive care.

Medical Adherence

One-third to one-half of patients in the U.S. do not take their medications as instructed. This leads directly to poorer health, more frequent hospitalizations, a higher risk of death and as much as $290 billion annually in increased medical costs. Non-compliance includes not taking medication on time, not sticking to the proper doses, or simply ignoring the medication by not filling the prescription, or filling it and not taking it. Reasons patients give for their non-compliance include: unpleasant side effects, confusion, forgetfulness, language barriers and feeling “too good” to need medicine. 

It is a known fact that patients with chronic conditions such as diabetes and high blood pressure are among the group less likely to follow their medication regimen. Perhaps if more providers were reimbursed based on outcome rather than on their fees for service, they would invest in the time, resources, counselling services, and necessary technology to educate patients and foster better adherence.

A study by researchers at NYU School of Medicine confirms that positive affirmation, when coupled with patient education, seems to help patients more effectively follow their prescribed medication regimen. How does that reduce costs? We know that with adherence comes better management of health issues. With better management of health issues comes fewer visits to the ER. With fewer visits to the ER comes lower cost of care because the patient who gets better by following the treatment prescribed does not need further intervention.

Access and Information

One of the most significant obstacles to improved patient care, at a reasonable cost, is access. The relative lack of real-time access to care and the absence of comprehensive patient information at the point of care are essential to improving outcome. Better access to care will lower the cost of care because patients do not have to wait to see their doctors and avoid having their health issues precipitate from an issue to a crisis. An example of that is an elderly woman who called her doctor’s office to request an immediate appointment for a rash that was painful and itchy and would not go away with topical medications. The doctor was on vacation and when the patient was finally seen several days later she was diagnosed with Shingles. Instead of a few days on an oral dose of an anti-viral medication, she ended up hospitalized for several days on IV medications, with a very severe case of shingles that had spread to several locations in her body.

The new patient-centered medical home model of care resolves some of these issues, by extending access to patients using the services of nurses, nurse practitioners, physician assistants and other well- trained professionals to deliver many basic health care services. With digital health records as a part of the medical home model, all of the patient’s information is available to all of these providers when the patient needs to be seen. This allows the physicians in the practice to focus on diagnosis and deal with the tough issues, while other competent, well trained healthcare professionals handle routine exams, coordinate follow up appointments, deliver counseling, and make sure that screen tests, vaccinations and other milestones for the patient are achieved.


Preventive Care

Prevention is clearly one of the touchstones of health care. To prevent deadly or disabling disease from occurring, or to stop it at an early stage, seems like an obvious way to cut health care costs and improve population health. Early intervention health and wellness programs are available but patients have to be willing receptors of these efforts, and providers have to spend time and energy to make these programs work. It is not an easy task. Some suggestions for carving out programs where preventive care is the focus include:

1. Doctors or their nurse practitioners or physician assistants have to provide patients with education and tools for proper weight control, fitness programs, stress reduction and relaxation techniques because we know that diet and fitness play a huge role in keeping people healthy

2. Immunizations and vaccinations need to be kept current. With the assistance of digital health records, there are no longer reasons why these should not be up to date.

3. Warnings about exposure to certain disease triggers need to be passed along to patients so they are aware of the risks when they travel or expose themselves to certain environments.

4. Doctors and patients have to engage in discussions about family history so they are aware of the genetic make up the of individual that could cause disease. Based on that information the patient needs to be sure to get certain screenings when appropriate.
Current initiatives in patient-centered care medical homes and accountable care organizations are a giant step toward collaborations between patients and physicians to jointly work toward better adherence, more immediate access and availability of information and better preventive care. These efforts will produce reductions in the cost of care but it will be a slow process.

User Friendly Medical Devices Could Alleviate Medication Non-Compliance

In my last blog post I noted that one-third to one half of all patients do not take medication as prescribed and up to a quarter never fill their prescriptions at all. This non-compliance with prescribed medication costs the US health system an estimated $290 billion annually. These costs are associated with expenditures for unnecessary hospitalizations, medical procedures, physician visits and treatments. Despite this staggering number this is just a starting point as the numbers quoted do not capture such costs as lost productivity and deterioration in quality of life. I put the blame for this non-adherence on the high, unaffordable cost of medication, the fact that people are forgetful and neglect to take their medications and the fact that often patients do not understand the reasons why following instructions about when and how to take medication is so important.

However, there is an additional  reason why people often do not take their prescribed medication properly and that is because the devices that deliver the medication are not designed in a way that makes them easy to use. In fact ,some devices are so poorly designed the patient cannot administer the medication at all.

Cambridge Consultants conducted a study that found a direct correlation between patient adherence to a drug regimen and the design of the drug delivery mechanism. The 240 diabetic patients who participated in this study indicated that they did extensive research on drug delivery devices that they would be using daily, and made their choices, not necessarily based upon their physician’s recommendation, but on their own perceptions about how the device delivered their medication. These respondents almost universally agreed that they would be willing to pay more for a device that is more user friendly and efficient.

A parallel study conducted by Cambridge Consultant of 100 health care professionals also concurred that the usability of a medical device impacts patient compliance with the medication therapy.,

The design of medical devices is regulated by the FDA , although the system is far from perfect. It has been a long road to institute regulations and standards that require manufacturers of medical devices to design in usability, design out usage errors, and provide documentation that is user friendly. By no means are we there yet.

The packaging of medication in containers that are safe and tamper secure, while at the same time enabling the average, possibly  elderly patient to easily access the medication is no easy task.

Over time this problem is going to become more complicated as the increasing numbers of individuals with chronic conditions use a variety of newly developed home monitoring devices and medication delivery systems, many of which will be based on a smart phone platform. It is important that patients have the right tools to manage their health conditions and medications. This will only happen when patients raise their  voice  and express their concerns so their health care providers  will  prescribe medications that patients completely understand and can use without a lot of challenges.

Sick Economy, Sicker Patients

The Commonwealth of Massachusetts recently announced that its senior citizens are going to experience significant increases in their copayments for prescription drugs as a result of an $11 million cut in the state-funded Prescription Advantage program that was set up to defray pharmacy costs for eligible seniors. The cut is part of the $1 billion in funds slashed by the Governor Duval Patrick in October 2008 due to the economic recession.

Many other states facing similar huge deficits are also reducing services to the most vulnerable citizens. At least 19 states have proposed or implemented cuts that will affect low-income children’s or families’ eligibility for health insurance or reduce their access to health care services. For example, Rhode Island eliminated health coverage for 1,000 low-income parents; South Carolina is limiting coverage for many services, such as psychological counseling, physician’s visits, and routine physicals; and California and Utah are reducing the types of services covered by their Medicaid programs.: At least 17 states plus the District of Columbia are cutting medical, rehabilitative, home care, or other services needed by low-income people who are elderly or have disabilities.

Almost 90 percent of individuals, age 65 and older, take an average of five or more prescription drugs daily. Many of these same individuals are retired and on a fixed income; 25% report that they do not fill one or more of the prescriptions their doctors write for them because of the cost. Others skip days or cut their dosage to make the prescriptions last longer.

In 2005, The New England Journal of Medicine reported that 33 – 69 percent of medication-related hospital admissions in the U.S. were due to poor medication adherence with a resultant cost to the American public of over $100 billion a year, because non-adherence results in more hospitalizations and more emergency room visits. This was part of the reason why Medicare instituted the drug benefit program, hoping Medicare Part D would make prescriptions more accessible and affordable.

In spite of the economic glitches that we face, as a society we have a responsibility to provide basic and essential health services to all individuals. What is going on with prescription drug co-payments and its impact on medication adherence should be concerning to payers, physicians and patients. When we accept short term solutions, such as cutting the budget for health reimbursement, we create longer term costly problems. When we force bands of citizens to seek care in emergency departments or end up as in-patients, the costs mound at a much steeper rate than if we foot the bills that keep co-payments at an affordable level. Doctors and patents need to work together to look at all possible options for addressing immediate and chronic health medication needs, including greater use of generics, and cooperative arrangements with pharma companies, associations and public agencies that might help fund some of the medical requirements of citizens who cannot afford to pay the full tab that is being asked of them. A sicker society is not an answer for anyone!!