MANAGED CARE December 2011. ©MediMedia USA
We look at a few programs designed to address adherence-related behavioral problems
“Adherence is a behavioral issue,” says Bob Nease, chief science officer at Express Scripts. And inadequate adherence is so widespread that the World Health Organization estimates that half of all patients do not take their medications properly. Yet few efforts to improve compliance are specifically designed to help people overcome internal barriers.
The obstacles vary so widely that no single approach can be effective. Stephen Wegener, PhD, a psychologist and associate professor in physical medicine and rehabilitation at Johns Hopkins University School of Medicine, studies noncompliance. He has described four categories of underlying impediments to adherence:
Access. Taking a medication presumes the patient saw a doctor, received a diagnosis, and was able to fill a prescription. “But some people may have trouble getting to a pharmacy and live in an area without delivery options,” Wegener says. Others hesitate to fill a prescription if their insurance does not cover the medication.
Knowledge. A patient may not understand all the instructions for how to take this particular drug, or may not fully grasp exactly what the medication is for, which limits the motivation to take it.
Cognition. Sometimes a patient with faulty memory simply doesn’t remember to take the medication on time or exactly as directed.
Behavior. “Any number of comorbidities can influence medication-taking,” Wegener says. Depression might lead to feeling, “Why bother? Who cares?” Anxiety about side effects can interfere. “It could make me gain weight” is a common deterrent, as are warnings about other unpleasant possibilities, like constipation. “Some people take too little medication because they are afraid of addiction. The fewer the side effects, the higher the adherence,” he reports.
Now, several ambitious projects are tackling adherence-related behavioral problems.
Education
At Thomas Jefferson University Hospital in Philadelphia, a “Heart Failure Readmission Reduction” pilot program began in November 2010 with 436 patients. The multidiscipline, low-cost education program — utilizing binders, online information, videos, phone calls, and frequent in-person contact with a cardiac nurse — was created to reduce heart failure readmission rates of Medicare patients. Readmission is important to payers because of substantial penalties to be imposed by the Centers for Medicare & Medicaid Services.
A main component is patient and family education, built around a binder that includes weight control, diet, and exercise materials; basic medical information; a medication log where patients review the medications they are supposed to take and when they are to take them; and discharge instructions detailing signs and symptoms that should trigger a call to the physician.
Medication education is the second component. A pharmacist compares medications patients have been taking at home with what is ordered in the hospital, reviewing all binder information to verify the patient’s understanding of every pill’s purpose. Each day, the nurse reinforces this education. At discharge, the pharmacist reviews the medications that the patient will take at home, whom to contact if they run out, and how to reorder. “We always encourage patients to take ownership of their treatment,” says Patrice Miller, vice president for clinical resources management. “We stress the risks of not taking a medication exactly as prescribed, and what problems can occur.” The family is alerted to possible side effects and reactions.
In the third component, post-discharge follow-up, pharmacists call each patient on the second, seventh, fourteenth, twenty-first, and thirtieth day. This is a unique program aspect, Miller says; such calls are typically made by disease managers. Pharmacists confirm upcoming scheduled doctors’ visits, review all discharge instructions, and check on the patients’ understanding of their current medication regimen and adherence to time and dosage instructions.
Several times a week, pharmacists encounter a problem involving reorganizing or timing a medication, reports Joanne Heil, PharmD, RN, advanced practice heart failure specialist, who coordinates pharmacists’ calls and questions to patients. “For example, someone may skip a water pill when out all day at a social event, or say, I’ll just take it at night — I’m at work all day. We explain what can happen when they miss a day, and that taking it near bedtime interferes with the sleep they need. We work with each patient to find a specific time of day when they will have enough hours at home, away from bedtime, to take that daily water pill.”
The pilot program required no additional staff; case managers, pharmacists, and nurses received brief training. Educational binders cost about $15 per patient.
“Expenses totaled much less than the cost of a readmission,” Miller observes. Jefferson is auditing admissions and readmissions for pilot program participants. “A common cause of readmission in heart failure patients is noncompliance. The [readmission] numbers look promising,” she says, but declines to report the actual reduction.
“On June 1, we rolled out this readmission reduction approach for patients diagnosed with pneumonia. We’re building a team for myocardial infarction, to launch in December.”
Counseling
“People don’t think of their insurance company as doing more than paying a claim. They don’t expect a more caring approach,” says Michael Golinkoff, MD, head of specialty clinical operations for Aetna. In the company’s behavioral view of members’ health and wellness, “Psychological factors affect whether people take their medications as prescribed. An important educational component is understanding the meaning of taking a medication.”
Savings is another consideration. “We want to avoid acute situations that send patients to emergency rooms or doctors, which is expensive,” says Golinkoff.
[1]“Psychological factors affect whether people take their medications as prescribed,” says Michael Golinkoff, MD, Aetna’s head of specialty clinical operations.
Aetna’s value-based insurance design (VBID) program is designed to remove financial barriers to medication compliance and encourage member participation in nurse counseling. People with chronic diseases are eligible for reduced drug copayments if they agree. “We want to support that core relationship with the nurse, who we trained to hear what the member is saying, and let that set the agenda for driving a patient’s range of services,” explains Golinkoff.
One goal of VBID is to increase adherence to drug regimens without increasing overall costs. Active Health Management, an Aetna subsidiary, administered a VBID program for a large employer. The employer reduced copayments for five classes of drugs prescribed for serious chronic conditions, including high blood pressure and asthma. Copayments for generics were lowered from $5 to zero, preferred brand drugs went from $25 to $12.50, and nonpreferred brands dropped from $45 to $22.50. All patients already taking these medications could participate.
The program increased medication adherence by 3 percent. The employer’s pharmacy costs rose by an average of $7.75 per employee per month, but costs for nondrug health care services such as hospital admissions decreased by the same amount. There was no overall increase in employer costs, and Aetna predicts that costs will have declined as a direct result of this compliance program.
The approach is being tried elsewhere. Researchers at the University of California– San Francisco and the University of Texas–Austin measured a VBID program’s effect at a large retail company. Employees with diabetes, asthma, coronary artery disease, or heart failure were offered reduced cost-sharing if they agreed to receive nurse counseling or educational materials, depending on whether they were high- or low-risk workers.
Better adherence sometimes comes down to financial incentive for the patient.
In the group receiving nurse counseling, medication adherence improved in patients taking diabetes medications, antihypertensives, and statins. After 1.5 years, the counseling group had significantly lower total overall cost compared with the control group.
Those receiving health education materials had an overall annual cost much higher than the control group.
Researchers concluded that active counseling is more effective than passive approaches for increasing appropriate health care utilization, improving clinical outcomes, and reducing total health care costs.
Targeting
In a pilot program involving more than 800,000 members, Express Scripts is testing an approach called “Advanced Adherence Solutions.” Its algorithms attempt to identify members at highest risk for adherence problems.
Whenever the predictive model, operating since February, projects a risk, an automated phone system gathers additional information from the member to pinpoint that member’s barrier.
In the first 96,000 interventions, the most common difficulty (49 percent) was simply forgetting to take a medication. About 21 percent hadn’t gotten a needed renewal. Another 15 percent were concerned about a prescription’s cost. The remaining 15 percent had what Nease of Express Scripts calls “clinical questions — when a drug seems not to be working, or they are concerned about a side effect.”
Each risk-prone person is automatically directed to appropriate staff members. Most are connected to the Member Choice Center. Forgetful patients needing reminders may be sent either a “passive tracker,” such as a labeled pillbox showing whether they’ve taken their medication, or an “active tracker,” such as a beeper or a high-technology device such as a programmed blinking bottle cap. For financial difficulties, representatives suggest lower-cost drugs, a money-saving home delivery arrangement, or payment options.
Renewals are increased through auto-refill, or a new approach for patients with “silent symptoms,” as in osteoporosis or hypertension, who may forget to schedule a doctor’s visit for a renewal. “If the patient agrees, we, as a PBM, can reach out to the physician to help get a new prescription. We’re chipping away at the renewal hurdle, tracking how many prescriptions can be written without a physician visit,” Nease says.
The pilot program is reducing expenses by identifying the 85 percent with nonmedical risk factors. “This frees up our most costly resources for those requiring a pharmacist’s assistance,” Nease observes.
“Some phone conversations between a patient and a pharmacist are under 15 minutes,” reports Heather Sundar, PharmD, senior director for clinical products at Express Scripts. “But a very complex patient may need lengthy discussion and further intervention. We inform and educate them about their disease and how to manage potential side effects — but we still have nonmedical issues to address. It really comes back to behavior,” says Sundar.
Some barriers involve self-esteem. Nease cites a window of opportunity for patients new to a particular therapy, especially their first maintenance medication, typically for hypertension or hypercholesterolemia. “For a week or two, some healthy people, gradually realizing that they are on this medication forever, may resist taking it. Our approach is to give them permission to admit their difficulty.”
Pharmacists gently encourage incorporating the new medication into daily life, reassuring the patient to allow adjustment time.
“We shoot for low-cost interventions to solve problems, and expect this pilot to decrease overall costs related to therapeutic adherence,” says Nease. “As we learn more, we’ll refine the program.
Patient perspective
Wegener, the Johns Hopkins psychologist, believes that patients decide whether to take medication through a personal cost-benefit analysis. Costs range from actual expense to side effects to mere inconvenience. Helping the patient realize the medication’s specific value and decreasing either financial or behavioral barriers — until its perceived benefits clearly outweigh any negatives — is the core of any successful approach to adherence.
Johns Hopkins Guided Care relies on primary care team
[3]Chad Boult, MD, MPH, MBA
Guided Care, a Johns Hopkins University primary care enhancement program, is designed to improve health care, quality of life, and cost-effectiveness for elderly chronic disease patients. Chad Boult, MD, MPH, MBA, professor of health policy and management at Bloomberg School of Public Health, who helped originate Guided Care, says, “Many evidence-based programs focus on one condition, like asthma. I don’t know of another that treats multiple chronic conditions based on evidence.”
Initiated in 2001, Guided Care supports each patient with a primary care team — a nurse, several physicians, and support staff — that tracks their health, provides regular support, and encourages self-management. The nurse’s structured, comprehensive initial at-home assessment leads to developing an individual action plan and care guide that emphasizes medications. In all patient conversations, the nurse reviews the importance of each medication and the proper way to take it. The team coordinates all the patient’s health care providers, smooths the transition between care sites, supports family caregivers, and facilitates access to community resources.
Coaching sessions
During monthly coaching sessions, often by phone, the nurse and the patient review the action plan, line by line. Each medication is carefully checked for missed doses, adherence to instructions, and upcoming renewal needs. For a hospitalized Guided Care patient, the nurse makes a home visit the day after discharge. “Frequently, the patient is confused by all the new medications, which may not match the bottles in the medicine cabinet,” says Boult. “The nurse reconciles the hospital’s recommendations with the medications they had before. If the nurse can’t sort out all the prescriptions, she calls the physician to discuss. This is very important.”
In the first eight months of a randomized controlled trial of 904 elderly patients in 2006, Guided Care patients averaged 24 percent fewer hospital days, 37 percent fewer days in a skilled nursing facility, 15 percent fewer emergency department visits, and 29 percent fewer home health care episodes than the control group. “A patient who received Guided Care compared to someone who received usual care was more than twice as likely to rate the quality of the care higher,” observes Boult, principal investigator of the study, which was published in the August issue of the Journal of General Internal Medicine.
The seven registered nurses in the trial, averaging 55 patients each, are an extra cost, says Boult. “After factoring in annual salary, benefits, equipment, and travel expenses, totaling about $96,000 per nurse, we saw net savings in the first eight months: about $75,000 per nurse per year.” Approximately two thirds of savings resulted from reductions in hospitalizations.
A new NCI-funded project at Yale University’s School of Nursing is studying whether adding a nurse navigator (a master’s-level nurse clinician) to the health team for female lung cancer patients can improve the quality of participants’ care, including their medication adherence.
[4]Ruth McCorkle, PhD, RN
“Many of these patients have comorbidities. A life-threatening disease can be so distressing that they forget to take medications needed for their chronic disease,” says the principal investigator, Ruth McCorkle, PhD, RN, professor of nursing. “Drugs for cancer treatment have to be compatible with their other prescriptions, so medication management and adherence take on added importance.”
Nurse navigators
The navigator’s role — guiding the patient to self-management — requires teaching “good understanding of what medications you need and how they help. The nurses have to teach the importance of taking medications on schedule — that’s what helps the patient stabilize. Once patients understand the principle, they are better at knowing why and how to take their medications.”
Nurse navigators average five or six patients each, and arrange ten telephone or clinic contacts over ten weeks. Earlier nurse navigator projects involving patients with solid tumors “have repeatedly shown that teaching people how to take their medications helps with adherence,” says McCorkle.