Playing the numbers game with adherence
Patient adherence has a lot of numbers associated with it. The National Community Pharmacists Association, for example, asserts in its recent adherence report card that non-adherence adds about $290 billion a year in health-related costs, while a 2012 ExpressScripts report attributed over 250,000 hospitalizations to asthma medication non-adherence. Earlier this year, the IMS Institute for Healthcare Informatics put the avoidable cost opportunity from non-adherence at $105 billion.
A logical conclusion would be that greater adherence could reduce costs, but a study of insurance programs that lower the cost of medications based on their association with reducing death and illness found that removing financial barriers to medication adherence improves the quality of patient care, but does not result in major savings.
Nor do these programs put the healthcare system on the hook for massive health-related costs, according to researchers who published the findings on value-based insurance plans (VBIDs)—also called evidence-based plans—in the July issue of Health Affairs.
The thinking behind this sort of plan is to create an inverse relationship between medication costs and financial responsibility: The higher-priority the condition in terms of overall health costs, such as diabetes or COPD, the lower the financial burden for the medications.
Consumer-directed healthcare plans (CDHPs), on the other hand, steer healthcare choices by having patients shoulder costs of care upfront, by treating all conditions as the same, and by creating a uniform optic through which choices are made.
The immediate results of these two tactics have been contrary, but not extraordinary. CDHPs have been associated with lower spending on healthcare. And this is where part of the problem with these studies surfaces: The unknown is whether skipping medications and screenings in the present has a heavy financial cost in the form of treatment-heavy conditions later.
The VBID researchers cannot claim this knowledge, but they did find that plans that increased medication access for high-priority conditions, like diabetes, which require chronic medication maintenance, were linked to greater medication use and less intense downstream effects in the form of fewer emergency room and physician visits.
Researchers noted that the greater prescription use, facilitated by lowering or removing co-payments for these medications, did not cause third-party costs to rise. For those focused on the short term, such findings are unsatisfactory, because the immediate goal is a balance sheet that's heavy on black ink.
Diluting the value of the VBID and CDHP data are two common issues. First, the concept of “savings” had to be defined. Second, the time frames are far too short to assess the long-term impact for such strategies. The latter would require taking the entire cost continuum into account, contrasting the cost of care when chronic conditions are avoided or managed through lower-cost interventions vs. care associated with undetected, unmanaged chronic conditions, including spin-off impacts (co-morbid conditions) associated with lack of management.
A recent editorial by the Institute of Medicine's Harvey Fineberg, however, offered context for what the long-term impact of doing nothing can be. “By every measure including death rates, life expectancy, and diminished function and quality of life…,” he wrote, citing data from the US Burden of Disease Collaborators, “the US standing compared with 34 Organization for Economic Co-Operation and Development countries declined between 1990 and 2010.”
Fineberg's op/ed, which appeared in Journal of the American Medical Association, also notes that low back pain, major depressive disorder, musculoskeletal disorders, neck pain, anxiety disorder and COPD—high-maintenance conditions which require adherence to medical regimens—were among the leading causes of “years lived with disability,” per the data.
The four leading causes of deaths during the period were heart disease, lung cancer, stroke and COPD. In short, despite technology and medication, the US is doing a poor job of promoting patient health.
A third study gives additional insight into how these components begin to fit together. This one, led by George Washington University School of Nursing professor Jessica Greene, found that a factor called “patient activation” is critical. The term, defined in the research published in the July Health Affairs, refers to “the knowledge, skills and confidence a patient has for managing his or her healthcare.”
This sense of competency, researchers wrote, correlates with the quality of a patient experience. Not addressed is how this translates into patient action. But the study found activated patients were “adept at eliciting care experience that satisfied them,” and the difference showed among patients who fell into the activated and non-activated buckets who saw the very same provider.This means the patients who think their job is to just comply with their HCP's advice will be less satisfied than those who feel they have a working relationship with their medical professional.