Avoiding First Event: The Importance of Adherence in the "Near Sick"

Appropriate interventions can help the “near sick” stay healthy.

Pharmacists—stand up and be recognized! In recent years, the role of the pharmacist has been increasingly acknowledged as an integral part of a coordina-ted and patient-focused health care delivery model.In fact, many provider organizations are seeing the important role of medication management to enhance health care quality, produce better clinical outcomes, and lower the total cost of care, with an overall goal to deliver patient-centered care.

From the Cleveland Clinic¹ to the naval base in Pensacola, Florida,² ambulatory, patient-centered medical homes (PCMHs) can now be found across the country. These organizations and many more like them, highlight the important role the pharmacist plays on the health care team to proactively manage medications for patients with chronic conditions. Today, the interation between the physician and pharmacist is called a “warm hand-off”—the transition that helps ensure coordination and produce individualized patient-centered care.

In order to uncover the true value of care coordination and medication management, we need to first look at the needs of the patient, and how our current health care system leaves a large unmet need when it comes to proactive treatment, better health outcomes, and quality. It begins with the epidemic of chronic disease in the United States, where it is estimated that 157 million Americans will have at least 1 chronic disease by 2020, with 81 million individuals facing multiple chronic conditions.³ Chronic conditions drive the majority of health care costs, and effective and appropriate medication adherence can minimize costs and improve quality of care in this population.

In 2012, the Congressional Budget Office published guidance stating that every 1% increase in the number of prescriptions filled by Medicare beneficiaries leads to a net decrease in medical spending of 0.2%.⁴ However, ensuring that patients take their medicine as prescribed is no easy task. In fact, 50% of patients do not adhere to their medication regimens, costing the US health care system an estimated $290 billion in preventable spending each year.⁵ Even patients who had health insurance and no cost sharing for medications still had close to a 40% nonadherence rate, according to a recent study.⁶

Management guru Steven Covey has a relevant quote that helps frame what we need to do in order to truly improve patient care. We must “Start with the end in mind.” For far too long, we have looked first at adherence, instead of seeing adherence as the result of a systems-based approach to medication management. It’s time to pull care coordination, medication management and medication adherence all together, integrating pharmacists on care teams and ultimately placing the needed emphasis on the role of outcomes based on comprehensive medication management as a core component of care coordination. However, we need to have the right tools and incentives in place to be successful.

Connecting the Dots: Providing Medication Management Across the Medical Neighborhood

In 2013, GSK and Community Care of North Carolina (CCNC) began collaborating to build HIT tools that could facilitate proactive medication management. The goal is to start with the end in mind. Better outcomes and patient engagement are achieved by connecting the right providers, in the right settings of care, with the right medication management guidance.

GSK statisticians combined with CCNC population health and decision support experts to design prospective models that could identify patients who were at risk for drug therapy problems. They added a logistics component that turned the predictive models into prescriptive modeling, which allows a provider to understand his or her patient’s medication challenges in real time to determine effective ways to overcome barriers to delivering quality care. The combined tool was first tested in a data laboratory, and then in late 2013 CCNC began testing in 2 real-world settings: Southern Indiana and North Carolina. This summer, testing expanded into additional pilot settings of care, including accountable care organizations (ACOs) and community pharmacies.

Early Learnings: Reframing How We Think About Population Health

One of the expanded test sites for the predictive models and logistics engine is GSK itself, as part of a separate patient-centered medical home pilot with CCNC that began in 2012. After interim results from the PCMH pilot suggested more should be done to close chronic condition care gaps, which are directly tied to appropriate medication use, CCNC implemented a comprehensive medication management program for the GSK population in early 2014. CCNC, using the new health information technology, applied predictive models to gauge drug therapy problem risk scores for the population using aggregate data. The results of the risk scores were fascinating.

The composite risk score takes into account 6 predictive models, which include risk of hospitalization and various drug therapy problems (eg, therapeutic considerations). Patient scores range from 1 to 100. A score of 65 to 74 suggest a high risk of getting sick, or a “near sick” population. A score of 75 to 100 is classified as an “already sick” population. Predictably, the GSK population has a very low incidence of “already sick” compared with the NC Medicaid population. However, GSK had a significant proportion of the “near sick” population, which is categorized as folks who have 1 to 2 chronic conditions but are currently highly functional. The problem is that this population could have significant underlying drug therapy problems, typically underutilization of appropriate medications, which might lead to complications down the road. This suggests that proactive medication management could lead to better management of their condition and avoidance of more costly complications in the future.

Upon further review of aggregated “near sick” populations, CCNC discovered something else very interesting. Members of this group, because they are not acutely sick, only go to the physician once a year on average and go to the hospital less than once a year. But they visit their pharmacy close to 30 times a year! We need to rethink our approach. In order to proactively and effectively engage with this population, one needs to think about the right setting, the right provider, and the right guidance. Appropriate interventions to help the “near sick” stay healthy could be comprehensive medication reviews provided by the community pharmacist—right in the pharmacy.

Connecting Pharmacy to Population Health

These early learnings around the “near sick” suggest a powerful opportunity for community pharmacy. There is a population of patients who need medication management services in order to avoid more costly exacerbations in the future, and who, by and large, aren’t being seen on a regular basis by their physician because they aren’t acutely sick. More rigorous scientific study is needed. GSK and CCNC, along with a pharmacy school, are currently in the planning stages of a formal evaluation. However, it is clear that taking care of patient populations isn’t just about caring for patients once they get to the doctor. It’s about identifying and engaging with patients who aren’t walking into a physician’s clinic every day, but who are at risk for negative outcomes. And that is where community pharmacy can help—one patient at a time.

Obstacles Become Opportunities: A Call to Action

As a fellow pharmacist, I’ve seen good outcomes-based medication management at work through up close and personal involvement in the Asheville Project and the American Pharmacist Association Foundation’s expansion of the model in the Diabetes Ten City Challenge. The obstacles to expand pharmacist services for patient care are also well documented, and we’ve heard about them for years.

Whether it is the lack of payment for services (no provider status), the scarcity of data, the difficulty of resourcing and work flow in a community setting, or the lack of training, pharmacists have battled the “chicken and egg” dilemma for a long time. But something is different now. It’s called value. And if we in health care can’t figure out how to begin moving from the current volume-based system to providing value in the new system, we are at risk of missing the boat. I heard one speaker recently say it is like having one foot in a volume canoe and one foot in a value canoe—very unstable.

The good news is that everyone in health care is trying to figure how to make that shift to stable ground—and a steady approach to health care—focused on value. That’s why GSK and CCNC are collaborating. We were sure we didn’t have all the answers, but through experimentation and pilot programs, we were confident that we’d collect learnings and insights that would help inform what medication management in the new world of value should look like, and how it can benefit patients to achieve better outcomes while lowering total cost of care. Through experiential learning, we can apply the insights from our pilots to inform our thinking, and share it with other health care stakeholders and policy makers. Together, we can develop best practices and evidence about how best to deliver value through optimizing medication management.

Through our collaboration and others like it, we’re starting to see the pharmacists as an integral part of a value-based system. Things are coming together. Technology is emerging that identifies patients in need and keeps them engaged. Providers are recognizing the need for clinical integration and are starting to share data. Payers are piloting new approaches to paying for services that produce better outcomes and lower readmissions. Pretty soon, pilots will be evolving into mainstream practice. That is transformation. And the best part: it’s the patient, your family and mine, who will benefit the most. If you haven’t already, it’s time to jump in—the water is warm.

Jon Easter, BSPharm, RPh, is senior director, delivery and payment reform, at GlaxoSmithKline (GSK). His primary focus is health care transformation and the health information technology (HIT) policy environment, where he works to maximize its value to enable better health care quality, enhance the US health care delivery system, and ultimately improve patient outcomes. At GSK, Jon has championed the company’s involvement in North Carolina First in Health, one of the nation’s leading patient-centered medical home projects. He was also directly involved with replication of the Asheville Project, a recognized model for care coordination to improve patient outcomes for chronic disease. Jon has spent 20 years in the pharmaceutical industry. In addition to his public policy experience, Jon has implemented patient registry systems within GSK’s care management division, covered the Pacific Northwest for the state government affairs organization, and spent several years as a sales representative and district sales manager.

References

• Patient-centered medical home. Cleveland Clinic website. http://my.clevelandclinic.org/medicine-institute/patient-centered-medical-home.aspx.
• Fournier leads pharmacists on primary care teams in Navy medical homes. Amercian Pharmacists Association website. www.pharmacist.com/fournier-leads-pharmacists-primary-care-teams-navy-medical-homes. Published February 1, 2014.
• Wu S, Green A. Projection of chronic illness prevalence and cost inflation. RAND Corporation. October 2000.
• Congressional Budget Office. Offsetting effects of prescription drug use on Medicare’s spending for medical services. November 2012. www.cbo.gov/sites/default/files/cbofiles/attachments/43741-MedicalOffsets-11-29-12.pdf. Accessed July 2014.
• New England Health Institute. Improving patient medication adherence: a $290 billion opportunity. www.nehi.net/bendthecurve/sup/documents/Medication_Adherence_Brief.pdf. Accessed July 9, 2014.
• Cutler DM, Everett W. Thinking outside the pillbox—medication adherence as a priority for health care reform. N Engl J Med. 2010;362:1553-1555.