The Compression of Morbidity: Where We Stand 35 Years Later

Pharmacists can play an important role in the reduction of disability through patient-centered care.

The economic importance of the compression of morbidity theory introduced by Dr. James F. Fries three-and-a-half decades ago is profound. Fully one-fifth of the United States population will be 65 years or older by 2030. This is a near doubling of the fraction of the population that had achieved that aging milestone in the previous 2 decades.¹ We are in the midst of the most significant shift toward population-level advanced aging in the history of the country, and arguably in the history of the world.

Consider this: if the US population’s average age increases even a single day, without a subsequent population-level compression of morbidity by an equivalent day, the resulting state of disability is increased for many millions of Americans. Disability dramatically reduces quality of life for patients as well as their caregivers. Disability is also extremely expensive. The average elderly or disabled person using Medicaid or Medicare as his or her payer (dually eligible) will incur more than $30,000 per year in health care costs.² Moreover, the actual cost to the system tends to be greater than that amount since Medicaid and Medicare typically reimburse much less to providers than nongovernmental payers. More risk in the citizenry is spread over fewer healthy, younger citizens.

Without successful compression, we will find ourselves in a state of global noncompetitiveness. As discussed in earlier supplements in the Directions in Pharmacy^TM series, the rise in proportion of gross domestic product (GDP) spent on health care is unsustainable. The “health care versus butter” phenomenon (choosing other goods and services over health care when sensitive to pricing) becomes stronger and stronger as health care spending nears 20% of GDP, and will only be amplified by the proliferation of high-deductible plans resulting from a confluence of pressures of premium inflation, the growth of the individual plan market, and the imposition of the “Cadillac tax.” The combined effect of a less healthy population and a low-value delivery system in a global marketplace could be devastating over the next 2 decades for both US employers as well as US taxpayers.

The compression of morbidity calls for a broader, more inclusive, and more longitudinal approach to medical care delivery. Traditionally, the medical system has been geared toward “sick care” on the “now horizon.” The mantra has been “come see us when you are sick, only when you like, and only about the maladies that are outwardly present.” For successful compression of morbidity, the system must reorient to “see us early, see us often, and see us for conditions that won’t ultimately affect you outwardly for years to come. And, oh, by the way, let’s talk about wellness, not just disease mitigation.”

We are seeing a slow, albeit steady, movement toward “patient-centeredness” and away from product and “service-centeredness.” Compression occurs, or doesn’t occur, as a result of patient choices in relation to the medical and nonmedical environment around them. Exercise, eating healthy meals, avoiding stressful life habits, and yes, medication adherence, are all ultimately determined by patient behavior. But these occur through multiple vectors such as access to healthy food, safe places to exercise, and medications; ill-coordinated and suboptimal drug regimens causing discomfort; belief systems; and behavioral health status.

The medication adherence movement is arguably the most significant indicator of this emergence of the movement to compress morbidity that has occurred to date within the medical construct—and the movement is here to stay. It gained popularity within health services research circles through the late 1990s and in the earlier part of this century to the point where over 60,000 publications now exist in the area of patient nonadherence to medications.³ But it wasn’t until the later part of the last decade that it gained widespread popularity as a movement in the mainstream, owed in part to the New England Healthcare Institute’s finding of $290 billion in unrealized gains in health care cost avoidance resulting from patient nonadherence.⁴

The medication adherence movement has all of the traits of a patient-centered model of care delivery with an extended time horizon to compress morbidity. To date, the most similar movement to this effect has been widespread adoption of vaccination programs, which are also quite relevant to pharmacy practice.

As discussed in prior Directions in Pharmacy editions, new payment models that emphasize value and risk-sharing over a longer time horizon are on their way. The typical fee-for-service payer-provider relationship is beginning to erode in favor of models that align with the patient-centered compression of morbidity approach. Medicare Star ratings are directly tied to medication adherence rates, and a plethora of other quality metrics across many payers and payer types are now indirectly related to patient nonadherence through outcome measures that are positively affected by optimal medication use.

Pharmacists can play an essential role in facilitating compression. Fries’ 5 opportunities in his article read like a “how-to” list for population health management. Put more succinctly, there are 2 dominant factors that drive this opportunity:

1) Drugs and vaccines have great capability to compress morbidity: Aside from lifestyle changes, medications (if used correctly) and vaccines are our primary mechanisms of intervention to slow or reverse disease progression.

2) Community pharmacy practice is a high-touch environment: It lends itself to patient coaching, monitoring, and reinforcement opportunities, both drug and nondrug related. Community pharmacy also lends itself to widespread availability of preventive services, which are only as effective as the ability to capture the population for which they are intended.

Despite these natural advantages, moving to a patient-centered compression of morbidity model of care will require significant disruption in the current community pharmacy practice model. Pharmacies are arguably the most operationally efficient entities in the health care system, with over 4 billion prescriptions filled with 3% to 5% operating margins (at best). However, the same operational processes that lead to efficient medication order fulfillment can also be an affront to patient-centered care delivery. It is essential that continued increases in operational efficiencies are accompanied by patient-centered orientation through activities such as medication synchronization, medication reconciliations, and other services that force the pharmacist-provider to think critically about the patient’s needs.

Even more essential is a payment model that supports longitudinal and continuous care delivery as a service and not as a product. Emerging payment models such as shared savings and per-member, per-month management fees serve to reinforce the patient-centered compression of morbidity model of care by de-emphasizing cross-sectional, disconnected prescription fill encounters, and replacing them with ongoing, continuous, and contiguous care delivery.

Troy K. Trygstad, PharmD, PhD, MBA, is the director of the Network Pharmacist Program and Pharmacy Projects for Community Care of North Carolina (CCNC) and co-editor of the Pharmacy Times series on Directions in Pharmacy.

References

• Department of Health and Human Services Administration on Aging. Older population as a percentage of the total population. www.aoa.gov/AoARoot/Aging_Statistics/future_growth/future_growth.aspx.
• Congressional Budget Office. Dual-eligible beneficiaries of Medicare and Medicaid: characteristics, health care spending, and evolving policies. www.cbo.gov/publication/44308. Accessed August 5, 2014.
• Seabury SA, Gupta CN, Philipson TJ, Henkhaus LE, the PhRMA Medication Adherence Advisory Council. Understanding and overcoming barriers to medication adherence: a review of research priorities. PhRMA Medication Adherence Advisory. J Manag Care Specialty Pharm. 2014;20(8):775-783.
• The Network for Excellence in Health Innovation. Thinking outside the pillbox: a system-wide approach to improving patient medication adherence for chronic disease. www.nehi.net/writable/publication_files/file/pa_issue_brief_final.pdf. Published August 12, 2009.