Rebecca Burkholder, JD

Care delivery is shifting to models that reward patient engagement and ensure that their voices are heard by the health care team.

When asked “Whose interests drive the value discussions in health care?” it is not immediately clear that patients are the driving force. Sometimes it seems like improving reimbursement rates, providing job security for providers, and ensuring performance bonuses and the like are more important in reforming the care delivery system than the patient’s needs. In the age of an empowered consumer, it is important that advances in care provide value for the consumer.

Too often it seems that the patient is the last to the table, but the first to be affected by major shifts in our health care system. The Affordable Care Act (ACA) presents a turning point in our nation’s health care, not only by providing coverage to the uninsured, but also by shifting care delivery to models that reward truly valuable, high-quality medical care. The ACA recognizes that engaging patients in their own care is a cornerstone of successful health-system reform and is critical to the success of accountable care organizations and patient-centered medical homes.

Recognizing the transformative potential of patient-centered care, new methods of organizing and paying for health care tie reimbursement to performance-based measures of patient satisfaction and engagement. The patient experience will matter—whether at the pharmacy, hospital, or the doctor’s office. Surveys assessing patients’ experience of care, meaningful use rules, and active use of shared decision making will all help ensure that the patient is truly empowered, and not just a bystander. Now is the time to reward solutions that add value to the patient experience.

In this new expanded health care setting, pharmacists certainly have an active role in patient care, providing an additional expert on the patient care team. As we discuss value at the pharmacy, let’s keep our eye on the center—the patient&mdash;and pay attention to which services actually add value or detract from the patient experience.

As a consumer advocate, too often I interact with patients who have trouble taking their medication, and those stories go a bit like this:

After a serious illness, 65-year-old Barbara left the hospital with an arsenal of new medications and very few instructions about how to take them. Upon refilling her prescriptions, Barbara had a hard time asking questions at her pharmacy. Overwhelmed, Barbara was confused about how often, when during the day, and how many of her medications to take, and she struggled to be in control of her medication routine. 

The current consumer experience at point of care within pharmacy is often dismal. Patients have minimal interaction with the pharmacist and often leave with unanswered questions about their medications. Accessing the pharmacist isn’t always easy; many patients mistake the cashier for the pharmacist and don’t even know who their pharmacist is. In many instances, consumers wait for long periods to get their scripts refilled, and don’t take advantage of the counseling that is available. Further, lack of privacy at the pharmacy counter and concern and confusion about cost also help create an unpleasant experience. Whether a brick-and-mortar pharmacy or mail order, from our point of view, the pharmacy experience is riddled with obstacles for the patient to get the care and services they value.

Stories about people like Barbara should help us shape the pharmacy experience, as well as define value for patients in the pharmacy setting. Value is receiving the greatest quality for the least amount of money, so striking the right balance between cost and quality is key. And understanding the context in which patients receive pharmacy services (it’s just 1 piece of the health care puzzle) can help drive improvements.

We know there are a few key things that patients expect from their pharmacy.

 Enhanced communication with the pharmacist is key for patients. Having that conversation about medication, general self-care, and other issues can increase each patient’s adherence and empowerment. Enhanced communication between the pharmacist and other health care providers is also key—in fact, most patients assume that their pharmacist is already in regular communication with their doctors(s) when we know that is not always the case.

 Sticker shock at the counter and confusion about copays and deductibles all contribute to patient dissatisfaction in the pharmacy. Many patients are unclear what their insurance covers and whether they have alternative options for medicine. We know the cost of many other items before we purchase them, why not medications? Can prescription pricing be simplified in a way that makes sense to the average consumer?

 The pharmacy can be made consumer-friendly by cutting down wait times, adding privacy at the counter, and offering more practical tools for medication management. Offering medication therapy management (MTM) or compliance packaging solutions can also be of value to some patients. Providing consumers with solutions to their questions on self-care and on-the-spot assistance with OTC drug purchases are other valued services. The entire pharmacy experience should promote wellness and health at every point of interaction with the consumer. By offering preventive health care services such as flu shots and blood pressure screenings, pharmacies are positioned as a community holistic care provider.

As patients, when our health is on the line, wouldn’t we all rather be a member of a team, rather than subject to what others decide to do? As the slogan “Nothing about me without me” from the patient safety movement suggests, patients must be integrated into the systems we are striving to change and improve. Most patients want to be informed decision makers and to actively share in the decision-making process with their health care providers, but they are often not supported in those efforts. Increasing use of shared decision-making tools and linking patient satisfaction surveys to reimbursement are examples of improvements in our system that help ensure that patients are an equal member of the health care team. There are also more opportunities for improving the pharmacy experience for patients.

 In order to be informed decision makers and advocates for their own health, patients and their caregivers need to have access to evidence-based tools and resources. A list of questions that patients can ask their pharmacists and medication charts to keep track of medications are simple yet helpful tools for the patient. Imagine a pharmacy where patients actually knew what their medicine did, why they were taking it, and what they should avoid!

Collaborative programs to improve adherence.

 Patient-centered medication management programs are great examples of value-driven care. Poor medication adherence puts patients, especially those with chronic diseases, at great risk for future complications. Simply telling a patient to take their medications isn’t enough, but actively working with the patient to identify their barriers to adherence and using tailored solutions can have an impact.

 In fact, recent research showed that value-based insurance plans that targeted high-risk patients, offered wellness programs, and provided benefits through mail order pharmacy had a significantly greater impact on adherence than plans without those features.

Access to patient-centric medication reviews, packaging.

 MTM is another solution that places the consumer in the center of care by providing patient counseling, medication synchronization, and even compliance packaging. Through MTM, a pharmacist can keep in touch with other health care providers, helping to bridge the communication gap that often occurs for patients when their providers are not working together to coordinate care. And adherence packaging provides solutions in the home to improve patient adherence.

 While a passive way to improve the patient experience by providing patients with an easy system to manage medications, packaging can alleviate key barriers such as forgetfulness and skipping doses.

 With health care reform and the ACA, we saw the creation of patient-centered medical homes with a holistic care team, but more can be done. The Agency for Health Care Research and Quality defines care coordination as the deliberate organization of a patient’s care activities and sharing of related information among all parties invested in the patient’s care.

Care coordination provides an opportunity for the patient’s needs and priorities to be discussed and understood by the whole team in advance. Additionally, it aids in establishing goals of therapy that are valuable clinically and personally to the patient. And with the movement to coordinated care for the patient, we can’t forget the important role of the family caregivers. Family caregivers are an essential piece of many care teams as they provide support to the patient and are often responsible for making many critical decisions. In the future, formalizing the family caregiver’s role in the care team is needed for the best health outcomes.

There are also system-level changes that can support additional movements in value-driven health care. As reimbursements and performance are tied into health outcomes, it is important that the measures we use to evaluate plans and providers are patient-centered.

 Measures that actually reflect the patient experience help to link patient improvements to meaningful health outcomes for the patient.

The good news is that in addition to the above, there are more promising things on the horizon that will keep the patient front and center in the discussions of value-driven health care.

From the patient perspective, advances in health information technology present a platform for patient engagement. New innovations in technology can open up avenues for patients to health information, communication with their providers, and health care management. Mobile phone apps, patient portals, and electronic health records (EHRs), and more provide a chance to revolutionize our health care, especially with patient involvement and ownership.

With EHRs, patients can go online and access their health information and make queries of their providers in real time. Some EHRs even allow patients to input information about their health to share with their doctor. In fact, a recent survey showed that 80% of individuals who have online EHR access take advantage of that access.

Health information technology has a long way to go to be truly integrated into our health care system, but it is essential to coordinating care and providing patients with a voice. We envision a future when EHRs evolve into a system where a patient can access their medication list, simply click on a medicine, and ask a question with a real-time response from a pharmacist.

As we envision the pharmacy of the future and the role of value-driven care—let’s remember that the “value” is for the patient, not the provider. It is for patients like Barbara, and others&mdash;our friends, family, and even ourselves, as we are all patients&mdash;and we need to keep that perspective front and center in order to provide truly valued care. 

Rebecca Burkholder, JD, is vice president of health policy at the National Consumers League, a national nonprofit organization that has represented consumers and workers since 1899. Ms. Burkholder coordinates the League’s work on various health care issues, including safe use of medication, patient safety, doctor—patient communication, and direct-to-consumer advertising. She is responsible for research on these issues, producing consumer information, and advocating for system changes. She also coordinates Script Your Future, a broad-based public awareness campaign to improve medication adherence.

Ms. Burkholder serves on numerous boards and advisory panels, including the National Council for Patient Information and Education Board of Directors, the National Patient Safety Foundation Board of Governors, and the Consumers United For Evidence-Based Health Care Steering Committee. Ms. Burkholder testifies before US government agencies on consumer health issues, and speaks at conferences across North America. 

Before joining the League in 2001, Ms. Burkholder worked as a health care attorney for the law firm of Reed Smith Shaw and McClay in Washington, DC.  Ms. Burkholder graduated with high honors from Georgetown Law Center, and is a member of the Washington, DC, bar.

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		Agency for Healthcare Research and Quality. 2012

		MWV introduces new customizable medication adherence package [press release]. 

 [online]. www.businesswire.com/news/home/20140210005083/en/MWV-Introduces-Customizable-Medication-Adherence-Package#.UychjPldUXF. Published February 10, 2014.

		RWJF awards $1.9 million grant to PatientsLikeMe to create world’s first open research platform to develop patient-centered health outcome measurements [press release]. Robert Wood Johnson Foundation website. www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/02/rwjf-awards-grant-to-patientslikeme.html. Published February 25, 2013.

Rebecca Burkholder, JD

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