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

AUGUST 20, 2014
Jon Easter, BSPharm, RPh

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.