Medication Adherence — Rx For Success - Optum

White PaperMedication Adherence: Rx for SuccessOptumwww.optum.com

Medication Adherence: Rx for SuccessWhite PaperMedication Adherence: Rx for SuccessIntroductionUniversal concern about rising health care costs combined with historic health carelegislation has created an unprecedented window of opportunity to improve the waycare is delivered in the United States. All interested parties—including health careproviders, patients, insurers, employers, policy makers, and drug manufacturers—arebracing for change. The challenge is to find areas of health care in which the largestimpact can be made on a humanistic, economic, and clinical scale. One such area ismedication adherence.A national public health issueThe problem is easy to state: Patients don’t always take their medication as directed.Sometimes they miss doses or don’t follow the instructions. Other times, they stoptaking it altogether. The ramifications of these behaviors are far-reaching, both interms of health care quality and cost.In 2003, the World Health Organization (WHO) identified medication non-adherenceas the leading cause of preventable morbidity, mortality, and health care costs1.Meanwhile, research has set the price tag for the direct costs of medicationnon-adherence in the United States at a minimum of 100 billion.2 The New EnglandHealthcare Institute estimates that non-adherence along with suboptimal prescribing,drug administration, and diagnosis costs the health care system as much as 290 billionper year—or 13 percent of total health care expenditures.3Research has found that higher levelsof medication adherence are associatedwith improved health outcomes andlower health care costs.The good news? As the WHO points out, the problem of medication non-adherence is“preventable.” In addition, research has found that higher levels of medicationadherence are associated with improved health outcomes and lower health care costs.This is where the opportunity lies for health care professionals and organizations thatwant to improve quality and avoid costs.The value of medication adherenceIt’s not hard to find research that underscores the importance of medication adherence.For example, evidence has linked better medication adherence in diabetes patients withlower total health care costs. (See chart on next page.) The study that produced theseresults also found that hospitalization rates were significantly lower for diabetespatients with high medication adherence. Similar hospitalization results were found forpatients with high blood pressure, high cholesterol levels, and congestive heart failure.Optumwww.optum.comPage 2

White PaperMedication Adherence: Rx for SuccessOther recent studies have generated comparable findings, including: Statin medication adherence is associated with reductions in subsequent total healthcare costs and cardiovascular disease-related hospitalizations.4 Adherence to blood pressure medications is linked to significantly lower total healthcare costs and significantly lower odds of cardiovascular-related hospitalizations andemergency department visits.5 Medication adherence by patients with at least one of four chronic vascular diseases(congestive heart failure, hypertension, diabetes, and/or dyslipidemia) leads to substantialmedical savings due to reductions in hospitalization and emergency department use.6Average expenditure per patient per yearTotal Health Care Costs for DiabeticsMEDICAL COSTSDRUG COSTS18,000 1,312 15,000 1,877 12,000 1,970 15,186 2,121 9,000 2,510 6,000 11,200 11,0089,363 6,377 3,000 0 1 - 19%20 - 39%40 - 59%60 - 79%Total healthcare costs godown asdiabetesmedicationadherencegoes up.780 - 100%Adherence level (% days supply per year)The value of medication adherence can also be seen in the way it’s embraced byorganizations that focus on health care quality and measurement. As the followingtimeline shows, medication adherence is viewed as a key health care metric by suchorganizations as the National Quality Forum, the Pharmacy Quality Alliance, and theCenters for Medicare & Medicaid Services (CMS).A TIMELINE: Medication Adherence as a Measure of Quality2007The National Council onPatient Information andEducation issues a “NationalAction Plan” calling uponstakeholders to improvemedication adherence.Optumwww.optum.com200920102012The National Quality Forumendorses medication adherenceas an indicator of quality in drugtherapy management.Pharmacy Quality Alliance(PQA), using measuresdeveloped in partnership withthe National Committee forQuality Assurance (NCQA),launches demonstration projectsto assess the impact ofpharmacists’ interventions onmedication adherence.CMS Star Rating measures onmedication adherence added.URAC adds new performancemeasures (seven domains) to itsaccreditation programs forPharmacy Benefit Managementand Drug Therapy Management.One of the key domains:Medication Possession Ratios(MPRs) as a proxy for adherence.Page 3

White PaperMedication Adherence: Rx for SuccessUnderstanding whyAt first glance, you might think that medication non-adherence shouldn’t be a problemat all. Why wouldn’t patients want to take their medications properly? There are,however, a number of barriers that make it difficult for many patients to take theirmedications as directed. Here are some of the most prevalent:PATIENTBARRIERS Poor health careliteracy (i.e., patientsdon’t properlyunderstand their illnessand the importance oftheir medication)PROVIDERBARRIERS Lack of knowledgeand poor communication with patientsabout drug costsHEALTH CARESYSTEM BARRIERS High drug costs Administrative issues(e.g., formulary complexity, prior authorizationrequirements) Lack of drug coverage Lack of knowledgeabout insurancecoverage for differentformularies Insufficient access to,and coverage for,medications Lack of understandingof how to use theirmedication Lack of knowledgeabout patientadherence Inadequate healthinformationtechnology solutions Low motivation/selfefficacy (e.g., patients Complex regimensmake it difficult toprovide patients withproper informationabout safe andappropriatemedication use Inability to payare not confident theirmedication will help) Forgetfulness Concern about sideeffects Poor communicationwith providerThe Optum solutionBreaking down these barriers is critical to improving the way patients use theirmedications. The OptumTM approach is a comprehensive one that uses a combination ofcutting-edge technology, expert analysis, patient and provider education, andscientifically valid health measurement tools to promote medication adherence andgauge its impact on health care quality and costs.The multi-step program is designed to use available health care resources mosteffectively and efficiently, and to encourage a culture of collaboration between allinvolved. A primary goal is to ensure timely intervention (e.g., prior to a patient’s firstscheduled refill) so that medication adherence is maintained and gaps in care that maylead to adverse health outcomes are avoided.Optum’s approach is a comprehensiveone that uses a combination ofcutting-edge technology, expertanalysis, patient and provider education,and scientifically valid healthmeasurement tools to promotemedication adherence and gauge itsimpact on health care quality and costs.Patient identificationBefore you remove any barriers, you must first identify those patients who are atgreatest risk for non-adherence and poor health outcomes. As you might guess,gathering and reviewing pharmacy and medical claims information is important totargeting these patients. Optum, however, goes further, and has developed apredictive model called the Drug Adherence IndexTM 8. In addition, Optum utilizesunique patient self-report surveys to fine-tune its search.Optumwww.optum.comPage 4

White PaperMedication Adherence: Rx for SuccessProactively targeting members at risk for non-adherenceThe Drug Adherence Index can help health plans identify patients who are likely tostop taking their medications by using proprietary predictive modeling that considerspast medical data, prescription behaviors, and socio-demographic data to generate arisk score. Armed with this data, a health plan can efficiently direct its interventionefforts toward at-risk members who need additional support. By intervening with theright members, a health plan can: Increase adherence levels Improve CMS Star adherence metrics Contain costs Improve health outcomesHow it worksFor most medication adherence programs, gathering and reviewing pharmacy claims ispart of a retrospective screening process. The Drug Adherence Index takes screening toanother level by generating a risk score for each patient based on past drug use andsocio-demographic characteristics.Each patient is given a risk score between 1 and 12. Patients who score a 7 or above arepredicted to be at least 80 percent adherent, while patients who score less than 7 arepredicted to be below the 80 percent, i.e. non-adherent. Some health plans may want tofocus on patients with a risk score of 5 or 6 as perfect candidates for interventionbecause they are just below 80 percent of the proportion of days covered (PDC), whileothers may also include members with risk scores of 7 or 8 since they are marginallyabove 80 percent and at risk to backslide below the threshold.The Drug Adherence Index is completely scalable and can be used with pharmacy-onlydata or pharmacy and medical claims data. The model can be applied across anypopulation and has a sensitivity rate of more than 70 percent, meaning that it willaccurately identify seven out of every 10 non-adherent patients.Comparison of Actual PDC vs. Risk Score100%PDC80%60%Oral Anti-diabetic40%StatinACE or ARB20%0%123456789101112Predicted Risk ScoreBarrier assessmentOnce at-risk patients are identified, the next step in the process is to determine whythey are not adherent by performing barrier assessments. Optum achieves this byreaching out to patients via personal phone interviews.Optumwww.optum.comPage 5