The US healthcare system is one of the most expensive in the world. Have you ever wondered what makes our system so costly?
According to a report from the Patient-Centered Primary Care Collaborative, nearly 75% of health care costs can contributed to the cost of chronic diseases. That’s concerning. But what’s more alarming is that according to the California HealthCare Foundation, the number of people diagnosed with chronic diseases is on the rise and is expected to continue doing so over the next several years.
Lifestyle changes can be an effective way to prevent, manage, and/or reverse many chronic diseases. For example, Dr. Joel Fuhrman has had many successes in working with patients to change their diets in order to reduce if not entirely eliminate medications related to chronic diseases. Other doctors have had similar results such as Dr. Dean Ornish.
But I know there are some individuals who are not interested in changing their diets. In fact, I have a friend who is on high cholesterol medicine. Someone said to him once, “No wonder you’re on cholesterol medicine. Look at the junk you eat!” He responded, “No. I’m on cholesterol medicine so I CAN eat this junk.” He had no desire to change his diet. He just wanted a pill.
I’m an advocate for improved lifestyles, particularly as it relates to diets, but the good news for people like my friend is there are medications that, if used properly, can lead to improved health.
The important thing is to make sure patients take their medications as prescribed. According to a 2003 Boston Consulting Group study, this is not always the case. In fact, patients report that they don’t take their meds accurately because of these reasons:
- Side effects
- Too costly
- Felt they didn’t need the drug
- Difficulties in getting the prescription filled.
According to Dr. Allen Dobson, North Carolina’s former Assistant Secretary of Health and State Medicaid Director, “Underutilization of controller medications in asthmatics and lack of adherence to medications in patients with congestive heart failure were major contributors to ER visits and hospitalizations.”
How can primary care practices realize the results of improved Medication Management? The Patient-Centered Primary Care Collaborative recommends these steps:
The first step is for practices to identify the patients who haven’t reached clinical outcome goals. Easy words to say, much harder ones to do. Here’s a couple of things that practices can do:
- First of all, the practice needs to agree on clinical outcome goals otherwise known as practice guidelines. This is no easy task and is estimated to take anywhere from 2 months to 2 years! You can make this process easier for your practice by beginning with templates of clinical outcome goals by disease. One example is the book, Current Practice Guidelines in Primary Care. Next, you need to garner provider involvement and buy-in. One place to begin is to agree that all practice guidelines will be evidence-based rather than experience-based. It’s important that the practice guidelines be easy to follow and not overly prescriptive. There are resources available to help your practice through this process, such as Managed Care Resources, Inc.
- Next the practice has to produce the data. For practices that use Electronic Health Record (EHR) systems, this means taking a peek under the hood to get to the data. If you haven’t done that before, it may require a call to the EHR system. For others it could be something as simple as producing reports using identified fields. For practices using paper records, it’s another matter altogether. In fact, for most practices using paper records, identifying patients with certain chronic diseases and determining their outcome results means some data has to be mined electronically either through an EHR system or by implementing a chronic disease registry system. The California Health Foundation provides a product review of various chronic disease registry systems. Once the practice has determined which patients are not meeting identified clinical outcomes, they can move to the next step.
2. Understanding the Patient.
This step requires knowing the patient’s personal medication experience, identifying actual use patterns. It’s more effective if you include everything from over the counter medication to supplements to prescribed medications.
3. Systematic Review.
Next, the PCPCC recommends that the provider “systematically review for drug interactions then assess each medication for appropriateness, effectiveness, safety and adherence (in that order) focused on achievement of the clinical goals for each therapy.”
4. Get into the Gap.
It’s important here to identify any gaps between the current therapy and what is needed to achieve desired clinical outcomes.
5. Develop a Plan.
Next, a care plan is developed identifying steps to be taken to meet desired outcomes.
6. Agree to Agree.
Patient Agreement is the last but by far not the least important step. According to a study published by the Society of General Internal Medicine, “patient agreement was associated with higher patient self-efficacy and assessments of their diabetes self-management.”
The practice needs to document all the steps taken in this process, particularly noting any gaps between current status and desired outcome goals.
8. Follow-through is key
In most sports, the follow-through is key to successful athletic performance. The same is true when it comes to medication management with patients. Follow-up with patients can help you determine effects of the prescribed change. I once observed a patient focus group session where a woman made this comment, “I get a phone call from my mechanic after repair work is done asking me if my car is now working fine or if more work needs to be done, but I never get a call from my doctor’s office asking me if the medication I was prescribed is working for me. It’s as if they assume when they don’t hear from me that everything is fine.” Follow-up calls and/or visits can be more than helping patients meet desired outcome measures, it builds relationships between the practice, the provider, and the patient.
Finally, the PCPCC recommends a reiterative process for medication management. They describe a reiterative process as one where “care is coordinated with other team members and personalized (patient unique) goals of therapy understood.”
The PCPCC report highlights a Minnesota Medication Therapy Management study that showed a reduction in annual health care costs of over 30% as a result of improved adherence to medication plans. In addition, the participants went from 76% to 90% reaching their therapy goals, including improved performance in reaching hypertension and cholesterol clinical goals. You can learn more about this PCPCC study by downloading the presentation, The Opportunity for Comprehensive Medication Management.