American College of Physicians: Internal Medicine — Doctors for Adults ®

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Do your patients comply?

Managed care forces physicians to revisit a nagging problem that's more common than they think

From the April 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Deborah Gesensway

Managed care is starting to force physicians to pay closer attention to a longstanding and well-documented problem in health care-non--compliance.

Doctors who cost health plans too much are already starting to find themselves unwanted and extra- hassled. And one sure way to end up ranked among the higher-cost providers is to have large numbers of patients who end up in the hospital simply because they refused to take their medicine properly.

"There is--clearly now more than ever before--an organizational provider that is at risk for bad outcomes resulting from non-compliance, whereas before, it was nobody's problem but the patient's," said Jerry Avorn, MD, associate professor of medicine at Harvard Medical School and an internist at the Brigham and Women's Hospital in Boston. "There is a realization that it will be the health care entity [including the physician] that will have to either pay for the hip fracture when someone falls down because she took too much of something, or the stroke if he didn't take enough of something else."

For the past couple decades, the evidence has been clear: Many fewer patients adhere to their physicians' recommendations and comply with their prescription doses and schedules than physicians think. In fact, over the years, studies have found that patient adherence varies widely for short-term treatment programs, with an average adherence of 60%. Adherence with long-term regimens is even poorer, with averages of 50% to 55%. And forget compliance with recommended lifestyle changes, such as exercising or eating a low-fat diet. According to a report in the Journal of the American Medical Association last year, non-compliance rates for lifestyle changes stand at something more like 75%. Rates of non-compliance seem to be the same with younger and older patients, but the consequences are more likely to be serious in the elderly patient, reports state.

Reasons for non-compliance are complicated and varied. Some have to do with a patient's disagreement with the physician's suggestions. Other cases grow out of misunderstandings, poor recollection or sketchy directions. Still others stem from the fact that treatment plans are sometimes too complex or inflexible to actually work within the patient's lifestyle. Or the side effects may be too tough to handle. Or pills may be too small to pick up. Or too large to swallow without difficulty.

Whatever the cause, the new environment of managed care is prompting a new look at the old problem. The reasons:

  • Managed care turns the economic incentives of the traditional American health care system on their head. Now it makes financial sense to keep patients healthy. You lose money when patients come into the office, show up at the emergency room or end up admitted to the hospital for something that could have been avoided if only they had taken their medicine.

"Drugs really are among the most cost-effective things out there, and I sure would rather spend $500 a year on somebody's drug for their hypertension than spend $20,000 on the care of their stroke," said Dr. Avorn, who has been studying issues of compliance using large insurance company databases.

In fact, some health insurance plans and self-insured employers are beginning to find it worth the expense to enroll particular non-compliant patients in private medication monitoring and support programs. According to Ron Dziedziula, vice president of marketing for APREX Corp. of Fremont, Calif., it can cost as much as $800 a year to monitor one patient's compliance with one medication. APREX in January began selling a telemedicine-type service called "Dosing Partners," which provides an enrolled patientwith a "smart cap"-type pill bottle that records how many times the bottle was opened. At day's end, the patient sets the bottle cap-down into a special modem that transmits the compliance information.

"It is expensive, but it may be the expense that saves [a managed care organization] a lot of health care dollars," Mr. Dziedziula said. "We can know when their 72-year-old congestive heart failure patient on Lasix misses his first dose so we can intervene before he misses doses two and three" with potentially expensive consequences.

To convince doctors to look at his firm's compliance aid as an additional tool in their black bags, Mr. Dziedziula reminds physicians that they are "clearly under more scrutiny in the managed care environment." They should know, he said, that the technology now exists, thanks to shared databases of billing and patient record data, for an insurer to be able to rate doctors on what percentage of their patient population complies with prescribed drug regimens.

  • Integrated systems of care require an infrastructure for sharing patient information among all the patient's care providers. Integrated systems, as well, have more of an incentive and an ability to invest in the computers and other forms of information technologies that make tracking and timely intervention possible.

It makes all the difference in the world to be able to improve compliance when physicians, pharmacists and case managers can all work off one database that includes the complete medical history of a patient, said William N. Tindall, PhD, executive director of the Academy of Managed Care Pharmacy.

"What managed care does is put everybody on the same team," he said. Until now, a significant part of the problem with non-compliance could be traced to troubles with communication. Physicians thought pharmacists explained drug regimens; pharmacists thought physicians explained them. "And everybody took for granted that the patient understood," he said. "Health care providers have made the false assumption that taking [his or her] medicine is the top priority in a patient's life."

  • To win in a competitive environment, a company must keep its customers happy. And the hot competition among HMOs for a growing pool of patients is prompting providers to introduce efficiencies into their systems.

"If you throw in on top of the growing number of people [joining HMOs] the fact that some people are having to come back because they just didn't comply in the first place, then you are just limiting your accessibility more," said Daniel M. Witt, PharmD, a clinical pharmacy specialist at Kaiser Permanente in Colorado. "You are taking up time doing things that should have been taken care of the first time."

Kaiser Permanente in Colorado has assigned Dr. Witt and a dozen other pharmacists to work in the medical offices alongside internists and family physicians. "I'm here as a consultant for drug-related programs and as a person who can provide supplemental education to patients," Dr. Witt explained. For example, patients taking the anticoagulant drug Coumadin are followed regularly by a clinical pharmacy specialist working under a protocol set by the physicians. The protocol is designed to make sure patients take their medicines regularly and properly.

"I think the data are pretty clear that a fair number of people are hospitalized every year because they didn't take their medicine and their condition worsened," Dr. Witt said.

  • Pharmaceutical companies are facing their own financial challenges, some of which are prompting them to pay attention as never before to issues of patient compliance and needs of managed care. The goal is to shore up market share for their products and to make money by branching out into the field of pharmacy benefit management.

For example, one of the things that happened after Merck & Co. Inc. bought Medco Containment Services Inc. last year was the creation of a clinical program to make sure geriatric patients take their medicine correctly.

According to Mark H. Beers, FACP, senior director of geriatrics at Merck, the drug company has recently gotten into the business of trying to improve prescribing behaviors of physicians and the drug- taking actions of patients. Pharmacy benefit management companies "began as a mechanism for controlling costs, so they were particularly interested in 'fill too soon,' " he said. "But pharmacy benefit management companies have taken on clinical duties for the very reasons of managed care." As a result, they have gotten interested in things like "fill too late," he explained.

"If you are paying for the pharmacy bills for your employees, you are very interested in reducing your overall health costs, and the pharmacy benefit management group that can say, 'Look, we're doing things to help you reduce overall health care costs' is the one that you'll give your business to," Dr. Beers said. Medco, he said, is now starting to use computer systems to look at drug use for the 9 million retirees it covers, feeding back information about usage and appropriateness to the patients and their doctors.

Says Harvard's Dr. Avorn, "Time will tell whether this is just another clever marketing strategy or a real re-orientation" of the pharmaceutical companies and managed care organizations due to concerns about quality and outcomes and not just costs and profits.

The fact that all these other groups and institutions are looking at issues of patient compliance does not mean that physicians will be let off the hook. In fact, Dr. Avorn said he would like to see managed care organizations' report cards on doctors include information about their patients' compliance rates. "It's my belief that non-compliance often is at least as much the fault of the doctor as it is of the patient, in that we don't do a good job of educating the patient about why they need to take this and how often and what they should do if there are side effects," he said.


Eight easy ways to make the medicine go down

Numerous studies during the past decade have proven that doctors who take the time to talk to their patients about their medicines are likely to have more compliant patients. Researchers, however, have also found that anywhere from 20% to 33% of all patients get no verbal instructions about their prescriptions from their physicians. Between 30% and 80% receive no instructions from pharmacists. Still other studies have concluded that health professionals overestimate how well their own patients comply with drug regimens by as much as 50%.

Experts offer some relatively easy ways internists can try to improve these statistics. Try the following, and remember that combined strategies have been shown to work better than single ones:

  • Target your intervention. Spend your time, energy and ideas on the patients least likely to be able to comply on their own-particularly the elderly who live alone and patients who have to take a lot of drugs or have complex regimens to follow. Consider paying close attention to patients for whom non-compliance might mean a trip to the emergency room or a stay in the hospital.
  • Delegate. Use your office staff. Make arrangements with case workers or with local pharmacists to whom you can refer patients for special education or intervention.
  • Take advantage of technology. There are all sorts of low and high tech compliance tools on the market, including caps that count, electronic pill boxes that beep, unit dose blister packs and private companies that use computers and case managers to promote compliance with particular patients. Insurance companies are sometimes willing to pay for such services if a cost-effectiveness argument can be made.
  • Give patients more information. Studies have found that giving patients information is a necessary, if insufficient, intervention. There are, however, a few ways to improve the chances a patient will hear, understand and buy into a regimen. These include discussing the most important information first, repeating key points, having the patient restate key instructions and asking nurses and pharmacists to repeat instructions. Combine verbal and written explanations. Emphasize the theme that patients have a responsibility for self-care.
  • Refer to support groups. Some managed care organizations have been able to improve compliance among the elderly by recruiting particular patients into support-type groups.
  • Listen. You are looking for clues to the underlying reasons behind their non-compliance. Try to avoid making the act of writing a prescription the signal that the visit is about to end.
  • Make it easy. Prescribe twice-a-day medications whenever possible. Send appointment reminders. Increase the frequency of visits to take advantage of the "white coat effect," which makes patients not want to lie to their doctor when asked if they have been taking their medicine as prescribed.
  • Don't reinvent the wheel. There are many organizations that have thought about this issue. Ask your drug company detailers, pharmacists, local pharmacy colleges, hospital case management staffs and managed care organizations what help they can offer patients having difficulty complying with treatment plans. Also, write for the latest "Directory of Prescription Medicine Information and Education Products, Programs and Services" ($12 postpaid) from the National Council on Patient Information and Education, 666 11th St. NW, Suite 810, Washington, D.C. 20001; 202-347-6711, fax 202- 638-0773.

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