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Medicine, Exercise and the Importance of Patient Adherence

July 18, 2014
12:41 pm

(This month, the Healthcare Leadership Council sponsored a Capitol Hill briefing on the importance of patient adherence in improving the quality and cost-effectiveness of healthcare.  The briefing featured expert perspectives from inVentiv Health, Novartis, SCAN Health Plan and Walgreens.  We were pleased to see commentary about this briefing on the “Be Active Your Way” blog sponsored by the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health promotion.  The blog post is reprinted below.)

On Monday, July 14th, the Healthcare Leadership Council hosted an excellent briefing on non-adherence to medication, highlighting the fact that 1 out of 3 patients never fill their prescriptions, and nearly 3 out of 4 Americans don’t take their medications as directed.

The panelists discussed innovative strategies for improving adherence, such as targeted and timely communication. Each strategy was based on the reality that a one-size-fits-all approach to communication is both inefficient and ineffective. Clearly, the digital age is creating medical providers with new opportunities for engaging patients and tracking their adherence, but there are no simple solutions for getting folks to take their medicine.

The problem of non-adherence to medication raises an uncomfortable question for physical activity advocates.

If 1/3 of patients are signaling that a visit to the pharmacy is a barrier too high to overcome, and 75% are finding it too difficult to take medication properly, how many patients can we reasonably expect to fill an exercise prescription that typically requires 150 minutes/week of exertion?

Although evidence suggests that patients are more likely to exercise if their doctors prescribe exercise, we suspect very few patients will stick to an exercise program unless medical offices and physical activity providers (e.g. health clubs, personal trainers, community centers) adopt engagement strategies similar to those being implemented by the pharmaceutical industry for medication adherence.

At Novartis, for example, a comprehensive study of patients revealed 4 clusters of patients, each with a distinct set of compliance barriers: “Strugglers,” who seem overwhelmed by the medical condition and necessary medications; “Skeptics,” who view medication as a last resort; “A-Students,” who are fully engaged with their health care and likely to adhere to their prescription; and “Independents” who are likely to adhere but not be consumed with their health issues.

Understanding the four clusters helps Novartis create targeted adherence plans for each patient. The plans include customized messaging, 6 months of support, 3 or 4 email and text messages per week, an interactive website, real-time messaging support, and more.

Can this level of engagement be accomplished by a fitness center? Absolutely. And I know there are some pioneering clubs already on this path and achieving great results. But effective engagement does not happen overnight. It clearly requires an investment of time and resources, both of which are in short supply at most fitness centers.

So let’s make sure we support the great work of the Exercise Is Medicine initiative and champions of the “exercise prescription” movement like Dr. Eddie Phillips and Dr. Bob Sallis, by making sure that fitness facilities are prepared to help patients adhere to those prescriptions.

What do others think? How can we help patients adhere to exercise prescriptions? Do you work at a fitness center with a great member orientation program? Perhaps you work for a software company developing tracking systems for medical fitness providers? We’d love to hear from you.

A Case for Retiring America’s Worst Four-Word Phrase

July 07, 2014
2:44 pm

As summer heats up, so will the mid-year congressional campaigns.  When they do, we can unfortunately expect to hear more of the dreary rhetoric that arises every time Medicare comes up for discussion.  Candidate X will support changes to strengthen Medicare and improve its financial sustainability.  Candidate Y will respond by charging that Candidate X wants to do away with Medicare “as we know it.”

Even though the “as we know it” accusation was dubbed the Lie of the Year in 2011 by the PolitiFact fact-checking service, politicians continue to use it freely to score points against adversaries who propose any sort of change to the status quo.

A column in today’s New York Times – no bastion of conservatism by any measure – makes a strong case that it’s time to retire this four-word phrase for good.

Health economist Austin Frakt writes that enrollment in Medicare Advantage plans, operated by private health insurers, is increasing significantly, even after the federal cuts to Medicare Advantage plans that were part of the Affordable Care Act.  Today, approximately three of every ten Medicare beneficiaries are enrolled in one of these private plans and current trend lines tell us that proportion will continue to increase.

Frakt speculates that a reason for this growth is the comfort baby boomer beneficiaries have with private plans, having been enrolled in them throughout their working years.  He writes, “…baby boomers, who are just entering Medicare-eligibility age, are more accustomed to the types of insurance Medicare Advantage offers, such as H.M.O.s, than their predecessors were. Newly retired Americans have probably been enrolled in similar, employer-based plans for years if not decades — perhaps by the very same companies that offer Medicare Advantage plans — making it a relatively easy choice to enroll in such a plan for Medicare coverage.”

At the Healthcare Leadership Council, we have commissioned focus groups of middle-aged and older Americans to discuss their perspectives on Medicare.  Our findings closely mirror Frakt’s column.  We have found that Americans in their 40s and 50s are not at all averse to choosing between private plans for their Medicare coverage, and even seniors are adapting well to consumer choice after having experienced it for a decade now in the Medicare Part D prescription drug program.

We also found that, when assessing various options to address Medicare’s financial challenges, middle-aged and older Americans would rather use private sector competition as a tool to contain costs than see deeper cuts to physician and hospital reimbursements.

So when political candidates talk about fighting for Medicare “as we know it,” this phrase rings increasingly hollow.  Millions of beneficiaries are already rejecting the idea of an inflexible Medicare status quo and are gravitating to privately-run plans.  Perhaps it’s time for politicians to follow where the people are already leading.

The Medicaid Standoff and the Need for Flexibility

July 02, 2014
11:55 am

The White House’s Council of Economic Advisors released a report this week that is clearly intended to intensify the pressure on the 24 states that have, thus far, refused to expand their Medicaid programs, as provided for under the Affordable Care Act.  As we recall, the U.S. Supreme Court ruled that the federal government cannot compel states to go along with the Medicaid eligibility expansion and many, predominantly with Republican governors and/or legislatures, have elected to pass.

In its report, the White House’s economic advisors make the point that almost 5.7 million more Americans will have health coverage in 2016 if these currently non-compliant states embrace expansion.

We’ve made clear in this space the Healthcare Leadership Council’s view that Medicaid is not the best option for reducing America’s uninsured rolls.  Medicaid’s reimbursement rates for doctors and hospitals, significantly lower than private insurance and even Medicare, underscore the point that coverage does not necessarily equal access.  Nonetheless, less-than-ideal coverage is better than no coverage for the millions of Americans who need healthcare but can’t afford to pay the providers who are delivering that care.

But, while it’s easy to blame states for not getting on board, the Administration needs to recognize its own responsibilities in this area.

It is fortuitous timing that the White House report was released in the same week that the state of Indiana submitted its proposal to the Department of Health and Human Services for an expansion of its Healthy Indiana program as an alternative to enlarging traditional Medicaid.  As Indiana governor Mike Pence wrote in an op-ed, Healthy Indiana 2.0 is a better fit for the sensibilities of his state in that in that enrollees can take greater control of their own healthcare decisions through contributions to private accounts that are not unlike health savings accounts.

As he put it, “As national leaders in healthcare innovation, Hoosiers understand empowering people to take greater ownership of their healthcare choices is better than government-driven healthcare.”  Pence backed up his rhetoric with metrics showing that Healthy Indiana participants use preventive health services at a high rate while making less use of expensive emergency room care.

The Indiana case, as well as the movement toward innovative Medicaid plans in Iowa, Arkansas and other states, emphasizes the argument that flexibility is critical in bringing Medicaid expansion to all 50 states.  It’s simply a political reality that many states with conservative-leaning leaders do not like ‘Obamacare,’ don’t necessarily trust the federal government to keep its promises in regard to financial support for Medicaid expansion and are not going to change their current programs.

On the other hand, granting flexibility to make better use of private health plans and to incorporate patient engagement and responsibility can help resolve a situation in which we’re essentially two separate nations when it comes to Medicaid.  HHS approving the Indiana proposal would be an excellent step in this necessary direction.

Determined to Despair

June 17, 2014
4:18 pm

If you’re following health news this week, the predominant message you’re getting is that the United States health system is in exceedingly bad shape, at least compared to other prosperous nations around the world.  The left-leaning Commonwealth Fund released one of its periodic reports telling us that the U.S. ranks last in healthcare quality, access and other selected categories compared to ten other developed nations including Canada and the United Kingdom.

The report has received broad visibility from media outlets, most of which have reported the Commonwealth findings as presented without challenging or even questioning the report’s methodology.  Thus, we’re left with the understanding that healthcare in the United States is far inferior to those nations with systems in which government plays a much stronger role.

There are some, though, who have closely reviewed Commonwealth’s work and are saying the situation for the United States is not as relentlessly grim as the Fund is telling us.

Philip Klein in the Washington Examiner writes that the Commonwealth report is “rigged” to favor countries with government-run universal healthcare system, noting that the study gives high priority to “equity” while leaving out consideration of medical innovation.

He wrote, “It’s an ideological decision to view equity as one of the most important factors in judging a health care system, just as it is for the study to leave out a factor such as medical innovation, which would work to the advantage of the U.S., or choice, which would work against the centralized NHS (the U.K.’s National Health Service).”  Klein also writes that the U.S. ranks ahead of the U.K. in five-year survival rates for 22 of the 23 types of cancer, another success story in this country that didn’t find its way into the Commonwealth Fund methodology.

And Avik Roy, opinion editor for Forbes, wrote in National Review that the Commonwealth study relies not on hard data, but rather subjective surveys.  He wrote, “While it is interesting to look at such surveys, it is simply not serious to draw hard conclusions from them.  U.S. consumer culture is famously more demanding than that of other developed countries; while Americans still defer to their doctors and pharmacists, they do so appreciably less than Europeans do.  They are more likely to suspect error, and far more likely to sue if they believe an error has been made.  An international poll that does not even attempt to normalize for these cultural differences is not informative.”

Thus, Roy notes, Commonwealth gives the United Kingdom higher marks than the United States on timeliness of care even though the U.K. is notoriously poor in this department and certainly well below the U.S., where waiting times for care are significantly less than those in other countries.

There is no question that there is significant room for improvement in the U.S. healthcare system, and those involved in all sectors of healthcare are working every day to achieve higher standards.  The Commonwealth report, though, paints a darker picture than is justified by reality.

Research and Healthcare’s Cost-Quality Challenge

June 10, 2014
1:36 pm

The Healthcare Leadership Council has long maintained that the nation can’t make its way toward a high-quality, cost-effective, sustainable healthcare system simply through arbitrary cuts in healthcare expenditures and controlling prices through government fiat.  The importance of targeted research to better understand how to improve the efficacy of healthcare delivery and achieve a higher level of population health can’t be overstated.

That’s why we’re keeping a close eye on the comparative effective research being undertaken by the Patient-Centered Outcomes Research Institute.  An important tool in this observation is the annual survey of healthcare stakeholders conducted by the National Pharmaceutical Council (NPC) health policy research organization.  NPC has just released the results of its fourth annual survey of insurers, government leaders, employers and others who have a strong interest in the progress of comparative effectiveness research.  Some of the facets of the survey we found most interesting include:

•    A large majority – 84 percent – feel this research has had very little impact on healthcare decisionmaking over the past year, but are confident it will have a greater effect in the next three to five years.

•    Stakeholders see a public-private partnership in the way healthcare research is conducted.  According to the survey, they believe academia and the pharmaceutical industry will conduct most of the actual research in the years to come, but PCORI and the National Institutes of Health will be the leading players in funding and monitoring research.

•    More stakeholders are saying that research priorities are adequately addressing the real-world choices faced by patients and providers – 37 percent now, up from 22 percent last year.

We believe comparative effectiveness research can be a valuable tool, if it is used to provide the different sectors of the healthcare community with the kind of information that can improve clinical effectiveness for all patients and healthcare consumers.  The NPC survey provides an important measuring stick on this evolving linkage between data and healthcare practice.