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Take Your Meds, Please!

When people forget, refuse or can't afford to take prescription drugs as prescribed, the consequences can be grave and expensive -- for patients and employers.

Sunday, October 16, 2011
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What affects millions of Americans, can lead to long-term health risks and costs hundreds of billions of dollars per year annually?

The wars in Iraq and Afghanistan?

Think again.

It's actually a lack of adherence to prescription medications. In fact, non-adherence costs the economy $290 billion per year in avoidable medical expenses, according to the New England Healthcare Institute, a Cambridge, Mass.-based nonprofit health-policy organization.

In addition to the monetary toll, the American Pharmacists Association reports there are 1.5 million preventable adverse events each year because of non-adherence, including injuries and death. If that weren't enough, a report by researchers at Brigham and Women's Hospital in Boston finds 22 percent of patients don't even fill their prescriptions. That number jumps to 28 percent for first-time prescriptions.

With numbers that bleak, companies are doing all they can to help employees adhere to their prescribed medications, especially for chronic conditions. Whether they're offering drugs for free or at reduced prices or working with plan sponsors and pharmacy-benefit managers to remind and educate employees about adherence, experts say, such programs will prevent expensive and dangerous complications in the future and lead to a healthier workforce.

A Carrot/Stick Approach?

On the surface, an employee who's not filling a prescription might initially save his or her employer money, says David Dross, the national practice leader of Mercer's managed pharmacy consulting group in Houston. But costs quickly mount up on the back end.

"Generally speaking, their medical costs are two to three times more because they go to the hospital more frequently, they go to the ER more frequently, their hospitalizations are longer and they have other medical complications," says Dross.

Companies also lose out on productivity, as people who are less compliant are more likely to call in sick.

"Patients are the least compliant with the 'Big Three' conditions: high blood pressure, diabetes and high cholesterol," says Dross.

"It is not unusual at all to see non-compliance [for those conditions] at 50 percent or more," he adds.

Bob Nease, chief scientist at St. Louis-based PBM Express Scripts, says he's surprised at just how non-adherent people are -- especially considering that modern pharmacy options are much more viable and less invasive than in years past. For example, years ago, people with high cholesterol would be forced to see a cardiologist -- now they can just take a statin such as Lipitor and lower their risk of heart attack by as much as 50 percent, says Dross.

"Relative to having your chest cracked open, the fact that you can reduce your risk of heart attack or stroke [by taking a pill] is pretty impressive, yet people do a miserable job taking their medications as prescribed," says Nease. "It's kind of a head-scratcher."

The reasons that people are non-compliant vary greatly. Cost is certainly an issue, as drugs continue climbing in price and people continue struggling to pay their bills. Patient education is also a driver, as people may not know the long-term effects of refusing to follow medication directions correctly. People may also choose not to take drugs because of side-effects, or because it's a preventive drug that doesn't make them feel any better day-to-day.

"They stop taking it because they assume it's not working," says Dross.

Nease cites other reasons: Patients forget to take medicines; people procrastinate when it's time to fill, leaving a gap in coverage; or worse, they're "active decliners" -- patients who simply choose not to take prescribed medications.

"The solutions are totally different for each of those," says Nease. "With multiple causes, there's no silver-bullet solution."

But there certainly are effective tools that companies and health plans can use to fight non-adherence.

Dross suggests a carrot/stick approach -- offering lower co-pays for chronic-care drugs if the employee agrees to participate in a disease-management program.

One employer that subscribes to that theory is Quad Graphics, a printing company in Sussex, Wis., that offers a value-based insurance design (VBID) -- a plan featuring low costs for drugs but higher ones for medical procedures not deemed critical, such as knee replacements.

Dr. Ray Zastrow, chief medical officer at the company (it has its own medical staff and several on-site clinics), says many diabetic employees were not adhering to prescribed medications -- and those slips led to hospitalizations or doctor's visits.

"If they were on top of their game, that wouldn't happen," says Zastrow.

In response, the company developed Well You for Diabetes, a program that offers diabetes prescriptions at no charge (a $640 per-year value) in return for patients enrolling in a disease-management program, agreeing to fill and be adherent to prescription medications and working with a disease-management counselor.

Dross says programs like this "address at least two of the biggest variables around adherence" -- cost and patient education.

If employees are not adherent (perhaps they don't fill their medication by a certain time), they're forced out of the program and will have to pay regular copays for diabetes drugs. Oftentimes, that's when employees realize just how good they had it.

"People come back, tail between legs. 'Can I get back in?' " says Zastrow, noting that people generally get a few chances to show they're serious about fighting the disease.

So far, 50 percent of the company's diabetics are enrolled in Well You for Diabetes, but Zastrow and HR are expanding communication efforts to drive that number higher.

Of that group, average blood sugar has gone down and adherence rates are up for program participants versus non-participants, according to Zastrow.

One company that has been a pioneer in the VBID space is Stamford, Conn.-based Pitney Bowes, which has offered it to employees since 2001.

The company realized that it's cheaper to offer medications for free or at reduced prices than it is to deal with the long-term complications arising from non-adherence later, says Andrew Gold, executive director of global benefits planning at Pitney Bowes.

The company first moved to such a plan because it saw its costs for chronic conditions going up -- particularly for sufferers of diabetes, asthma and high blood pressure, he says.

"If they're not taking [medications], then they're not getting the benefit that the drugs provide -- and, in the long run, we're not saving the cost of long-term health issues," says Gold.

Reducing that cost barrier has led to healthier employees and dependents, less long-term patient costs and more productivity for Pitney Bowes, says Gold.

While Pitney Bowes was among the first to offer a VBID, Gold believes the trend is catching on.

"When we did it, it was very odd," he says. "It has become much more accepted now."

After offering a VBID for 10 years, company leaders have learned plenty. For example, the program alone will not make people adherent. Companies need to enlist their PBMs to help communicate to employees just how important it is to take medications, especially for chronic conditions.

"You have to have targeted outreach from your pharmacy-benefit manager to reach out to people and say, 'It seems like you're not being adherent. Why?' " says Gold, noting that companies should also instruct health plans and PBMs to discuss adherence when patients call them for other reasons.

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Gold also recommends setting up reminders on cell phones, moving people from 30-day fills to 90-day fills and using mail order because "it just shows up" at their house.

While different drugs have different adherence rates, compliance overall has gone up considerably says Gold. For diabetic adherence, for example, the workforce is more than 80-percent compliant, a number it had not reached before starting the program. Asthma adherence also climbed by more than 10 percentage points, while emergency-room visits for the condition have dropped.

Reaching Out to Employees

There are certainly other ways to increase drug adherence. Express Scripts is now piloting predictive-modeling programs that estimate adherence rates for patients up to a year in advance. Analyzing 400 variables, such as claims data, eligibility information, socioeconomic factors and consumer data, the programs are intended to show how adherent people have been and predict how adherent they're likely to be in the future.

Still in the early stages, the company currently has 7 million lives on various adherence pilots, says Nease.

Once companies know the adherence rates, they can use their PBMs, health plans or disease-management vendors to reach out to employees in danger.

In its pilot program of 600,000 patients, Express Scripts tried out some approaches that have had some effect. Of the non-adherent patients in its program, 49 percent forget to take their medications and 21 percent procrastinate refilling them. However, reminders via beeper or phone call increased adherence by 16 percent, while moving patients from retail to mail order drove adherence up 8 percent, says Nease.

But could preventive models such as the one offered by Express Scripts end the need for VBID?

Nease says it's more likely that the two work hand-in-hand. VBID typically removes the cost factor; however, cost is just 15 percent of the problem, says Nease.

"I think we may find a home for VBID for patients for whom cost is really the determining factor of non-adherence," says Nease.

But then there's the other 85 percent.

"The results have not been impressive ... the effects have been more modest than everyone had hoped," says Nease. "When you lower the price [of co-pays and medicines], you get a much smaller movement in demand than when you raise the price. That's because people are really sensitive to losses."

Companies such as Sprint Nextel Corp. aren't changing their plan designs or offering predictive modeling -- but they're still very concerned about drug adherence.

Diabetic employees at the Overland Park, Kan.-based telecommunications company can receive an additional $400 in their health-reimbursement accounts just for adhering to a diabetes disease-management program. While the program is still too new to provide metrics (it's in its first year), Collier Case, director of health and productivity, says it's working for both the company and its employees.

"If you're better at managing your condition, you're going to avoid unnecessary hospitalizations later," says Case. "Particularly with diabetes, the progression of the disease can be really devastating, so managing it early is really the best prevention for a full life."

But other conditions, such as cancer, pregnancy and musculoskeletal disorders, are even more costly for Sprint. For those, the company has Catalyst, its PBM, help employees manage their conditions and stay on top of taking prescriptions.

"Ten days before each prescription is up, there is an outreach call to the individual," says Case. " 'Are you still tolerating the medication? Has your doctor made changes? OK, we'll send out your refill.' "

All told, the company gets a lot out of it. "Medication is oftentimes the most important line of defense in terms of maintaining quality of life -- managing pain, managing mobility, preventing disease from progressing further," he says. "That's allowing those individuals to remain active in the workplace."

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