A major challenge facing the American healthcare system today is finding strategies that will help deliver higher quality, lower cost care. Metrics for quality reporting are still being defined but will ultimately need to focus on access, process, and outcomes. Patient adherence to clinician recommendations requires a process that includes effective communication to the patient, a full understanding of patient concerns – such as side effects and costs of treatment – and lastly, careful follow up either with a care coordinator or return visits to the provider. Positive reinforcement of desired performance leads to better adherence, and when patients are compliant, desired outcomes are more likely to follow.
As the focus on achieving clinical outcomes has increased, value-based healthcare reimbursement has also become a growing trend. Rather than basing medical reimbursement solely on volume of activity – such as office visits, procedures, hospitalization, etc. – several payment models are moving toward reimbursement based on outcomes. The evolving value-based healthcare landscape includes arrangements such as Pay For Performance, Quality Incentive Programs, Primary Care Medical Homes, Accountable Care Organizations, Shared Savings, Bundled Payments and Capitation. Many organizations are modeling their outcome measures around the Centers for Medicare & Medicaid Services (CMS) Medicare Share Savings Program biometric measures of hemoglobin A1C, LDL and blood pressure. Pharmacy benefit managers have substantial databases that reflect patients’ adherence with their medications. But can these data be used to predict desirable biometric outcomes?
Validating the Relationship Between Adherence and Biometric Outcomes
Express Scripts recently partnered with the Scarsdale Medical Group (SMG), in Harrison, N.Y., and Gold Health Strategies, Inc. in New York City, to conduct a retrospective analysis of the biometric data (specifically, LDL levels) from Express Scripts members cared for by SMG providers from January 2012 through July 2014. During this time period, there were more than 2,000 members receiving therapy for hyperlipidemia from SMG providers. Of these, 835 qualified for analysis based on eligibility and claims history. Express Scripts pharmacy claims and SMG LDL measurements were matched and de-identified prior to analysis. Adherence was measured by determining the percentage of pills available to each member during the 90 days prior to the most recent LDL measurement. LDL results were extracted from SMG’s NextGen electronic medical records system.
Medication Adherence in 90 Days Prior to LDL Determination
The analysis revealed a nearly linear and statistically significant relationship between higher adherence to LDL therapy and improved LDL biometric outcomes. Members with increasing availability of oral therapy (percentage of pills available) demonstrated improving (lower) LDL values. Only those patients with optimal adherence (80-100% of pills available during the 90 days prior to testing) had an average LDL level below 100 mgm%, which is commonly regarded as the treatment goal for successful hyperlipidemia therapy.
This retrospective study supports the proposition that increased adherence is associated with improved biometric measures and reinforces the importance of programs such as ScreenRx®, Express Scripts’ advanced adherence intervention solution, as well as Scarsdale Medical Group’s high-quality patient care and case management.
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