Though she has been studying treatment adherence for 35 years, Robin DiMatteo, PhD, adherence expert and psychology professor at the University of California-Riverside, says interest in the field has recently exploded.
"Four years ago I mostly spoke to medical groups," she said. "Now it is major health systems, health plans and their CEOs and CMOs.”
In a healthcare environment dominated by chronic diseases and their associated costs it is no wonder that so many organizations are taking interest in affecting patient health behaviors.
The Affordable Care Act (ACA) required Medicare to reduce payments to hospitals with excess readmissions. Hospitals that did not meet the required measures sustained a maximum payment penalty of 1.0 percent in 2013, which will increase to 3.0 percent by 2015. Heart attack and heart failure were among the original diseases targeted, while chronic obstructive pulmonary disease will be added in 2015. Readmissions for all three chronic diseases are highly influenced by patient adherence to medications, attending cardiac or pulmonary rehabilitation, and lifestyle behaviors like smoking.
Additionally, the Accountable Care Cooperative is now tracking 608 active ACOs in the United States. ACOs that minimize per member per month costs through minimized hospital readmissions and lower overall costs of care are entitled to 50 percent to 60 percent of the shared savings they generate under the Medicare models. Because chronic diseases account for three-fourths of healthcare costs, patients’ adherence to prescribed treatments are at the core of these efforts.
Studies show that 20 percent to 30 percent of medication prescriptions are never filled and an average of 50 percent of chronic disease medications are not taken correctly. Patient non-adherence to medication regimens alone has been estimated by the New England Health Institute to drive as much as $284 billion in annual costs. Non-adherence to medical advice for dietary, exercise, smoking and alcohol use have been observed to be significantly higher.
“Patient behavior is a wild card,” DiMatteo said, “and many physicians don’t know much about adherence.”
On November 2, 2011, the Department of Health and Human Services (HHS) issued an interim final rule identifying legal waivers afforded to ACOs. HHS specifically identified patient incentives among the five types of waivers. The intent of this patient incentive waiver is to help ACOs foster patient engagement and improve quality and lower costs for Medicare by removing any perceived obstacles from the Beneficiary Inducements Civil Monetary Penalty and the Federal anti-kickback statute.
While incentivizing patients to adopt (or stop) a behavior may appear to be the simplest solution to improving adherence, DiMatteo said that a behavior can usually only be jump-started with incentives if the patient is already engaged. Incentives alone may not be effective or may cost too much over time. Also, the target behavior may stop (or start) as soon as the incentives cease.
There are fundamental prerequisites that must be achieved before an adherence intervention is attempted in a clinical setting.
"Patients only adhere if they understand and remember the treatment," she said. "The real product of a medical office visit is well thought out advice. However, 25 to 50 percent of information conveyed during an office visit is getting lost.”
Institutionally, basic health literacy can be addressed by providing visit documentation in layman's terms, using pictograms, emphasizing and reinforcing the information, and conducting follow-up calls to verify understanding is achieved. Institutions can support their primary care physicians by developing these collateral materials and systems to foster patient understanding and retention.
After basic health literacy, patient beliefs are the second prerequisite for treatment adherence. Patients have to believe (1) the seriousness of their illness, (2) the treatment will work, (3) the benefits outweigh the costs, and (4) that they have confidence in their ability to adhere to the treatment. Sophisticated adherence interventions and technologies are wasted if patient engagement is not attained first.
Nurse call centers are a standard business model for care (case) management services offered by health plans, as well as chronic disease management companies and health systems. DiMatteo believes telephonic interventions can be very effective as long as good signal reception is available.
DiMatteo has observed thousands of patient-physician interactions and found that computer-based adherence technologies can be a good adjunct, but require serious consideration in selection and testing of outcomes. Vendor claims about adherence improvement rates should be analyzed closely.
Treatment adherence is a complex, multifaceted issue. There is no single, simple solution. Thoughtful design, specialized training and cultural acceptance are necessary to successfully implement treatment adherence assessments and interventions in practice.