If there's one thing that doctors, pharmacists, health plans and drug companies all agree on, it's that the health system needs to do more to keep patients compliant on their prescribed medications particularly those that prevent serious and expensive health complications of chronic illness.

We know that when patients are compliant with their medications for cholesterol, diabetes and hypertension, their health status improves and overall medical costs are lower. During the Academy of Managed Care Pharmacy Conference this week, however, it became clear that our health system hasn't yet broadly organized itself to achieve the goal even in the Medicare Advantage arena, where plans star quality bonuses depend in part on members apparent compliance with statin, oral diabetes and hypertension prescriptions.

The evidence shows there's no magic bullet: value-based formularies can lower copays for the most high-value medications, health plans can send informational mailings, health plans can fax alerts to fill the waste-baskets at physicians offices, vendors can make robo-calls offering Medication Therapy Management, and pill bottles can be equipped with reminder-beepers. And the evidence shows each of these efforts can and do  have some effect.

Still, on average, prescriptions written in the US have about a 50 percent chance of having a first fill, and compliance with chronic medications even the inexpensive ones remains frustratingly low.

Here's the problem, as described bluntly by one academic at the conference: physicians say they don't have time to monitor and follow up with whether Mrs. Smith ever filled her statin prescription, much less track whether she refilled it a month later. Many don't like the idea of having their reimbursement tied to their patients compliance or non-compliance. Pharmacists are not equipped or paid to monitor compliance or to make sure Mrs. Smith understands the importance of taking her statin daily. Health plans most of which still take a passive care management role  generally don't know when a drug is prescribed until after it is filled and picked up. And they don't track whether Mrs. Smith is getting refills on time.

Newly mandated Medication Therapy Management for some Medicare Advantage members has had limited success: many plans continue to take a passive approach to inviting members to participate in MTM.

But several plans are creating better mechanisms to monitor compliance, identify the need for patient intervention, and coordinate effective intervention that changes patient behavior. CareFirst BlueCross BlueShield in Maryland, through its patient-centered medical home initiative, is using stratification techniques and plan-paid care coordinators to track compliance of patients at high-risk and medium risk of becoming ill due to medication non-compliance. It has instituted higher payments for PCPs and incentives for outcomes, paying clinicians and giving them the data and other support needed to facilitate ongoing care management. They've engaged local pharmacists to do in-person medication therapy management with members. Importantly, CareFirst is not doing this as a pilot or with a segment of its membership, but across its commercial membership.

But this innovation isn't limited to regional colossi such as CareFirst. Cigna and Aetna are building ACOs and ACO-style coordination with key provider groups in key markets to enable a greater degree of clinical integration for their members. They're also using risk stratification, rewarding PCPs for care management and quality, and they're paying care coordinators who will close the loop between the prescriber and the patient.

Innovation also extends to vendors who have developed sophisticated systems of stratifying patients need for pharmacy intervention by using demographic data, pharmacy claims data and clinical data to make sure intervention can happen before patients health deteriorates.

But the question occasionally comes up: what about those patients who, for whatever reason, just cannot or will not take their meds How long before these individuals  statistically more likely to be poor, under-educated and even cognitively impaired  become a segment to be avoided by physicians, hospitals and plans. Is it really fair, one AMCP panelist asked, for providers and plans to lose money on these people.

Fair or not, CMS has made plans responsible through the Medicare Advantage star program, and the economics of healthcare reform is making plans responsible on the commercial side as well. The smartest of the plans are taking that responsibility seriously.

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