Choosing which college to attend is a huge decision for students. Whether they’ve earned their associate’s degrees from community colleges and ready to move on to earn their bachelor’s degrees, or currently enrolled in four-year schools that aren’t the right fit, one-third of all students transfer at least once before earning a degree.
Aimee Viggiani, associate director of transfer admissions, was recently featured in two articles which provide helpful tips for transfer students. She said, "All too often, students wait until too late in their college careers to ask why a certain class didn't transfer. Even if you don't need the credit right away, you may need it in the future. So ask transfer credit questions as soon as possible."
Over the past several months, we’ve delved into two separate yet very important aspects of healthcare and pharmacy practice. We have followed the birthing pains of President Obama’s signature legislation some weeks while discussing the importance of medication adherence other weeks. We will now discuss how these two seemingly isolated realms of healthcare are indeed intertwined.
The goal of the Affordable Care Act (ACA) is to improve the well-being of American citizens, rein in costs associated with healthcare in our country, and provide health insurance to those that could otherwise not afford it. As a future pharmacist, I will focus on the goal I perceive to be most important to my chosen profession: improving the well-being of my fellow Americans.
As we’ve discussed in previous posts, medication adherence is paramount in the constant battle to improve patient care. In the past, topics such as technology and techniques to monitor patients were assessed in Mission Impossible: How to tell if your patients are taking their medications; as well as why patients don’t take their medications in Why Don’t You Take Your Medication? in Part I and Part II installments. While it is the responsibility and duty of us as pharmacists to make sure that patients are taking their medications as directed, Uncle Sam has taken matters into his own hands by passing legislation to encourage health care professionals to improve outcomes.
Why has Washington taken such an interest in medication adherence? The reality is that medication non-adherence is estimated to cost $290 billion per year in additional healthcare costs. With almost 13% of the total yearly expenditure in healthcare being spent on preventable diseases and procedures, law makers and healthcare professionals alike see an opportunity to make medicine more affordable to the American patient.
The ACA has multiple provisions aimed at improving patient outcomes. Under the ACA and Medicaid expansion, hospital re-admission for certain conditions will result in penalties to the institution. With the real threat of not being compensated for services provided to re-admitted patients, hospitals across the country are revising procedures and doing their best to increase medication adherence and lower re-admission rates. As pharmacists, we will have a pivotal role in this revision of policy.
Along the same lines as re-admission rates, hospitals will now be subjected to quality assurance measures to hold them accountable. The Pharmacy Quality Alliance (PQA) is a non-profit organization that has developed measures related to medication use; PQA has adopted ten such measures that will cover a range of services, including medication adherence. In addition to such assurance measures, there is something known as Medicare Advantage “Star” ratings that will provide financial incentives to plans in the Medication Advantage (MA) program. In the Star Ratings system, medication adherence is weighted HEAVILY because of its importance (medication adherence accounts for 11% of the total star score). This “Star” rating system has the opportunity to influence the care of over 12 million Medicare beneficiaries.
Three models being experimented with now are patient-centered medical homes, accountable care organizations (ACOs), and episode-based payments. These models are intended to lower health care costs and improve the overall quality of care being distributed to patients. And as is the case with hospitals, they will be evaluated on measures established by the ACA. ACOs for example will be assessed by the same kind of quality assurance measures as previously discussed. And as discussed before, medication adherence is a number one priority in those measures with 20 of the 33 measures relating directly to medication adherence.
When we discussed in previous posts why patients don’t take their medications, cost was a major factor. An important aspect of the ACA is to lower costs that would deter a patient from seeking care or filling a potentially life-saving prescription at a pharmacy counter. A portion of the ACA that doesn’t get much publicity is that it has a provision that impacts Medicare and Medicaid benefits. Under the new healthcare law, the threatening “doughnut hole” has been closed. This effort to close the gap in Medicare coverage is estimated to save beneficiaries $3.4 billion in prescription drug costs which comes out to $837 per person, per year. This is no small amount of money and could indeed encourage people to get that necessary prescription filled. When the decision for a retired individual on a fixed income to choose between their groceries or medicine is no longer necessary, everybody wins.
While this is an exciting time for healthcare, we as pharmacists are entering a brave new world. As I’ve discussed, the ACA calls for many changes in the way healthcare will be administered with an emphasis on medication adherence; and with pharmacists being the medication experts, we will be expected to lead the charge in making many of these changes a reality. This presents our profession of choice with an opportunity to not only create value as health care professionals, but also put our foot in the door and establish ourselves as vital cogs in the 21st century healthcare machine. At this time the ACA does not establish a system by which we as pharmacists will be compensated for our increased duties and responsibilities which is obviously not a desirable situation. But don’t be discouraged. We as pharmacists should take this opportunity to not only elevate the prestige of our profession, but also establish value that will positively impact the way we are compensated in the future. Pharmacists are no longer ‘pill counters.’ We are well respected experts in a vital facet of medicine and it is time we are recognized as such. As Horace so eloquently put it: Carpe diem!
Mackenzie F. Blair, PharmD '15
Stephen Metraux, PhD, associate professor of health policy and public health, has done extensive research on homelessness and housing,as well as other aspects of urban health. He is also working with the U.S. Department of Veterans Affairs as part of their commitment to ending homelessness among veterans by 2015.
With the recent streak of bone-chilling weather, Dr. Metraux weighed in on how this weather impacts Philadelphia's homeless community. Here's what he had to say:
If you were fortunate enough to be somewhere warm during this recent cold snap, you may have been wondering what happens to those who do not have access to warm shelter. In particular, how do people who are homeless and subsisting on the streets go about surviving in this cold?
Data on how many homeless are stuck out in the cold are difficult to come by. The homeless population is notoriously challenging to count, as they usually strive to stay inconspicuous amidst the public spaces to which they are relegated. The best available number comes from the City of Philadelphia’s annual “Point in Time” count, when teams of volunteers canvass the shelters and the streets and count the homeless people and families that they encounter. Of the 5,625 homeless persons counted on a January night in 2012, 526 (9%) were unsheltered.
So how do these 526 persons survive the elements on nights like those we have recently had? The first line of defense is provided by the City of Philadelphia, who implement a “Code Blue” on any night when “real feel” temperatures fall under or around 20 degrees. On Code Blue nights, outreach workers and police can bring any homeless person in to stay in a shelter or other public facility temporarily designated for overnight accommodations. No one gets turned away and, if necessary, a Court Ordered Transportation to Shelter (COTS) can be quickly obtained to bring resistant persons indoors on occasions when leaving a person outdoors may subject him or her to danger from the elements.
Code Blue’s success is best indicated by the rarity of hypothermia deaths among homeless persons in the past few years. But Code Blue is at best a stopgap solution. The best solution for protecting the homeless from the elements is through renewed efforts to reduce homelessness. The number of street homeless in Philadelphia have been declining over the previous few years, due largely to innovative programs to engage the most recalcitrant homeless persons and provide them with housing and services. The more this continues, the less we need to worry about homeless persons on nights like these.
The rollout has been a bumpy ride to say the least. The website still has its glitches, and the problems are being labeled President Obama’s Hurricane Katrina by many political pundits. In this week’s entry we will try to separate fact from fiction and take an objective view at the law and where we go from here.
The October enrollment numbers were only 20% of predicted targets. More than 106,000 people enrolled, but only 27,000 of those did so by way of the federal website; the vast majority of those that enrolled utilized the state ran exchanges. To put the 106,000 person total in perspective, this is only 1.5% of the anticipated enrollee total at the end of the 2014 period. To bring things closer to home with regards to our local states, Maryland had 1,700 enroll while Pennsylvania enrolled 2,207. These totals are considered low across the board but enrollment numbers seem to be improving with the November enrollment period now concluded.
While these numbers are disconcerting, optimists and supporters of the law stress for us to look at the precedent set by Massachusetts’s model in 2007. The Affordable Care Act relies on young and healthy people (those under 35 years of age) to enroll to offset the cost of those that are older and more prone to illness. If the trends seen in the MA plan stay consistent, these healthy individuals will procrastinate until the last possible second (March 31st deadline) to enroll so as to avoid the financial penalties. Jonathan Gruber, an architect of the Massachusetts plan, advisor to the President on the implementation of the federal system, and proponent of the individual mandate, stresses us to ‘be patient.’
In contrast to the multitude of issues encountered by those enrolling through the federal website, the poster boy for the state ran exchanges appears to have gotten it right. Kentucky enrolled approximately 15,000 people only 21 days after the exchanges opened on October 1st. Governor Steve Beshear heralds their website a success and claims that close to 1,000 Kentuckians enroll every day. The success of Kynect.Ky.gov highlights the advantages of a state-ran exchange and provides a framework for the federal program to glean vital information to ensure its own success.
With the November 30th deadline now past, reports are coming in that healthcare.gov is indeed improved over the debacle that was the October 1st launch, but it is not yet perfect. Concerns are that the very people the ACA relies upon for its success, the young and tech savvy generation, will be turned away if the website does not meet their expectations. This fear has increased the urgency to get the portal working as smoothly as possible, as soon as possible.
As with most laws, the Affordable Care Act is not a perfect law. It has its opponents and it has its obvious flaws. But instead of throwing in the towel, I’d like to see our nation’s leaders work together and find solutions to this law’s problems. Millions of Americans don’t have adequate health insurance and this law was intended to help those people, and those people still need health care now.
Mackenzie F. Blair, PharmD ’15 Candidate
In our previous blog, we delved into how fear and confusion can negatively impact medication adherence. Now we will examine how health beliefs and finances can influence patients and a service we as pharmacists can provide to improve outcomes.
Health Beliefs. A difficult barrier pharmacists must overcome to improve adherence is the health beliefs our patients have towards medications, their disease states, and health care in general. A study examined how health beliefs impacted medication adherence in patients being treated for HIV/AIDs and discovered that those patients who were asymptomatic were more likely to be non-adherent, while those who experienced negative effects from their disease were more likely to be adherent to avoid such negative effects. Pharmacists must stress that even if a patients are feeling well and does not physically feel sick, they must continue to take their medications. This challenge arises with disease states like hypertension or mental illness where the person may feel fine after taking their medication for a while and then discontinue there medications thinking that they are now cured.
Financial Constraints. An estimated 14 million Americans with chronic medical conditions cannot afford their medications. Doctors may not consider the price of a drug when prescribing and as pharmacists, we are at the point of care when a patient must make the difficult decision to pay for this month’s supply of medication or food for their family. Pharmacists must take due diligence to discover whether their patients are adherent as result of financial hardship. It can be a difficult subject to approach, but there are some questions that can be asked to indirectly ascertain this information; examples of such questions include: “Are there circumstances that make it difficult to fill your prescriptions?" or "Are you testing blood glucose less often because you're trying to conserve supplies?" If it is discovered that a patient cannot afford their prescriptions, we as pharmacists could contact the prescribing physician and request a generic alternative or contact the pharmaceutical company for possible discount/assistance programs. Medication adherence is a significant barrier to achieving positive therapeutic outcomes in our patients, but there is a tool that has been developed over the last several years that will make the task of overcoming these barriers much more attainable.
Medication therapy management (MTM) was developed in response to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. MTM provides pharmacists the unique opportunity to be the ‘medication expert’ and improve patient adherence, and thus outcomes. With pharmacists now becoming more integral in the health care team, and being able to interact with patents in a more prominent role, we are now in a great position to correct the factors that interfere with a patient being adherent. By using tools like the interview a pharmacist can glean valuable information from their patient and make adjustments when necessary before the patient is potentially harmed. Communication and information gathering are valuable in improving overall outcomes and MTM gives pharmacists the necessary means to not only communicate but do something about it.
It is our role as pharmacists to communicate, educate, and in turn ensure that our patients take their medications as prescribed. We’ve discussed why a patient might not take their medications and how to counter such obstacles to adherence as well as the ever evolving role of MTM in healthcare.
Mackenzie F. Blair, PharmD ‘15
It is a question that thousands of pharmacists and health care professionals ask their patients on an almost constant basis; but many times this inquiry falls on deaf ears and the patient remains noncompliant. It is a frustrating reality that approximately 50% of patients are non-adherent to their medication regimens. It is common knowledge that these patients can’t achieve their therapeutic goals if they don’t take their medications as prescribed and adherence is the key mediator between medical practice and patient outcomes. As pharmacists, we should take a closer look at WHY our patients don’t take their medications, and what we can do about it.
Fear: While modern medicine can save lives and cure disease, the fears many have towards medications can prevent these people from being helped. Fear is a powerful influencer and it can manifest itself in many ways. A patient could be afraid of a startling side effect, the risk of drug addiction, fear of needles, or even the negative stigma that taking a medication has in society as is the case for drugs associated with mental illnesses. Culture can even have an impact if the prescribed medicine is in contradiction to the patient’s religious beliefs.. As pharmacists, it is important for us to interact with patients and assess their attitude towards their therapeutic plan. It is vital to identify fears they may have and help alleviate their anxiety or hesitation. For example, if a patient is frightened of a rare side effect, framing the risk of developing the side effect with real data may reduce the fear. If the patient has a phobia of needles it might be possible to alter the therapy so that injections or needles can be avoided. While it is unrealistic that we can calm all the fears patients may have, it is possible that with proper communication and education, many of these fears can be minimized.
Confusion and poor health literacy: "Take two tablets by mouth twice daily." To a trained pharmacist or student like myself, those instructions appear clear and concise, yet a study revealed that nearly half of all people who read them misunderstood them. And with 81% of older adults taking one medication with 29% of them using five or more prescription medications, confusion can easily arise from multiple drug regimens and multiple disease states. It is the pharmacist’s responsibility to limit confusion as much as possible. This can be achieved by writing simple instructions on prescription labels and communicating with the patient in a counseling session. Nothing should be assumed and every aspect of the medication should be addressed with the patient. It should be stressed to the patient that there is no such thing as a stupid question. It is a fact that a poor patient-pharmacist/physician relationship hurts the chances of patients actually taking their medicine as prescribed.
Fear and confusion are only a few of the barriers that pharmacists encounter when trying to improve medication adherence. In the next blog we will examine and discuss health beliefs as a barrier to medication adherence and what we as pharmacists can do to improve outcomes.
Mackenzie F. Blair, PharmD ‘15
By Dr. Daniel A. Hussar, the Remington Professor of Pharmacy at University of the Sciences' Philadelphia College of Pharmacy. He serves as the author and editor of The Pharmacist Activist newsletter (http://www.pharmacistactivist.com) from which this editorial was taken.
The "old" health care system had serious deficiencies. Almost every participant (e.g., pharmaceutical companies, hospitals, physicians, pharmacists) could determine the prices to be charged for products and services and expect to be compensated in the amounts requested. However, there were valid questions as to whether this health-care model was financially sustainable. In addition, there was little or no attention given to assessing the quality of health care provided and the outcomes for patients.
The "new" health care system (i.e., the Affordable Care Act [Obamacare]) that is being implemented has serious deficiencies. The health-care providers who provide services, care, and products for patients have little participation or influence in the determination of the scope and terms of the program or the compensation they will be provided. Instead, government agencies, insurance companies, and organizations such as pharmacy benefit managers are making these decisions. The scope and services of the new system raise valid questions as to whether this health-care model is financially sustainable. In addition, there is inadequate attention given to assuring the quality of health care provided and the outcomes for patients.
The old and new systems are markedly different, yet many of the questions and concerns are very similar. Is progress really being made or have we just replaced one set of problems with other problems of equal or greater importance? I do not defend or advocate the return of the old system. However, the new system is seriously flawed and will collapse as a consequence of the problems and concerns with which it is burdened unless major changes are made. We can and must do better!
Continuing concerns: The current problems that individuals have encountered in attempting to learn more about the health-care benefit options and to choose a particular type of coverage are just the latest of a long series of concerns regarding the parameters and implementation of Obamacare. Indeed, the secrecy surrounding the development and approval of the legislation that has enabled the changes in the health care system was an early indicator of the problems ahead (Please see my editorial, "Health Care Reform - Let's Start Over and Do It Right!" in the January 2010 issue of The Pharmacist Activist).
The current problems have, however, greatly increased the awareness of the public of the challenges that exist. These challenges include, but are not limited to, employers reducing the number of full-time positions and increasing the number of part-time positions; decisions of employers to change health benefit programs for employees and retirees; insurance companies canceling policies; the President making changes in the terms and implementation of the program without accompanying legislative authority; whether individuals can continue to use the same physicians and pharmacies; other terms of the health coverage options; access to needed information using the online network; and the cost of the coverage options.
Positives of Obamacare: The sharp differences of opinion that exist regarding certain provisions of Obamacare have polarized discussions and precluded consideration of areas of agreement and constructive change. I would identify the following as components of the legislation for which I feel there is strong support:
Is compromise possible?: To date, it has not been possible to reconcile the two markedly different positions regarding Obamacare. Advocates extol the benefits and claim the authority of the legislation that established it. Opponents have such strong concerns that they strive to defund the program and/or repeal the legislation. There is seemingly no hope for compromise. However, this impasse is a "lose-lose" situation for both advocates and opponents, Democrats and Republicans.
Advocates for Obamacare have the position of strength and some feel there is no need for any compromise. But hardly a day goes by without an announcement that a large employer is making substantial changes in its health-care benefits or that an insurance company is canceling thousands of policies. Does anyone really think that these changes will be of greater benefit for employees and/or individual policy holders? Of course not! The employers and insurance companies are making these changes to protect their own interests.
The implementation of the early phases of Obamacare has revealed serious conceptual and operational flaws and limitations. And consumers are not yet even close to learning the options regarding health care providers and services and the cost of the insurance coverage. In my opinion, there will be additional problems that will be worse than the ones that are recognized now. The problems and challenges may be of a magnitude that the program will fail. Advocates for the program must be willing to compromise.
Opponents of Obamacare must also be willing to compromise. Their criticisms of the program have not been accompanied by suggested revisions or recommendations of viable alternatives. Their position would maintain the present system, and that should no longer be considered acceptable. There is an important need for progressive changes in the provision of health care services and insurance, and compromise will be essential for the attainment of this goal.
I would like to think that there are legislators who have the personal character to rise above partisan politics and provide bipartisan leadership for the Congress and Administration in forging a compromise on these issues. To not do so risks the failure of Obamacare and the possible development of alternative health care systems and insurance coverage that are even more problematic and divisive.
Where are the health care providers?: Health care services and insurance coverage for such are of the greatest importance for the recipients of these services. But these issues are also of great importance for the providers of health care services (e.g., pharmacists, physicians, nurses). To what extent have health care providers and our professional organizations been involved in the development and implementation of Obamacare, as well as active participants in the discussion/debate regarding the benefits and deficiencies of the program? Our involvement and influence have been limited at best. Some would suggest nonexistent or ineffective.
Our organizations of health professionals must do more! We are in the best position to identify the parameters of a program that would assure the effectiveness, safety, and quality of health care. We can work effectively with those with administrative and financial expertise in developing those components of the program. However, experience has demonstrated that when health professionals are not involved and/or effective in the development of health care benefit programs, important decisions are made by others and we must cope with the consequences.
If the current impasse among our legislators continues and a compromise is not reached, there could be an even greater opportunity for our organizations of health professionals to fill the void with progressive recommendations.
Even if the legislators do reach a compromise, it is essential that our organizations become more involved, both independently and in collaboration. To address just one of the important issues, I recommend that the American Pharmacists Association and the American Medical Association work together to introduce and seek support for a provision that patients have freedom of choice in selecting their physicians and pharmacies in health care programs that are funded by the government. I am certain that there would be strong public support for this recommendation.
Led by Stephen Metraux PhD, interim director of the Health Policy Program, masters and doctoral students in the Department of Health Policy and Public Health are examining the Patient Protection and ACA as it evolves in real time. Here's what he has to say about the course:
Last summer, the faculty the Department of Health Policy and Public Health at University of the Sciences decided to implement a seminar course devoted to the Affordable Care Act for the Fall 2013 semester. We realized with the exchanges set to come online in October, this would be a unique opportunity to observe and assess policy as it unfolded, and that it would likely entail a wild, unpredictable ride. As the person who first pitched this idea, I got to facilitate the class.
The course consists of three touch points – studying the nuts and bolts of the ACA based on reading about the act and its implementation; a series of speakers who would come into the class and give in-depth presentations related to specific aspects of the ACA; and taking time each class to discuss the week’s events related to the ACA. Taken together, the class has been exciting, interesting and informative.
The speakers so far have included community perspectives from hospitals, physicians and public health providers, as well as University faculty talking about the economics, political science and occupational therapy perspectives of the ACA. The nine students enrolled in the class have each taken one of the nine titles (i.e., sections) of the original ACA and have delved into the details. And finally, the government shutdown, the debacle of healthcare.gov, and the individual policy cancellations have been the backdrop behind a greater awareness and a greater understanding of the headlines.
Based on this, students from the class will, in the upcoming days, provide brief entries for this blog related to specific ACA-related topics upon which they are focusing. The first entries in this series came from Tom Godfrey, a physician and PhD Health Policy student:
My contribution to this is a top-ten list of general themes about the ACA that have become clear through this course.
10. To focus on the individual mandate is to miss 90 percent of the ACA.
9. If you are sick and poor before the ACA you will likely remain sick and poor after the ACA.
8. The ACA is sitting on the shoulders of over a century of health care reform efforts.
7. It is possible to have too little income to benefit from the ACA.
6. Public health never gets the money it needs.
5. The ACA just ain’t socialized medicine in any form.
4. To work, the ACA must hit the health care trifecta: simultaneously expanded coverage, improved quality, and reduced costs.
3. Opponents hate the ACA; proponents see it as a set of necessary compromises.
2. No one knows whether and how the ACA will work.
[insert drum roll…]
1. Students in the class already know more about the ACA than most physicians.
As a pharmacy student, I’ve been drilled rigorously that medication adherence is a vital cornerstone to effectively treating patients and achieving positive clinical outcomes. Yet with so much emphasis dedicated to ensuring that patients are taking their medications, it is estimated that approximately 20-50% of patients are non-adherent. With such high numbers of patients not adhering, it is crucial that pharmacists find tools and strategies to monitor and improve adherence.
The simplest way to find out if a patient is taking a medication is to ask. There is a simple 4 question assessment to better gauge whether or not patients take their medications. This scale, the Morisky scale, allows for pharmacists to not only interact with their patients, but also allows him to ‘score’ the interaction and get a better idea of their patient’s compliance. A study using the scale observed that if a patient was found to be compliant, there was a 93% chance that they were indeed compliant (high sensitivity). But the study does lack specificity as indicated by the finding that if a patient was found to be non-compliant, there was a 53% chance that that was indeed the case. The Morisky scale is a great tool to use when interviewing a patient, but again, the low specificity leaves a level of ambiguity.
A more direct, but still primitive method of determining patient compliance is a pill count. While the method is simple, the accuracy of the information gathered is directly dependent on the patient. Unfortunately, patients could manipulate the number of pills in the vial and you still aren’t certain whether the medication is being taking as directed. However, one study showed that unannounced pill counts by phone improved compliance in AIDs patients and this method could feasibly be applied to other realms of practice. While pill counts are an acceptable first line of defense against non-compliance, more advance methods are available.
With the level of automation in pharmacy nowadays, digital records of refill and prescription pick-ups are simple to compile and interpret. A pharmacist can easily access a patient’s records and observe their refill habits. It can be determined if the patient is picking up their medications on time and in line with when their quantities should be depleted if the drug is being taken as directed. But as with the pill count, the use of a pharmacy record is limited. The patient could be using multiple pharmacies and the patient’s actual habits cannot be assessed by simply looking at when they come in for a refill. Records are important, but what if a doctor or pharmacist could actually verify the exact time when their patient takes their medication?
The future of medication adherence monitoring could come in the shape of a digital pill. A transmitter the size of a grain of sand can be embedded inside a pill which then can send a text, email, or tweet to the patient/health care provider when it was taken. This technology could do wonders for patients with high risk disease states like cancer or HIV. While this sounds like science fiction, Proteus Digital Health claims that this incredible technology will be available to
drug companies within the next three years.
While it seems like a daunting task at times, medication adherence monitoring is an important aspect of what we do as pharmacists. By utilizing the tools discussed, we should be able to improve ompliance and make a positive impact on patient outcomes.
Mackenzie F. Blair, PharmD '15