Adherence Initiatives – What Have Payers Done for Us Lately?

By | November 20, 2013

Health insurers can undoubtedly influence improvements in medication adherence. So what kinds of adherence initiatives are payers actually sponsoring? Read on for answers based on a sample of five leading payer organizations.

The short answer is “a lot”!

The five payers reviewed were Aetna, Humana, Kaiser Permanente, United Health, and WellPoint. Sources of information were either corporate websites or web search findings. The results were very interesting! Different approaches across the five payers are divided into three sections:

The Predictable – the kinds of adherence initiatives that are probably expected.

The Innovative – initiatives that break new ground and test new approaches.

The Future – based on a report summarizing future payer priorities.

There are major differences between individual payer activities. The sections below provide an overall summary of findings.

The kinds of adherence initiatives that you would probably expect to see.Payer Adherence Initiatives: The Predictable

It’s not surprising that two payers report using claims data to monitor adherence. Both follow up with patients to encourage adherence. One uses care managers for follow-up, the other does not specify.

It IS surprising though that only two payers report doing this. Health plans are unique in having broad access to hard evidence of non-adherence. I would have expected all five to make active use of this information.

All five payers provide patient reminder services to support adherence. Two of these services involve text messaging, two are by phone, and one uses letters (still?).

Patient education is also a common service, with four payers providing this. The importance of adherence is usually included in the educational content

Two payers have mail order pharmacies in their networks and claim better adherence through easier patient access to medications.

Pharmacies in fact feature quite frequently in different adherence initiatives. In addition to the service already mentioned, two payers provide medication therapy management through their affiliated pharmacies. Drug reviews, adherence counseling, and pre-sorted medication packages delivered to patients’ homes are among the specific services mentioned.

Again, it’s surprising that only two payers offer medication therapy management. Though perhaps the others don’t have direct access to affiliated pharmacies?

Two other payer adherence initiatives are provision of free pill organizers and implementation of a health literacy program.

The types of adherence initiatives that break new ground and test new approaches.Payer Adherence Initiatives: The Innovative

Four out of five payers appear to offer value-based insurance design (VBID). I say “appear” as it’s not always easy to accurately interpret the language used in some web sites or articles. This 80% endorsement of VBID is encouraging.

Four payers are also investing in accountable care organizations (ACOs). The goals of ACOs include improving healthcare quality while also lowering healthcare costs. Once waste is teased out of the system, it’s to be hoped that improving adherence will play a pivotal role in achieving these goals. By the way, the fifth payer is Kaiser Permanente, which is effectively a huge ACO already! So, all five organizations are effectively supporting ACO initiatives. Again, this is very encouraging.

Three payers have specialty pharmacies in their networks, which focus on adherence. Specific programs mentioned include: adherence risk assessment, adherence monitoring, and adherence coaching.

Interestingly, three payers are sponsoring behavioral support initiatives. Of these, two programs specifically mention motivational interviewing (MI). Aetna, one of the companies majoring on MI, uses disease management nurses who are trained in the technique. These nurses elicit, rather than impose, motivation to change (see here). While MI has many possible applications to improve patient health, it has also been shown to be of significant value in improving adherence behaviors.

Special disease- or patient-focused programs are supported by three payers. These are:

  • A chronic care program, where care managers work with healthcare professionals to help improve patient’s adherence, using both phone calls and home visits
  • A diabetes control program, run by pharmacists who coach and counsel patients
  • A patient self-management and adherence program, where case management nurses trained in adherence work with pharmacists to build patient’s self-management skills, and improve patient-physician communication (see here)

To round this section off, here are a couple of additional programs that caught my eye.

Firstly, as Kaiser Permanente is an integrated health system, it’s EHR system truly links up physicians, pharmacists, and patients. Based on a large internal study, Kaiser credits their integrated EHR system for low levels of new script non-fulfillment (see here).

Lastly, Kaiser Permanente is unique (as far as I can see) in running an adherence training program for healthcare providers. Given poor physician capabilities with regards to adherence (see here), such training is much needed. Something the other four payers should perhaps consider?

Payer Adherence Initiatives: The Future

Overall, payers are working hard to include adherence initiatives – and through this improved quality – into everyday practice.

From a recent report, quality and cost (ie, value) are the major future payer priorities. Moving to value-based payment models is a major priority, and payers expect significant business impacts in getting there.

Interestingly, it’s likely that ACOs will become the most prevalent value-based payment model; possibly within the next 2 years.

In this new future, adherence initiatives – effectively implemented – will contribute to achieving value goals. They can also help healthcare providers achieve their value-based payment incentives.

A little extra motivation to move things along, perhaps?