Prescription drugs are by far the most common medical intervention for managing chronic illness in the United States. And because they’re so frequently used, there’s ample opportunity for things to go poorly. Without appropriate medication management, the burden on the entire health system increases. Costs increase and impact everyone: from insurers to health care providers to patients. Ultimately, it’s the health outcomes of patients that suffer.

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Recent estimates are that the United States spends $528 billion a year on suboptimal medication use. With just over 3,000 counties in this country, that’s approximately $175 million per county per year which isn’t being optimized in healthcare. Much of this is due to unnecessary hospitalizations and emergency room visits. Without proper medication management, patients with chronic conditions aren’t meeting their healthcare goals. Instead, they’re getting sick enough to end up in the hospital or the emergency room.

The importance of medication management in healthcare reform 

Even among those who agree that medication management must be improved, many attribute the problem to patients taking their medications incorrectly. This conveniently places the blame on the patient rather than on the system. But this assertion is simply false. In fact, studies have shown that the number one issue with medication use is not adherence. It’s that patients need a medication no one has told them they need. Or, they’re getting a sub-therapeutic dose of medicine that hasn’t been increased.

Experts refer to this practice as clinical inertia, which can be compounded by gaps in care or lack of care coordination among multiple clinical providers. It’s one of the reasons why too many patients aren’t reaching their clinical goals, which contributes to ineffective spending in healthcare.

We need a sustainable mechanism to deliver services that improve patient medication use. Why? Because improving patient health leads to better metrics for the health plan, which results in lower costs. It’s about creating value for the health plan because the patients are their beneficiaries. 

Why focusing on local rather than national efforts is key

So how do we begin changing medication management in the U.S.? National reforms and best practices that include medication management as an essential component of primary and specialty care are certainly important. But how this gets implemented and delivered to patients will vary by the types of services and providers available to patients in their local community. 

To create this change, we must forge a partnership between the providers who deliver the service and the health plans managing the benefits design. At the national level, this requires changes in Medicare. I would acknowledge that this is the “big get” because if Medicare changes, it will change the game for everyone. 

But the fact is that our efforts to change medication management at a national level have already been 20 years in the making. It’s not the place to win quickly – which is why we should increase our efforts at a regional level. This allows us to create change locally, region by region (or state by state) while simultaneously working towards our big goal of changing Medicare – an outcome that will likely take another decade or more to reach. 

Why is it easier to affect change locally? Because commercial health plans have more control over their benefits design. They’re not responding to the Centers for Medicare and Medicaid Services. They can alter their benefits design on an annual basis. For much of their business, they’re accountable to self-insured employer groups. There’s often a closer connection between that health plan and who’s really footing the bill.

Regional plans are also more nimble in many ways. They can tailor service offerings to take advantage of the strengths of a local health care environment. As health plans grow to cover larger regions or become national in scope, they’re dealing with a lot of variances in health care delivery in the region, which can limit innovation or unique regional partnerships. 

Which variables matter most when optimizing medication management? 

First, regions with a state-level quality reporting entity can create a higher level of accountability for performance. Examples include Minnesota Community Measurement and the Wisconsin Collaborative for Healthcare Quality. While all health plans will be influenced by national measures like the Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Star ratings, regional quality reporting entities can add significant influence on quality performance with their focus on health care providing entities.

Another key variable is geography. For example, 3.5 million people live in the Minneapolis-St. Paul area. This represents more than half of the population of Minnesota. North Carolina is also mostly rural but has several larger population centers. These demographics will affect how health care is delivered in that region. It determines whether a region has vertically integrated health systems (a large health care organization offering a broad range of different patient care and support services) or private medical groups. It also affects whether the region has chain versus independently owned pharmacies. 

Finally, the degree to which performance-based or value-based payment strategies have already been piloted or implemented in a region will influence what factors will drive change in care delivery, including medication management services. In my home state of Minnesota, the health care landscape is dominated by large, vertically integrated health systems, and the vast majority of care delivered is connected to value-based contracts with shared risk with a health plan. But in a state where the adoption of value-based health care payment strategies has been more limited, drivers for change will be different. State dynamics influence health care. A region with a higher uptake of accountability for performance will create a different type of opportunity for change. 

To invest in a service to improve medication use, a health plan must know there are enough providers in the service area where their beneficiaries live. The readiness and the level of engagement expected from a practice community are important to health plans because service has to be consistently accessible to its beneficiaries. Establishing this level of engagement is more feasible when working with regional versus national health plans. 

How do you create change on a local level?

To effectively create change regionally, you need a convener to bring stakeholders together. Ideally, this is an organization that’s not viewed as having self-interest. The convener establishes a leadership voice that declares, “We can do better, and we’re going to bring people together to figure it out.” They invite stakeholders with varying perspectives to be in a conversation unlike any they’ve had before. 

Stakeholders in a region can be payers, providers, physicians, pharmacists, or policymakers. 

The purpose of their first meeting is to create relational understanding. It’s not trying to solve the problem or to get anyone to commit to anything long-term. The goal is simply relationship development. And through relationship development, we’re working toward a solution that benefits all parties. 

On one side, you have health plans. It’s their job to keep patients healthy and build a benefits design that produces health in an economically efficient way. On the other side, you have health care providers who deliver the services that help health plans achieve that goal through patient-centered care. Both sides have to see that there’s a benefit in reimagining how medication management is supported in the region. The solution can’t be good for one side but not the other.

That’s the real bottom line. Local conversations bring us to a point where new relationships are formed that produce better health. There must also be a fiscal element that allows the service to keep going. Once this effort has been sustained over time, we’ll have successfully changed the system. 

Contact AIMM to help get started
If you’d like support in identifying a convener and facilitating conversations with local stakeholders, contact AIMM.

Todd D. Sorensen, PharmD is the Executive Director of the Alliance for Integrated Medication Management. AIMM is a non-profit organization working to support the widespread adoption of team-based medication management services in the care of high-risk, high-cost patients suffering from multiple chronic health conditions.