Data Analytics Takes on Medication Management

The expansion of e-prescribing and data analytics is leading to improved outcomes, reduced costs, and enhanced patient engagement. And technology is allowing providers to earn hard cash for meeting medication adherence targets.

This article appears in the January/February 2014 issue of HealthLeaders magazine.

Billions of dollars are wasted and thousands of lives lost each year through inefficient or ineffective medication management. It has been estimated that the misuse of prescription drugs in our healthcare system is up to a $300 billion problem annually.

From the doors of the emergency room to the drawers of patients' home nightstands, medications are mixed up, misremembered, overdosed, underdosed, and laboriously documented or misdocumented.

But things are changing: E-prescribing is now the rule, not the exception. Data analytics is red-flagging areas of concern from the doctor's office to the pharmacy and all throughout the chain of care. And technology is allowing providers to earn hard cash for meeting medication adherence targets.

ACO partnerships

Coventry Health Care, a division of the insurer Aetna, is a Bethesda, Md.–based managed healthcare company with 5 million members across the nation. Coventry uses predictive modeling technology from RxAnte to target a population of patients who could most benefit from improving their medication adherence. Then, Coventry offers physicians $50 per medication class per quarter in bonuses to make it happen. The bonuses target three classes of medications and use predictive modeling to narrow the focus.

"Providers are getting bombarded by a bunch of noise, and the worst thing you can do is send them a mile-long list of patients, most of whom are going to be adherent on their own," says Michael Kavouras, vice president for Medicare Stars for Aetna.

"Nothing will frustrate providers more than wasting their time and the time of their office staff and their nurses," he says, "so one of the things we've done is we've used the RxAnte algorithms to skinny down the lists and get to providers and communicate to them that we're not going to do this the old-fashioned way where we're just going to send you every patient that is currently nonadherent."

So far, 570 practices have committed to participating in Coventry's initiative during the third and fourth quarters of 2013, which account for almost 20,000 of Coventry's Medicare Advantage members out of 300,000 total Medicare Advantage beneficiaries.

Medicare Shared Savings Programs are also using analytics technology to manage patients' medication adherence. On January 1, 2013, Baroma Health Partners became the first MSSP-approved ACO in Miami-Dade County, Florida. Baroma Health Partners, a subsidiary of Baroma Inc., consists entirely of independent physician practices.

"Medication therapy is really important for anyone who's discharged from the hospital," says Ricardo Matos, CIO of Baroma Inc. At the time of discharge, Baroma Health Partners and its pharmacy partner, Walgreens, perform a medication reconciliation to make sure patients do not leave with more of a particular medication than they need, or with any medications that may have an adverse effect interacting with other drug therapies, he says.

"It's all independent physician practices down here in south Florida," Matos says. "Trying to help solve this healthcare puzzle down here, we thought that might be some of the low-hanging fruit to help our population coordinate care between the different providers that they see that are not necessarily communicating well, until the ACO provided the avenue to do so."

Such coordination can help hospitals in the area avoid penalties imposed by CMS on those whose 30-day readmission rates are too high, Matos says.

Using Direct encrypted email enabled by technology from Loopback Analytics, Baroma Health Partners is able to transmit personal health information to primary care providers so they can see hospital discharge instructions, be aware of medications the patient has received within three days of discharge, and in return be made aware of patients following up for PCP visits within 14 days of discharge. "That's where it's been successful," Matos says.

Walgreens' role in managing medication has been to give the fledgling Baroma ACO a reputable partner to help convince independent physicians to also partner with the ACO, Matos says.

Although the ACOs under the MSSP are not at risk for Medicare Part D, drugs covered under other parts of Medicare are important to Baroma Health Partners, Matos says. "Although we're not at risk for it, we can't ignore it, because the proper management of medications is going to keep the patient out of high-risk and high-cost settings," he says.

"What we bring is that visibility, that connection, that follow-up, from a community standpoint, that traditionally on its own a hospital wouldn't have," says Joel Wright, group vice president of enterprise specialty at Walgreens.

Walgreens formed three ACOs with physician practices in January 2013: Advocare Walgreens Well Network in Marlton, N.J.; the Diagnostic Clinic Walgreens Well Network in Largo, Fla.; and the Scott & White Healthcare Walgreens Well Network in Temple, Texas.

Walgreens' WellTransitions program, recently endorsed by the American Hospital Association, "really focused around the six core disease states that Medicare has outlined" as highest risk for readmission, Wright says. Those disease states include acute myocardial infarction, coronary artery bypass grafting procedures, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, and percutaneous transluminal coronary angioplasty.

Walgreens, using Loopback technology, is able to provide patients' medication history to hospitals at admission to facilitate medication reconciliation, and then to take that reconciled medication list back for use in the community pharmacy postdischarge, Wright says. "Right then we clean up that patient's outpatient profile and close prescriptions the patient should no longer be on," he says. "That way the prescriptions don't get filled in error, and it helps reduce the chance of patients being confused about which medication they should really take or not take."

Within the first six months after the program's implementation at five hospitals, WellTransitions patients had a 9.4% unadjusted rate of 30-day readmission, compared to a 14.3% 30-day readmission rate for patients eligible for but not participating in the program, according to Walgreens.

Mobile apps

At home, patients may find themselves looking at a bottle of pills, wondering if they have taken their medication or not. Many choose to skip a dose because of their uncertainty. Others ignore warnings not to take medicines with other drugs or food that could have an adverse effect.

But one thing has changed in most of those patients' lives: They now have smartphones capable of running medication adherence apps. One such app, MediSafe, is used to provide gentle, simple-to-understand reminders by patients of Barbara Zink-Frederick, a geriatric and internal medicine nurse practitioner in New Freedom, Pa., about 30 miles north of Baltimore.

After trying other apps, Zink-Frederick settled on MediSafe, preferring the app's division of a day into morning, lunchtime, afternoon, and nighttime, visually displaying the medications at the appropriate time of day, and alerting patients it's time to take their meds with the sound of a pill bottle shaking, to distinguish the alert from other smartphone alerts.

Zink-Frederick also likes that MediSafe now allows patients to enter the time a pill is taken when that happens to be later than the originally recommended time, and that it reminds busy workers to take their pills with them before heading off to work.

When patients visit with her, the app reports a medication adherence score with drill-down details, and the bulk of the patient's visit can consist of meaningful interactions, including education addressing ways to obtain medications if the patient is low-income, for example.

"We set up a plan," Zink-Frederick says. "I actually help them put their original drugs in, to make sure that they get them right. They try it for a couple weeks, see if the way they're taking it is okay, or if they have problems, then it gives me the ability to adjust, move this medication to this time, maybe that won't make the patient have an upset stomach, or maybe this medication will help them with their appetite for dinner."

E-prescribing

The boom in e-prescribing is another way that medication management is bridging gaps in care. As many as one-third of prescriptions written in the past never made it to a pharmacy, says Harry Totonis, president and CEO of Surescripts, the e-prescribing network provider owned in part by Walgreens and CVS. If a doctor instead writes an electronic prescription, now that pharmacy knows the patient needs to come in and pick it up, Totonis says.

E-prescribing now accounts for 50% of the prescriptions in the country, Totonis says, and Surescripts is on track to process 6 billion transactions a year. He says that in the next five years, as that figure approaches 80% to 100%, Surescripts will tackle other aspects of adherence, such as whether refills are picked up or not.

Recently, the Drug Enforcement Administration issued a rule that controlled substances could be prescribed electronically. In 2015, starting in New York state, e-prescribing will be mandatory for all controlled substances, and other states will be watching New York's progress, Totonis says. "The minute that every prescription goes electronically, and we take out the paper pad altogether, adherence now just becomes a much stronger case," he says.

Addressing cost

Throughout the healthcare industry, medication management and adherence are sure to dominate much of the discussion about readmissions and other drivers of healthcare costs.

"It really is one of the industry's best opportunities to reach the largest number of consumers and patients and really impact one of the key drivers of healthcare: cost," says Frances Dare, a Dallas-based managing director of connected health services at Accenture, a global management consulting company.

"It's really across all patient populations, from the young to the elderly," Dare says. "It's people who are episodically ill just as much as it is people who are more chronically ill, and includes both over-the-counter medications and prescriptions and multiple medications. I think it's one of the biggest opportunities we have."

Still, as so often is the case, technology alone won't be sufficient, Dare says.

"We are on the journey of figuring out how this works," she says. "I do believe there is a wide range of capabilities—secure text messages that remind folks to take their meds or gamification—there's such a huge range out there that we really do have an opportunity to personalize for folks, or they have an opportunity to find a platform that really does meet their personal needs."

Reprint HLR0214-8

This article appears in the January/February 2014 issue of HealthLeaders magazine.