The Medical Moment of Truth Can Reduce Gaps in Care

San Diego—The best time for a physician and patient to decide on an effective, comprehensive, and manageable treatment plan is during the initial prescribing visit. This is, according to a Contemporary Issues session at the AMCP meeting, the medical moment of truth, which can make or break a patient’s pattern of medication adherence and set the tone for the efficacy of his or her treatment.

The session, titled Reducing Gaps in Care by Leveraging Technology at the Medical Moment of Truth, opened with a presentation from Eric Wright, PharmD, BCPS, associate professor of pharmacy practices, Geisinger Center for Health Research at Wilkes University. Dr. Wright’s presentation was titled Medical Moment of Truth.

The Geisinger Center for Health Research is part of the Geisinger Health System, which operates 42 primary care clinics across the north-central tier of Pennsylvania, as well as 6 acute care hospitals, including its flagship facility, the Geisinger Medical Center, in Danville. The system has 18,000 contracted physicians who serve 291,000 members.

The best care is achieved by combining an optimized diagnosis with optimized treatment, optimized adherence, and, perhaps most important, optimized monitoring of the patient. Managed care organizations are often confronted with gaps in care, Dr. Wright said. Often these gaps are a result of impaired access to the most important factors in optimized care.

One of the major factors in gaps of care is adherence to medication regimens. The paradox in medication adherence is that increased or improved adherence for patients can lead to increased costs for them and for managed care organizations. On the other hand, it can lead to a reduction in total healthcare costs, Dr. Wright noted.

Some of the main medication-related gaps in care, at least by HEDIS measures, include asthma medication use, post-myocardial infarction beta-blocker use, and comprehensive care for patients with type 2 diabetes.

Geisinger was able to ascertain rates of medication compliance by linking electronic health records to their pharmaceutical claims database. For Geisinger Clinic patients, there was an 85% first-fill rate within 6 months of the first A1c reading. From the initial prescription for diabetes medicine, A1c levels declined for all patients.

A copay of <$10 and an A1c reading of >9 were associated with a higher first-fill rate. However, the investigators found that treatment adherence rates—the level of persistence—fell as time increased from first fill. At 50 days, the adherence rate for patients was 90%; after 250 days the rate had fallen to 60% and after 300 days the rate was 50%.

Dr. Wright outlined several possible solutions to the adherence gap. These solutions included simplified dosing, special packaging, telephone follow-up, counseling, psychological therapy, family interventions, group meetings, rewards, and increased access to care. In its attempts to improve adherence, Geisinger instituted the following 4 methods; (1) telephone follow-up, (2) text messaging reminders, (3) direct consultation (especially to pharmacies), and (4) a system of dispensing the drug Plavix^® (clopidogrel bisulfate) to patients following cardiac stents.

The session continued with a presentation from J. B. Jones, PhD, MBA, research investigator at the Geisinger Center for Health Research. Dr. Jones focused on the challenges facing primary care providers to improve adherence and ways those challenges can be met. He outlined a 7-step process that includes (1) patient-reported data capture; (2) quantifying risk; (3) shared decision-making; (4) evidence-based clinical decision support; (5) intuitive visual displays of information; (6) automated physician ordering and documentation; and (7) continuous communication and care.

Each of these steps contains challenges, Dr. Jones continued. Obtaining accurate data is difficult and hard to translate. Most quantifying risk information tools are not used in routine clinical practice. While shared decision-making has potential to improve outcomes, it has not yet been widely implemented in routine clinical practice. These challenges, and others, can be met with innovations in health IT, he added.

The final presentation was from Scott Taylor, BS Pharm, RPh, MBA, executive director, industry relations at Geisinger Health System. Mr. Taylor commented that reducing gaps in care and reducing adherence are important to all stakeholders in a healthcare system. The provider, patient, and health plan all benefit from improvement in adherence rates, he said.

“The medical moment of truth is the moment at which patients are most receptive to making changes in their behavior, which will lead to better adherence and more efficient care. It is up to the provider, the health plan, the institution, and the patient to work toward changing this situation,” Mr. Taylor concluded.