Wednesday, December 21, 2011

User Friendly Medical Devices Could Alleviate Medication Non-Compliance

In my last blog post I noted that one-third to one half of all patients do not take medication as prescribed and up to a quarter never fill their prescriptions at all. This non-compliance with prescribed medication costs the US health system an estimated $290 billion annually. These costs are associated with expenditures for unnecessary hospitalizations, medical procedures, physician visits and treatments. Despite this staggering number this is just a starting point as the numbers quoted do not capture such costs as lost productivity and deterioration in quality of life. I put the blame for this non-adherence on the high, unaffordable cost of medication, the fact that people are forgetful and neglect to take their medications and the fact that often patients do not understand the reasons why following instructions about when and how to take medication is so important.

However, there is an additional  reason why people often do not take their prescribed medication properly and that is because the devices that deliver the medication are not designed in a way that makes them easy to use. In fact ,some devices are so poorly designed the patient cannot administer the medication at all.

Cambridge Consultants conducted a study that found a direct correlation between patient adherence to a drug regimen and the design of the drug delivery mechanism. The 240 diabetic patients who participated in this study indicated that they did extensive research on drug delivery devices that they would be using daily, and made their choices, not necessarily based upon their physician’s recommendation, but on their own perceptions about how the device delivered their medication. These respondents almost universally agreed that they would be willing to pay more for a device that is more user friendly and efficient.

A parallel study conducted by Cambridge Consultant of 100 health care professionals also concurred that the usability of a medical device impacts patient compliance with the medication therapy.,

The design of medical devices is regulated by the FDA , although the system is far from perfect. It has been a long road to institute regulations and standards that require manufacturers of medical devices to design in usability, design out usage errors, and provide documentation that is user friendly. By no means are we there yet.

The packaging of medication in containers that are safe and tamper secure, while at the same time enabling the average, possibly  elderly patient to easily access the medication is no easy task.

Over time this problem is going to become more complicated as the increasing numbers of individuals with chronic conditions use a variety of newly developed home monitoring devices and medication delivery systems, many of which will be based on a smart phone platform. It is important that patients have the right tools to manage their health conditions and medications. This will only happen when patients raise their  voice  and express their concerns so their health care providers  will  prescribe medications that patients completely understand and can use without a lot of challenges.

Wednesday, December 14, 2011

Did I Take My Pills Today?

One-third to one-half of all patients do not take medication as prescribed, and up to one-quarter never fill their prescriptions at all. According to the New England Healthcare Institute, (a health policy research organization focused on enabling innovation in health care.) medication non-adherence costs  the US health system an estimated $290 billion every year.

This non-compliance regarding medication is not a new story. In April 2007, I wrote a blog where I pointed out that not taking medication properly was the cause of more than 50% of medication- related hospital admissions. A study of 39,000 patients and 335 primary care doctors by the Consumer Reports National Research Center, published in the February 2007 in Consumer Reports, noted that doctors’ number one complaint about patients is their failure to follow advice and adhere to a treatment regimen, which results in the high numbers of people landing in the hospital or back at a doctor’s office with the same complaint that they brought to their physician days or weeks earlier.

A new study, which focuses on four chronic conditions, found that patients who regularly adhered to their prescription regimen significantly reduced their total health care spending and lowered the number of emergency room visits and the number of days spent in the hospital. Specifically, adherence reduced average annual health care spending by $7,823 for patients with congestive heart failure, $3,908 for hypertension, $3,756 for diabetes, and $1,258 in patients with high cholesterol according to the article.

There are three  reasons why people do not follow directions and take medication prescribed by their physicians:

1. Cost – many people, particularly those with chronic conditions who are on several medications come to a point where they have to make budget decisions and the pills are among the first things to go when money gets tight. The solution for these individuals lies not with changing their behavior but with the system. We have to find a way to bring down the cost of medications and co-payments to affordable levels so people can continue to take their medications . There have been several proposals that advocate paying people a financial incentive to comply with prescribed treatment such as lowering co-payments or creating incentives which reward people with cash if they comply.  To achieve a lasting solution, however, health insurers must begin to work with pharmaceutical companies and carve out plans for lowering the cost of some medications, as well as subsidizing \ individuals who cannot afford to pay.

A study funded by Aetna and the Commonwealth Fund, found that eliminating out-of-pocket costs for secondary prevention medications for patients after a myocardial infarction resulted in modest increases in adherence and improvements in some outcomes. This randomized trial showed adherence was roughly 4 to 6 percentage points higher among patients whose health insurers waived co-pays, than among those who continued to pay for prescriptions. Although these are not large percentages, it is good start toward making long term medication affordable to people with serious conditions.

2. Forgetfulness There are a large number of people who simply forget to take their medications either because they are too busy or they have memory lapses. The good news is that there are new systems with alarms available that remind patients when it’s time to take their pills - some even incorporate data collection to confirm that pills were taken on a regular basis. Devices like MedSignalsVitality Glo-Caps, and Dosecast, an app for the iPhone, IPad, iPod and iTouch that thelps you to remember when to take your medicines each day are examples.  Dosecast will even let you know if you have taken your last dose and if you are due for a prescription refill.
3. Education – patients frequently walk away from their visit with their doctor and have no understanding of why a prescribed medication is important and what will happen if they do not follow the treatment. Although there are isolated examples where physicians and pharmacists have worked together to develop effective programs to help people understand the purpose, potential side effects and why, using and completing a medication treatment is the only way the patient will recover, these coooperative programs are too few. As a result most patients are not given enough information and many opt not to refill their prescriptions. or they  self diagnose and determine that a drug is ineffective for them so they stop taking it. There are also the individuals who have difficulty swallowing their pills, or difficulty opening their containers, so they get frustrated and stop using their pills.

What can the patient do to take responsibility for medication adherence?

First and foremost, patients must speak up and question their providers about all of their medications and be sure that they completely understand why they are necessary, how to take them (in what dose and when), and the potential side effects. 

Patients who are still confused about a medications should talk with their pharmacist for further clarification.

Patients who have difficulty remembering to take their medications need to find one of the many medication reminders that are inexpensive  and available at the pharmacy,or free on many smartphones.

Patients who have difficulty opening the bottles should talk with their pharmacist who can supply bottles that are easy to open.
Patients who have difficulty swallowing should talk with their physicians who can prescribe substitute medications that may come in liquid form or who can suggest easier solutions for swallowing the medications.

Empowered patients do not leave these matters to chance or ignore the potential consequences.  They seek assistance and confirmation to make sure that they stay on track..

Tuesday, December 6, 2011

Personalized Medicine and Participatory Medicine Intersect

Since the time that the Human Genome Project was completed in 2003, gene sequencing technology has moved rapidly, becoming less expensive and therefore more available. In the very near future the cost of doing a whole genome sequencing will be under $1,000 and affordable to many individuals in the mainstream. What this means is that physicians will be able to tailor medical treatment to the individual characteristics of each patient, based on their unique molecular and genetic profile that indicates whether or not they are susceptible to certain diseases.

This will help physicians determine which medical treatments will be safe and effective for each of us and which might be counter. It means that individuals will have to become even more engaged in their health care, because they will be faced with the dilemma of having to make decisions about their life and life style based on knowledge about what they might be physically dealing with, as they age. It is in the nature of humans to want knowledge and information, especially about themselves. Ultimately many individuals, who can afford to, will make the decision to do whole gene sequencing.

There are already studies where findings based on genetic variations are initiating changes in options and treatment approaches. For example, researchers, using gene sequencing,  have learned that not only does lung cancer vary in patients based on the specific genes that contribute to its onset and progression,

In cardiac disease as well, genetic tests which detect variations in the way people may be at risk of excessive bleeding, and other genetic tests that determine how people metabolize the drug Coumadin (warfarin) which is used to prevent blood clots, determine how the drug is administered to different individuals, and in what dosage.

Eventually gene sequencing will spread throughout the population. A study is underway at Inova Health Systems of 500 families whose newborns’ medical history includes a preterm whole genome sequencing to identify molecular markers and genetic differences. The goal of the study is to learn more about disease prevention and detection as the newborns mature.

While this is a tiny segment of the newborn population, there will be a time (perhaps in 25 years, or less) when all babies will have their genome sequenced and the results preserved as part of their digital health record. This genetic information will become a standard element of a person’s medical history, and will follow that individual through life. It will determine many aspects of the individual’s medical treatment.

There are many hurdles and challenges before whole genome sequencing will become ubiquitous. There are issues of bringing down the cost of whole genome sequencing so that it is affordable and perhaps even covered by medical insurance. There is a greater challenge of how to deal with the massive amounts of data that result from whole genome sequencing including who will pay for the analysis of the data, how will the data be stored and regulated and how privacy of health information will be attained.

Personalized medicine forces all of us to be more participatory in our health care because decisions about whether or not to opt for genome sequencing is one that we have to make for ourselves. We are also forced to make life altering decisions, based on the data, regarding:

  • Whether we are going to address a potential disease that may be in our genetic markers, in advance of the onset of the disease.
  • How the genetic information we receive might influence our decision to have children.
  • How to protect our children regarding what is revealed in their genetic history.

Personalized medicine is a revolutionary trend that deserves the attention of every individual who is engaged and educated about health care because the benefits are huge and the responsibilities, both on the part of the individual and society, to use this information for positive medical advancement and better personal outcomes is daunting.


Thursday, December 1, 2011

Understanding Consumer Directed Health Plans

Knowledge is the most important thing in most circumstances, but when choosing a health plan that will protect you and your family you need to know everything there is to know about your costs vs your payments. Consumer-Directed or Consumer-Driven Health Plans that include health savings accounts, (HSA) flexible spending accounts (FSA) and health reimbursement accounts (HRAs) could save you money and help you plan wisely for unexpected health expenses. 

Health savings accounts are like personal savings accounts, but the money in an HSA can only be used for health care expenses. Both employees and employers can contribute to an HSA up to an annual amount limit, set by a statutory cap: @$3,000 for a single individual and @5,000 for a family. (

Employee contributions to an HSA are made on a pre-income tax basis and some employers arrange for contributions through payroll deduction. However, individuals own and control the money in an HSA. Once deposited, this money cannot be accessed by your employer or your insurer. The money is not taxed, and you can invest it in stocks, bonds and mutual funds. . Further, you don’t have to spend the money put into the account by year end or otherwise lose whatever is left. Money can be rolled over from year to year which enables you to accumulate tax free dollars that can be withdrawn at age 65.

 To be eligible to open an HSA,  you must have a special type of health insurance called a high-deductible plan.  High-deductible plans act like a safety net if you need extensive medical care. Like any health care option, HSA’s have advantages and disadvantages. When considering an HAS, you must review your anticipated health care expenses, your financial situation and how much control you want over your health care spending. If you're generally healthy and want to save for future health care expenses, an HSA may be an attractive choice. However, if you anticipate needing expensive medical care in the next year and would find it hard to meet a high deductible, an HSA might not be your best option.

The Flexible spending account is another tax-advantaged financial account and allows you to set aside a portion of your earnings to pay for qualified expenses, most commonly for medical expense but often for dependent care as well. Money is deducted from your paycheck into an FSA and is not subject to payroll tax, resulting in a substantial payroll tax savings. FSAs are commonly offered with more traditional health plans and do not require you to enroll in a high deductible plan. Most people who have an FSA use it to pay for medical expenses not paid for by insurance, usually deductibles, copayments, and coinsurance. Prior to January 1, 2011, over-the-counter (OTC) items such as bandages, rubbing alcohol, first aid kits, and other medical expenses not distinguished as a drug or medicine were reimbursable under health care FSA plans. The Patient Protection and Affordable Care Act changed the rules, allowing reimbursement for these items only when purchased with a doctor's prescription. FSAs can also be established to pay for care for dependents who live with you and need care while you are at work. This includes child care, for children under the age of 13, or for children of any age who are physically or mentally incapable of self-care, as well as adult day care for elderly dependents. The dependent care FSA is federally capped at $5,000 per year, per household. The minimum annual amount you can elect is $250 per account. One significant disadvantage to using an FSA, unlike the HSA, is that funds not used by the end of the plan year cannot be rolled into the next year.

Health Reimbursement Accounts are medical care reimbursement plans established by employers and used by employees to pay for health care. Employers typically commit to a specific amount of money to be available in an HRA for an individual to pay premiums and other medical expenses. Unspent funds in an HRA are usually carried over to the next year; however, employees do not take their HRA balance with them if they leave the job. HRAs are initiated by the employer and serviced by a third-party administrator or plan service provider. The employer may provide in the HRA plan document that a credit balance in an employee's HRA account can be rolled over from year to year like a savings account. This is an individual employer decision.

The money set aside in health savings accounts, flexible savings accounts and health reimbursements accounts provide a cushion and a comfort against unexpected health care expenses and are worth investigating. Choosing the right iteration is an individual decision based on projecting your health needs for the coming year. It is important that you arm yourself with as much information as possible to make the best choices.