Monday, August 12, 2013

Flash follow-up

In my last post, I suggested that patients carry a flash drive that contains their health information.  This drive would contain all medical information, including all labs/procedures/prescriptions that were ordered.  Upon admission to the hospital (or visit to the physician) the staff could review this information and be able to see if the patient had been compliant with the prescribed treatment plan.

I realize that asking the typical patient to keep track of a flash drive is an impossibility.  But with the way technology is evolving it wouldn’t surprise me to see data like this being able to be stored on a chip that is embedded in the patient’s insurance card.

It would be easier to just design a system where all of this data feeds into a central database, but I can’t see how such a system could be secured.  When our government can’t keep national security documents safe I really can’t trust that the medical records of millions of people would be able to be secured.

A few days ago I was talking with an acquaintance who works with health insurance.  We discussed compliance, wellness plans, cost of healthcare.  Pretty much everything that has come up over the past ten years in the world of health care costs.  We came to the same conclusion after our discussion.

People are going to do what they want.  You can only incentivize so much, and some people won’t go for the incentives no matter what. 

With the way the system is currently operating, we are enabling the patients to be non-compliant.  If the patient doesn’t follow the treatment plan that has been developed by their physician/health care facility, it’s the physician/facility that is going to get dinged by not getting reimbursed.  The patient has no skin in the game.

By capturing all of the ordered procedures/tests/medications on a device that the patients must carry with them, compliance with therapy can quickly be determined.  If the patient is not compliant with therapy, the financial responsibility would get shifted from the provider to the patient.  Patients who are chronically non-compliant would, as mean as it sounds, receive a lesser standard of care as providers will be able to see that the patient is not compliant and adjust the treatment to a level with which the patient would be able to comply.

Before jumping down my throat about not giving the best care to all patients, remember that the patients who this would apply to are the patients who have already been given the best care.  They have chosen not to continue with the care plan that has been determined.  The cost for the additional health care expense should not be passed on to the other members of the health care plan or to the taxpayers if the patient is on government-funded insurance.

A provider/facility can only order so many tests, arrange so much home health care, and provide so much medication to a patient.  But when the patient doesn’t have the tests run, cancels the home health care, and doesn’t get their prescriptions filled, is it really the provider/facility’s fault that the patient is readmitted to the hospital twelve days after discharge for the exact same diagnosis?

Maybe a little de-incentivizing is what is needed.  When the patient realizes that they are going to bear a greater portion of their health care expense if they are non-compliant, perhaps they will follow the treatment plan.  For people who want to be compliant, but financial situations prevent them from doing so completely, services such as pharmacist-provided care could help them find alternatives to therapy that help achieve the therapy goals (at a lesser expense).  These services would be reimbursable to the providers, and would be recorded on the device that the patient carries with them as proof that they are attempting to comply with the treatment plan.

Wednesday, July 10, 2013

Is the answer as simple as a flash drive?

Back in my community pharmacist days, one of my biggest pet peeves was the lack of coordination of care that occurred when patients were discharged from the hospital and transitioned back to the care of their primary care provider.  Many times when a patient would follow-up with their primary care provider, they would have medications ordered that were either duplications in therapy or worse yet, contraindicated to the medications that were ordered upon discharge.  It seemed as if nobody at the physician’s office had reviewed what the discharge orders were.  Figuring out exactly which medications a patient was supposed to be taking took up a good portion of many days at the corner drugstore.

Now I’m on the other side, at the hospital.  When patients are admitted to our floor it can take hours to figure out what medications a patient is actually taking.  At my facility, a large portion of our patients are poor historians.  They don’t know what medications they are on.  They don’t carry an updated medication list.  Many don’t even know who their physicians are.  It takes hours to figure out what medications they are taking upon admission, potentially delaying care.  Heck a couple weeks ago it took 36 hours to get an accurate medication list from the VA for a veteran that was admitted to our facility.

There has to be a better way to reconcile medications to allow for a better level of care for our patients.  Is there a role that pharmacists can play in this process?

Some pharmacists would jump in and say MTM is the answer.  I’m not so sure about that, at least not with the way that MTM is currently structured.  With pharmacists not having provider status, we are not able to bill for our services unless the patient is referred to us by their Medicare-D plan (at least that’s how it is in my state).  Second issue with this, not all patients who are in need of our services are Medicare patients.  I have had many patients in their 30s and 40s, working full-time jobs who could have benefited from pharmacist-provided care. 

But back to the main point, improving communication between physicians, facilities, and pharmacists.  I don’t advocate a central database that contains all of a patient’s health care information.  In recent times we’ve seen far too many sites get hacked and expose sensitive personal information.  I know that I don’t want my information stored in such a manner.

I would like to see patients carry their information with them, say on a flash drive or similar device.  At each encounter at the physician’s office, hospital, pharmacy, etc… the device could be accessed to update information.  Providers would be able to see what treatment was ordered and check to see if the patient actually followed through with the treatment plan.  For example, patient is discharged from hospital with an order for a LABA/steroid inhaler following an admission for a respiratory problem.  Five days later they present to the ER for difficulty breathing.  The ER staff could access the record and see that the patient did not have their prescription filled, thus the return to the hospital.  The hospital would not get dinged for a readmission within 30 days since the patient did not follow the treatment plan.  Compliance issues could be identified and referred to the appropriate persons, say a pharmacist who could educate the patient.

The flash drive would also enable providers to see changes in a treatment plan.  Let’s say that a primary care provider starts a patient on a medication.  Two months later a specialist changes the treatment plan.  The specialist could document that the original medication has been discontinued.  When the patient presents the flash drive at the pharmacy for updating, the discontinue order would be executed.  Too many times I have seen a family member try to help their loved one with medications, only to request refills on a medication that has been stopped for months.  A system like this would help prevent such situations.

I know there are many gaps in my plan that would need to be addressed, but this could be a start.  What are you thoughts?

Monday, January 28, 2013

Forget MTM, I'm doing PPC

Medication therapy management.


That's been the focus of the pharmacist organizations for the past several years.  The thought of pharmacists providing direct care to patients in an effort to improve the health of the patient, as well as decrease the health care expenditures for both the patient and the third-party payer.

In my state, as well as many others, the focus of medication therapy management has been the Medicare patient.  Those who have already reached "retirement".  When Medicare Part D was introduced, the idea of providing direct care to patients via comprehensive medication reviews made many pharmacists happy.  But as the years have passed, we've seen that not all Medicare D patients are eligible for the CMRs.  Only the patients who meet insurer-defined criteria have been eligible to receive these services from pharmacists.

Shortly after providing my first comprehensive medication review for a Medicare D patient, I realized that the focus of pharmacist-provided care shouldn't be on the Medicare D population.  These people are already well into their disease processes.  Sure, we may be able to help educate these patients and help slow the progression of their health problems.  But if we want to show the value of pharmacist-provided care, we need to change our focus.

We need to educate the younger patient.  The 30-somethings who are being started on statins.  The twenty-somethings who have been diagnosed with type-II diabetes.

I was pleased to see that the recent petition to recognize pharmacists as providers received the required amount of signatures.  Provider status from Medicare will get the ball rolling for pharmacists as a profession.  But we shouldn't wait around for CMS to act.

We need to take it to the local insurance companies.  To the local employers.  Sell the idea of pharmacist-provided care to the people in your community.  If you generate a local buzz, people will take notice.

Go to the local self-insured employer.  Talk with them about how pharmacists can help decrease their medication expenses.  Talk with them about how medication adherence can reduce other health-care expenses.  Remind the employer that you can help employee be more productive during their work day.  Teaching that diabetic employee about how to better control their blood sugar may increase their productivity by two hours each day.  No more early afternoon blahs because the blood sugars are out of whack.

The profession has created a little bit of buzz about pharmacist care lately.  Let's not let the momentum die as we wait for CMS to act or not. 

Personally, I'm not going to use the term "medication therapy management" when I go out and talk about these services.  Mostly because my state requires collaborative practice agreements to actually "manage" the patients' medications.  I'm going to simply use the term "pharmacist-provided care". 

MTM keeps the focus on the medication.

PPC puts the focus on the pharmacist.  The pharmacist as the provider.  The pharmacist as the care-giver.  Because folks, it's not all about the medication.  It's about the knowledge that the pharmacist has that will make the difference in the health of our patients.  Medications are simply one tool that we may use.

We can impact the lives of our patients.  Let's not wait until they reach retirement age.  Let's roll PPC out to the younger patient and make the difference in their health that we know that we can.