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Current Challenges and Opportunities Around Medication Management

Perspectives From Cureatr's Richard Resnick

Cureatr's CEO Richard Resnick recently appeared on the Becker's Payer Issues Podcast. Below are some of Resnick's key takeaways from the program, edited for length and clarity. You can listen to the podcast here.

On the Challenges of Patient Discharges and Transitions of Care

Richard Resnick: Every provider has experienced these challenges over and over in their career of delivering healthcare. The primary issue is simply not knowing your patient has been discharged from a hospital. You either don't have this information or you don't get it in a real-time fashion.

If you want to intervene during a transition, you're doing so because you care about the patient outcome. It's not really a matter of doing this for a quality measure. Although there are quality measures that drive such behavior, you're doing so because research shows about 53% of all discharged patients are sent home with at least one medication error. If you look across all 30-day readmissions, a full third of them are because of medication errors. For providers that have been given the grace of time or incentive to focus on this first problem, the challenge they face is knowing their patient has been discharged.

The second issue is having the time to allocate to this work. Most providers are doing 15-minute visits and this kind of work is interruptive. It's not scheduled. It's a discharge notification that needs to be addressed. There are some HEDIS® and CMS Stars measures around doing post-discharge medication reconciliation (MRP), for instance, because failure to do so puts patients at high risk. A patient can have several medication changes occur over the course of their admission and then they come home to an already stocked medicine cabinet. They were being instructed at discharge on what to do when in a state of some fear and confusion. Now they are expected to know what to do and do it right when they return home. Providers need the time to slow down, be with a patient, and perform an MRP within a couple of days after discharge. Otherwise, the impact of the readmission avoidance doesn't happen.

That's something you need to invest in. But even if you have that time, there are patients healing at home and they're potentially aggravated because of multiple in-person, face-to-face visits through home care. They eventually go to their primary care doctor and may need help navigating through social determinants of health and other barriers. Once they arrive, the primary care doctor is going be a great generalist for that patient. The problem: medications are not general. They come from specialties and specialists. They're advancing all the time. There are lots of medication regimens we see where there's no way anyone but a clinical pharmacist could make sense of where the inherent danger is because of the multiple interactions and dosings. It takes training to do that kind of work.

Finally, you need to know all the medications patients have in their medicine cabinet. That's not just what's in your EMR, but the other medications that come from other providers.

If you're a provider who is interested in this important effort around making sure transitions are done safely and optimally; if you've got the time; if you know your patient has been discharged in real time; if you've got all this information, including what's available in your EMR; if you know how to reach the patient in a non-abrasive way; and you actually can speak to and identify all of the risk without overinvesting time, money, brain power, you can solve this problem. It's "that easy."

On How Quality Standards and Measures Fall Short

RR: That's our soapbox at Cureatr. We're glad for the kinds of quality standards and measures that follow because they do drive behavior. If you think about some of the measures, for instance, Cureatr influences effectively, they're the post-discharge medication reconciliation measure — MRP — and then the newer cousin that includes MRP, which is transitions of care (TRC). In each case, they're essentially asking for a fast med rec and then entering data in the right place — that's the kind of work that needs to be done. It's great that those measures exist, and they exist because something like a dozen years ago, some smart healthcare leaders got together and recognized these as points of real danger for patients. Then they spent three years writing a measure, and then another three rolling it out, and then another three incentivizing it and then changing it.

As a result, we're always essentially doing the right thing based on data from the past. It takes a really long time, understandably, to regulate an industry which is about 20% of the nation's GDP. It should be done slowly, but that's an inherent conflict. It's a cognitive dissonance within that system. Worse, the incremental value of a single post-discharge med rec is zero in the eyes of a health plan or health system executive. In fact, they're all zero. The only MRP that they do deem valuable is the one that takes you from one star to another, which can be somewhat random. After you’ve completed the one MRP that raises your score, the value of the others following is back to being zero. It's the unpredictability — the disconnect between the action and the incentive — that weakens its cause and the behavior of buyers.

What I'm saying is I know if I eat just 1,200 calories a day, I'm going to lose weight. But what if I eat 1,500 calories and I also ran and I think I burned 300 calories. I'm not sure, though. There's confusion in our minds about some single measure that's easy to optimize, but there's lots of ways to optimize it. You can optimize HEDIS® and Stars by approaching medication-related measures, or by approaching measures around home care, or many other places you can go to fix these things. It's very difficult to choose which is the right one. Sometimes you believe you've done enough investing over here and now it's time to focus over there, so you surge forward toward measures in a second area, yet you hadn't finished the first one.

The clarity decision-makers are provided is boggy. It's not great. That's a big issue. The measures drive incentives and weekly decision-making. What happens to us every time is we use a quality measure to start a conversation and begin doing work with a health planner, a health system, or an independent physician association. Then we show, by virtue of the work we do, the readmission reduction that is caused. That's what can be attached to real value. That's how return on investment is established, even though we're still building value in this weird, unpredictable, stepwise way of improving the numbers on the quality measure. That's frustrating, that's difficult, and it makes buying suboptimal and inefficient.

There are a few other things that come to mind. We're creating all this structure to incentivize on the upside and downside our health plans and our providers to behave well. This is the way they want to behave. But all the data from each one of these records that could allow primary care providers to do this work is simply not there. We wish CMS would focus as much on incentivizing or penalizing, EMRs and health information exchanges as they do providers and payers so the providers and the payers can get this stuff done right. They're essentially not regulating the whole industry in a way that's balanced, which puts an undue burden on the folks who are trying to just do the thing we all think healthcare is: the delivering of care.

A final thing is our dirty little secret — or something we're a little grateful about — is providers are oftentimes still in the fee-for-service worlds where they've got RVUs that matter most. As pharmacists, we can't submit codes for billing. We don't have that status to do it. So as clinical pharmacists working generally off telephones and video, we have all the data to be able to solve these problems, but we can't submit the fee-for-service fees. That's pushed clinical pharmacists away generally because it's tricky to generate the revenue you'd need to support their salaries, but this has also pushed us in a great direction.

It's sort of better to have things be more difficult. By having it hard like that, we have no choice but to demonstrate ROI in value-based care, enhancing quality metrics, and lowering readmissions. That's how we get paid. We're necessarily ahead of the curve being more innovative as we grow, as are others who are a little bit outside of and not allowed into that fee-for-service world. I'm happy value-based care and the kind of the quality measures that accompany it exist, however imperfect they are.

On the Difficulty of Maintaining a Current Medication List for Patients

RR: Let me try to make it somewhat personal. I have high blood pressure. It's very well controlled, but I take a lot of medications to control it. I'm not that old. I'm pretty healthy. I eat well.

I go to my primary care and a specialty care provider. The specialty care provider sometimes asks me what medications I take. My primary care provider always does. Sometimes as good as I am with my brain and as knowledgeable as I am with this medication management problem, I have misconveyed the medications I currently take to my providers. Now imagine you're a Medicare patient and you probably take as many or likely more meds than I do. We see some patients on 50-plus medications. That is psychotically dangerous. Even if you're just on five medications and they come from a few different prescribers, you're likely not communicating effectively with each one of your doctors about what you're taking. You may be picking up medications your insurance company doesn't know about. It's not in your medical record through claims.

Everybody listening probably has experienced personally or seen a love need to manage a complex regimen because they were being hospitalized or they were dealing with chronic care. But since nobody outside of this individual was helping to manage it, mistakes were being made. This is happening because of a gap of information and coordination across the care team and an overwhelming sort of responsibility placed on patients who are sick to make sure all their medication stuff is happening correctly. The support isn't always there because there's not enough time for their doctors to slow down.

There are some things we work to do to navigate these challenges. It's one thing to reconcile a medication list. In fact, you can do med rec and submit this work for payment without ever talking to a patient. Another extreme is you can take the time to go through every piece of medication-related data you knew through claims from the pharmacy benefit manager, the cash pay data from pharmacies, and the coupon data. That's data you can likely also obtain if you slowed down and you had a nice, easy, motivational interviewing conversation with the patient. That's one where you're talking about each medication, and you're talking to patients not just about whether they take a medication but also what do they think it does for them. What they believe about the medication matters. The placebo effect matters. If they have a belief that a medication causes them a terrible side effect, whether true or not, that's something to know and something to deal with because it gets directly to adherence.

If they have difficulty accessing medication because of transportation or money, you're not going to find that out if you don't talk to them. Establishing connections as a care provider who really understands medications — that's really the way to do it, but you can't do it quickly. You need to take the time to do it. What we find is if you take the 30 minutes, the 45 minutes, to establish that connection and have those conversations around medications with patients, it's so much cheaper than a readmission that is more likely to occur without those conversations.

We just reduced readmissions for chronic heart failure patients in a random controlled trial by almost 55% at a four-star hospital. It's unbelievable how much a 30-minute motivational interview and follow-up discussion with prescribers can change the game.

On What Providers Can Do to Overcome Medication Management Challenges

RR: There are varying degrees of idealism here. One of the things providers can do is remember the thing they know, which is that caring for patients requires a team. It's a team of healthcare providers and non-clinicians with differing skills and foci. That's so important. We're getting this abundance of interest now from independent physician associations that in some cases have the benefit of a small clinical pharmacy team they make available to their providers. They're working in areas around triple-weighted adherence, and they are being given the time and bandwidth to keep up with some of those measures, but they want to expand to do all the transitional care stuff, which is harder to do and requires more data.

In a setting like this, recognizing the value of having an expert like a clinical pharmacist look closely at all the medications you may not even see for one of your patients and give you evidence-based advice, which you get to decide whether or not to accept, why would you not want that?

Another thing I would advise would be to look into and understand how you get paid. Be more active in designing the quality measures themselves. Jump in and start to play a role. Speak up about the things you can't see.

Finally, the thing we did that was transformational for us as we metamorphosized from a pure technology and data company into a telepharmacy clinic is we made a commitment to ourselves through our values that we were not going to engage in any business activity whatsoever that didn't benefit the patient with evidence.

Ask yourself: What would your practice look like if every decision you made may be neutral to patient outcomes but sort of favorable to administrative outcomes were scrutinized? What will happen if you do that is, first, you'll have a big stiff drink that night. The second thing you'll do is come back the next day and allow yourself to scrutinize everything and not allow yourself to accept the fee-for-service requirements. You'll sign up for the risk because that's makes patients safer, and they get to spend more of their time at home and in the real world where they belong. In the end, it makes your lives more meaningful. It makes your lives more valuable. It makes your impact more significant.

For us here at Cureatr, it's been like every day is a day of goosebumps. We're literally running Cureatr as a venture-backed company but also as a double bottom line company. We're counting the patients who we are keeping out of the hospital and who we're keeping alive every day. Like most of those in the healthcare industry, that's why we got into healthcare in the first place, so let's get back to it.

Whitepaper: Medication Management Challenges and Opportunities for Payers and Providers

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