Terry McInnis, MD, MPH, CPE, is one of the leading healthcare experts recently named to Cureatr's Strategic Advisory Board, which is providing expertise, insight, and guidance to the company's management. Dr. McInnis is the founder and president of Blue Thorn, a healthcare and policy consulting firm. She is a physician executive with 25 years of experience in clinical practice and leadership positions in military and civilian hospital/private group practice settings. She has also served in multi-national corporate medical director roles.
Dr. McInnis sat down with Cureatr to discuss challenges and opportunities around care coordination and medication management.
Q: Where do you think the U.S. healthcare system has made the biggest gains in improving care coordination in recent years?
Dr. Terry McInnis: I'd say that the biggest improvements in care coordination have been on the provider side. If you look at how we've progressed toward value-based care, vertical integration, and the movement of risk toward the delivery system, you've seen more of an emphasis on care coordination that the fee-for-service system does not align with at all.
Consider some of the earlier gains we saw around hospital readmissions and reducing the 30-day readmission rate. Before any of the financial alignment was in place to support such improvements, you didn't see much care coordination on the provider side. As we've seen more risk shifted, we've seen a bigger emphasis on care coordination during transitions of care or visits between providers and specialists with the goals of reducing total cost of care and improving outcomes.
Even though we're seeing more care coordination in our delivery system, we're somewhat stuck in this middle ground because a lot of the basis for care is still rooted in the fee-for-service side. This is not where it needs to be, but we're making progress. In those pockets around the country where we're still very much engrained in fee-for-service, what we can do is continue to move at a faster pace toward risk. It needs to be a continuum.
Q: Medication management has long been understood as a significant challenge, yet it remains difficult. Why is that the case?
TM: There are a lot of reasons. If you think about the traditional fee-for-service system, there's no financial incentive to keep people well. Under that system, you don't get paid when people are not in the office or hospital. Managing medications to optimize patients' outcomes was not really a focus or service that was paid for. In fact, one study showed that physicians spent just 49 seconds on average discussing new medications during patient visits.
If you go back 25 years or so, a lot of the medications in the market were prescribed by primary care. Most of the medications that are now coming into the pipeline are drugs that various specialists will prescribe. What we find is that there are essentially no providers who understand all of the medications, and particularly the interactions of those medications. Medication management has become a much greater challenge with the newer and innovative medications. Management becomes even more complex for those patients with multiple chronic conditions who are seeing multiple providers and being prescribed multiple, specialized medications.
The other element to consider is that if you look at the role of pharmacists, the way they have typically been compensated in the United States is around dispensing medications. Pharmacists are not recognized as providers under the Social Security Act, so, for the most part, their services have not been paid for.
Yet, consider that pharmacists go to school for four years to earn a Doctor of Pharmacy degree, many have residency training, and there is now board certification. So, here we have these experts in medication, which is great. But their utility, especially within the ambulatory care side where pharmacists are increasingly working with patients to integrate medications and working collaboratively with various physicians, is not at the level it needs to be.
We see pockets where such utilization is occurring very successfully, such as the Department of Veterans Affairs (VA). It has around 4,500 clinical pharmacists who work collaboratively with physicians and other providers. I was informed by Anthony Morreale, PharmD, MBA, BCPS, FASHP, associate chief consultant for clinical pharmacy and policy for the VA's pharmacy benefits management service, that these pharmacists were responsible for 6.5 million patient encounters in fiscal year 2020 and they were able to add, change, and modify 95% of the drugs through collaborative practice agreements without needing to go back and ask a physician or other provider prescriber to make those changes.
When we have such systems in place, whether at the VA or what we've seen in organizations such as Fairview Health Services, Kaiser Permanente, or other more innovative systems, we've seen some real inroads in terms of the successful management of medications. If we can further financially align and recognize the role that clinical pharmacists can fill concerning medication management, that will be huge. We've seen similar success with social workers and recognizing the key roles that behavioral health specialists and case managers can play on a patient's care team.
Q: What are some steps organizations should take to better understand where they're struggling with medication management and where the opportunities for improvement exist?
TM: In terms of organizations, let's first look at the delivery side and provider groups. They need to do a good job with their population risk management to determine which patients are truly having issues with medication management. Part of the way to do that is actually looking at those patients who have not achieved their clinical goals of therapy.
For example, consider a diabetic who is out of control, a patient with hypertension whose blood pressure goals have not been met, or a patient who feels depressed. By definition, all of those patients have a drug therapy problem. Medications are estimated to be 80-85% of the means by which we either prevent or control disease in this country. If patients have not reached their clinical goals of therapy for most conditions, that likely means their medications need to be more effectively managed. We certainly must continue to look at all sorts of factors, such as exercise, disease prevention, and eating right, but we cannot ignore that 80-85% of the equation, which is effective use of medications.
The other aspect I think we must look at from the organizational level is what I feel is an over-reliance on clinical guidelines. Clinical guidelines are generally good for about 80% of the target population. That has its limitations. We must get into more of a personalized approach to medications.
Take an 85-year-old patient who is frail and has mild dementia. Does this individual really need to remain on statin medication? Does their diabetes need to be as tightly controlled? We need to individualize our approach to patients. That's why, especially in the elderly population, we've seen an increasing emphasis on what's called "deprescribing." This entails better ensuring that patients are on medications that make sense for them now. This means they're not still taking medications that are no longer indicated and are also not on medications contributing to increased morbidity and mortality.
When you're looking at which patients need better medication management, you must perform that population segmentation and then figure out which opportunities are most worth pursuing. A good place to start is by closely reviewing hospitalizations, emergency room (ER) visits, and the diseases that are not controlled.
Another type of organization that should look into opportunities for improvement is health plans. The Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare star ratings place a lot of emphasis around "adherence." I believe that's a problem. What we find when looking at whether a patient is on a medication related to a condition is that they may be adherent to the medication, but that doesn't mean the condition is under control. We need to look at more than just whether a patient is on a medication. Are they on a medication that is actually the right dosage? Does it actually have their disease under control? This means going beyond just looking at raw adherence numbers.
One of the steps we can take is to begin looking more closely at those patients at higher risk for hospitalizations and ER visits who haven't met clinical goals. These can be the patients to target with comprehensive medication management (CMM). If you look at drug therapy problems, one study showed that nonadherence is about 16.5% of all drug therapy problems. Issues like untreated indications, incorrect dosages of existing drugs, or wrong drugs entirely are much more common drug therapy problems.
Health plans can play a role here by working to take a holistic approach to patients and beginning to implement benefit designs and payments that emphasize medication management as a key to reducing total medical costs, not just as a key for reduction of pharmaceutical spend.
Q: What can we learn from the pandemic that can be applied to strengthen our healthcare system?
TM: I think the pandemic has taught us a lot about our healthcare system. It has really pushed virtual care to the forefront, highlighted the need for it, and demonstrated that a lot of virtual care can be performed successfully. It has also shown us what can't be done in a virtual scenario.
The pandemic has shown us that delivery systems which had not moved more toward value-based models, capitation and taking on risk were the systems most negatively impacted by COVID-19. We saw this accentuated for groups such as independent physicians who are largely depending on that fee-for-service, face-to-face visit for income. It was much easier for those systems that had already taken on risk to pivot to other forms of care coordination and virtual visits. We are seeing more recognition that moving to risk is good. I expect the pandemic will further accelerate this trend.
We also learned that the need for integrated medication management is huge. Patients, especially those with multiple chronic conditions, often need to undergo continual checks and sometimes require changes to medications to keep their conditions under control. For example, if you have a patient with congestive heart failure who starts gaining weight, you must adjust their medications. We've also seen how you can begin to integrate the necessary team members like clinical pharmacists and social workers in a virtual way to begin to address some of those problems.
Finally, we are gaining a greater appreciation for how we need to use analytics and data more effectively, especially for population health management.
Q: How do you view the role that Cureatr's technologies and services are playing in helping to improve healthcare delivery?
TM: I think what Cureatr is doing is critical. With its Meds 360° platform, Cureatr is able to show the drugs a patient has been prescribed from multiple sources and whether the patient has filled those prescriptions. When you are able to pull this information — and in fairly real time — that is immensely helpful in making informed decisions about changes to a regimen. To know whether my patients are actually picking up their prescriptions is key, especially when I can support this patient virtually.
Combining that offering with Cureatr's clinical pharmacy services are parts of the solution. Putting all the different facets together in terms of integrating medication management and achieving a more comprehensive approach to medication management is our holy grail.