The practice of "dispense as written" (DAW) prescriptions — whereby doctors or patients demand the dispensing of a specific brand-name drug and not a generic alternative — reduces the likelihood that patients actually fill new prescriptions for essential chronic conditions and has important implications for medication adherence, according to a new study by researchers at Harvard University, Brigham and Women's Hospital and CVS Caremark. Moreover, this practice costs the healthcare system up to $7.7 billion annually.

The study reviewed 5.6 million prescriptions adjudicated by CVS Caremark for 2 million patients in January 2009. The review found that 2.7 percent of those prescriptions were designated DAW by doctors, while another 2 percent were requested DAW by patients. Researchers found that when starting new essential therapy, chronically ill patients with DAW prescriptions were 50 to 60 percent less likely to actually fill the more expensive brand name prescriptions than generics. "Although dispense as written requests would seem to reflect a conscious decision by patients or their physicians to use a specific agent, the increased cost sharing that results for the patient may decrease the likelihood that patients actually fill their prescriptions," the researchers said.

The study determined that if existing safe and effective generic alternatives had been provided in place of those brand-specific prescriptions, patients would have saved $1.7 million and health plans would have spent $10.6 million less for the medications. The researchers said that assuming a similar rate of DAW requests for the more than 3.6 billion prescriptions filled in the United States annually, patient costs could be reduced by $1.2 billion and overall health system costs could be reduced by $7.7 billion. Annual excess healthcare costs due to medication non-adherence in the United States have been estimated to be as much as $290 billion annually.

According to William H. Shrank, MD, MSHS, of Brigham and Women's Hospital and Harvard, "This study shows that dispense as written requests are costing the healthcare system billions and that patients with prescriptions specifying a certain brand seem less likely to fill their initial prescriptions, adding to the medication non-adherence problem."

"We started out the process of defining activation by first asking whether it is something that we can measure. The first step was to get some clarity on the definition of activation, because people use the term loosely. We went through a rigorous process that included reading the literature, holding patient focus groups and having expert consensus panels. For all of those groups we asked the question, "what does it take to manage successfully when you have a chronic illness?" However, the definition that emerged was that people need to believe that they have a role to play in self-management, in collaborating with their provider and in taking preventive action. They also need to have some skill and confidence."

                                        — Dr. Judith Hibbard, University of Oregon.

An automated patient identification and outreach program can help to ensure that patients with chronic conditions in need of care are engaged in receiving the necessary treatments, according to a Prevea Health study.

The study found that patients who received automated communication messages were more likely to have both a chronic care office visit and an appropriate test than patients who were not contacted. Diabetes patients who were successfully contacted were significantly more likely to have both a chronic care-related visit and an HbA1c test than their counterparts who were not contacted. Also, hypertension patients were significantly more likely to have both a chronic care-related visit and a systolic blood pressure reading recorded in an EMR.

Richard Hodach, M.D., M.P.H., Ph.D., chief medical officer of Phytel, commented, “This important study demonstrates the utility of the use of automated population health management capabilities to improve healthcare quality and contain costs. The automation of preventive and chronic care can help physicians and healthcare systems keep patients engaged in their recommended care and are a prerequisite for the success of patient-centered medical homes, accountable care organizations, and future healthcare delivery models that depend on care coordination and population-based health improvement.”

Prevea’s automated patient identification and outreach program uses data feeds from Phytel's practice management system. This service builds a registry of patients who require preventive and chronic care. Based on nationally validated, evidence-based protocols, the technology triggers automated messaging to patients when they are due for office visits, tests or other services.

In this month's healthcare performance benchmarks podcast, Healthcare Intelligence Network's Melanie Matthews analyzes the industry's acceptance of and participation in accountable care organizations derived from HIN's February 2011 survey results.

This podcast also features Jeffrey Ruggiero, Esq., who advises ACO participants to prepare for the legal and regulatory hurdles.

Even in a fragile economy health and wellness coaching programs are flourishing. We wanted to see what ROI was generated from health coaching programs.

Question: What is the most effective way to get a patient to follow through on education, make an appointment with a physician or take medicine as ordered?

Response: There is no easy way. At any given day and time, getting someone to take a medication or make an appointment may have different barriers. However, presenting what you want people to do in an easy way that they can understand, afford and feel is going to help them is going to maximize effectiveness. People are less likely to make an appointment if they have to sit on hold for 45 minutes to have a conversation with their doctor’s office. They are less likely to visit the office if the doctor is only available Monday through Friday from 9 a.m. to 5 p.m. because they would have to take a day or part a day off from work. They are not going to take their medication if they don’t understand why it is going to help them, if it is too expensive or if they feel like it could make them sick instead of healthy. Therefore, making instructions understandable, easy and affordable is going to help in all of those areas.

(Jan Berger, MD, chief medical officer for Silverlink Communications, Inc.)

In tandem with adoption of post-reform care delivery models like the patient-centered medical home (PCMH) and accountable care organization (ACO), healthcare organizations are constructing payment and compensation models that reward physicians for improving population health, the patient experience and per capita cost — approaches that may lure more medical residents back to primary care. The Guide to Physician Performance-Based Reimbursement: Payoffs from Incentives, Data Sharing and Clinical Integration explores newly minted reimbursement formulas at two health plans and two independent practice associations (IPAs), providing payor and provider perspectives on the formula development process; clinical, quality and efficiency measures in use; physician incentive payments and program outcomes. This 60-page special report also examines the collection and sharing of physician performance data by these four organizations and the impact of data sharing on physician engagement, health outcomes, utilization and cost.

HealthCoach Huddle subscribers should use ordering code HCH to purchase this product at a special price!

This white paper captures the ways in which 161 organizations are implementing health coaching in 2010 — including the top three areas targeted by health coaching — as well as the financial and clinical outcomes that result from this health improvement strategy. These benchmarks are based on organizations' responses to the Healthcare Intelligence Network August 2010 e-survey on health coaching.