Previous articles in this series looked at barriers to taking medication and possible solutions, including special conditions that produce challenges. This final article in the series turns the question on its head. Can patients get better without the medications?
Dr. Omar Manejwala, CMO of DarioHealth, goes so far as to use the terms “paternalistic” and “infantilizing” to label claims that people fail to take medication solely out of ignorance or forgetfulness. To all the other factors that hold people back from taking their meds, he adds social and religious factors, concerns about side effects and interactions, the stigma to admitting that the patient has a condition (particularly concerning mental health), and sometimes even opposition by family members.
Many of my respondents said that clinicians must, foremost, get onto the patient’s level. In a small sample of 15 hypertension patients, a survey found that clinicians undervalued self-management. Patients need a lot of help adopting a lifestyle that can reduce their risk, monitoring their progress, and uplaoding the results of monitoring to their portal.
Rich Steinle, CEO of Carium, emphasized that medication is part of a holistic approach to health that includes exercise, lifestyle, mental state, and other health care conditions. He asks, “How does medication fit into the rhythms of your life?” Similar concerns were cited by Dr. Paul Peak, vice president of clinical pharmacy at Sedgwick.
The patient can be encouraged to adopt better habits by family, friends, and even a community institution like a church. Steinle says that social workers often operate out of a church.
Bryan Hill, VP of digital health and innovation at Cognizant, offered a theoretical grounding for behavior adjustment: the Fogg Behavior Model that asks the person to define motivations, triggers, and abilities. He also acknowledged the influence of family members, friends, and the patient community.
First Do No Harm
Dr. Mitzie Meyers, Nursing Professor at Pacific College, also reminds the clinician to treat the relationship with the patient as collaborative, not patriarchal.
Let’s make sure, she says, that we really need to prescribe a medication. Antidepressants and anti-anxiety drugs are overprescribed. Patients ask for antibiotics for a viral infection that won’t respond to them, and the notorious direct-to-consumer advertising encourages patients to ask for expensive drugs that don’t benefit them. Weaning off a medication can also be complicated and hard.
Dr. Charles Lee is senior director of clinical knowledge at Meducation, part of FDB (First Databank). He pointed out that the more medications someone takes or the more multi-day dosing they have, the less they’re likely to adhere to their regimen. So doctors should try to consolidate medications and simplify the regimen. At each clinical visit, the staff should help the patient develop a schedule and remind the patient of the purpose of each medication.
The article Cost of Prescription Drug-Related Morbidity and Mortality, recommended to me by Jason Rose of AdhereHealth, suggests that medications themselves can cause symptoms, and require careful review. The article recommends comprehensive medication management (CMM) and medication therapeutic management (MTM), which are comprehensive and holistic.
Alternative Medicine
Alternatives to medication are growing in popularity. Even CMS has admitted that alternatives to conventional medicine, such as acupuncture, can be effective and should be considered for risky situations such as chronic pain. Taking advantage of the body’s and mind’s own healing powers, through art, singing, dance, etc., are a low-cost intervention without side effects.
I talked to Rachel Francine, CEO of SingFit, which offers therapeutic music. Singing helps balance endorphins, dopamine, and melatonin and releases oxytocin. It can improve mood and reduce agitation, which makes it useful for people with dementia. SingFit finds that their practice can reduce the need for the anti-anxiety and anti-dementia PRNs.
Associate professor Caroline E. Ortiz, who teaches holistic nursing at the Pacific College of Health and Science, says that a patient might have many reasons to alter or divert from the medical plan, and might not inform the healthcare provider aboiut not taking the medicine as prescribed.
She pointed out that many people are members of ethnic cultures that have their own deeply embedded traditional remedies and treatment approaches. The patient might harbor a preference for remedies tied to that culture. The patient may well also feel more comfortable talking to a community member knowledgeable in traditional remedies than to a healthcare provider in a payer-funded institution. Ortiz herself researches the use of traditional Mexican medicine in the United States.
All You Have To Do Is Ask
Many of my respondents said the doctor must talk to the patient and ask questions directly. Ortiz said that open communication is invaluable, based on mutual trust between the healthcare provider and the patient. A key part of optimal medical management is asking direct questions and listening to the patient’s verbal and non-verbal responses.
Does the patient have problems with cost or with access to medication? Does the medication fit their schedule and habits? Would they prefer a different treatment approach? Perhaps a change in medication is required because of the patient’s available resources of other barriers to following the treatment plan.
Ortiz talks about connecting patient needs with assistance from family, friends, a nursing agency, or other help. Dr. Peak similarly said, “Help people take ownership of their own care.”
Of course, our reimbursement system doesn’t allow time for such conversations. But because lack of medication adherence can have such dire effects, a fee-for-value system should encourage dialog. The clinicians then have to learn how to hold the dialog with sensitivity.
Another article recommended by Rose points out that medication adherence for some of the most important and effective medicines (statins, hypertension, diabetes) directly determine about 9% of the Star Ratings for Medicare Advantage health plans. However, when CMS calculates the overall Star Rating score with the “adherence multiplier,” the reality is that more than 50% of the actual weighting can be attributed to medication adherence. The ratings thus add tremendous pressure to engage patients to improve this value-based care outcome. Each year, the best Medicare Advantage health plans (as defined by their Star Ratings) can gain a portion of the $50 billion in available revenues.
Medication Adherence in Context
This series, based on several studies along with interviews with more than a dozen clinicians and health IT company managers, has shown IT can play a role in improving medication adherence, with help for everything from cost to reminders. But the clinician must always remember that treatment is meant to improve the life of the patient, and the way the patient views their life may be quite different from the doctor’s viewpoint. Whether the doctor seeks improved adherence or an alternative treatment plan, the relationship with the patient remains central.
