Testing, Testing… $, $$, $$$

healthcare-costsIf doctors knew the exact price of expensive medical tests would they order fewer of them?

That’s exactly what Johns Hopkins researchers wanted to know.

The answer has just been published in the Journal of the American College of Radiology, and it’s a resounding: No!.  According to the investigators, revealing the costs of MRIs and other imaging tests up front had no impact on the number of tests doctors ordered for their hospitalized patients.

Cost alone does not seem to be the determining factor in deciding to go ahead with an expensive radiographic test,” says the study’s senior author, Daniel J. Brotman, M.D., director of the hospitalist program at The Johns Hopkins Hospital. “There is definitely an over-ordering of tests in this country, and we can make better decisions about whether our patients truly need each test we order for them. But when it comes to big-ticket tests like MRI, it appears the doctors have already decided they need to know the information, regardless of the cost of the test.”

MRISome earlier studies have suggested that much of the expense of laboratory tests, medical imaging and prescription drugs is unknown or hidden from providers and patients at the time of ordering, leaving financial considerations largely out of the health care decision-making process and likely driving up costs. Other studies have shown that doctors ordered fewer laboratory tests in some cases when they were given the price up front.

But, imaging tests appear to be “a different animal.”

Although there are certain inherent disincentives, aside from cost, to ordering some major tests, such as the potential danger of radiation used, physicians also need to learn how to explain to patients why they may not need them.

For the six months of the study, Brotman and his colleagues identified the 10 imaging tests most frequently ordered for patients at The Johns Hopkins Hospital. Five of these were randomly assigned to the active cost display group and 5 to the control group. During a 6-month baseline period from November 10, 2008, to May 9, 2009, no costs were displayed. During a seasonally matched period from November 2009, to May  2010, costs were displayed only for tests in the active group. At the conclusion of the study, the radiology information system was queried to determine the number of orders executed for all tests during both periods.

And, when they compared the ordering rates to the rates from a six-month period a year earlier, when no costs were displayed at all, they found no significant difference in ordering patterns.

Is this a good or a bad thing?

MRI of strokeCertainly there are many instances when expensive tests are justified. When a key diagnosis is needed there are limited options for comparison shopping.  For example, when a patient appears to have had a sub-acute stroke, an MRI is needed regardless of cost.

That is not to say there aren’t times when physicians need to look more closely at whether too many imaging tests are being ordered. Do ventilated intensive care unit patients really need a daily chest X-ray to look for potential lung problems?  Especially when there is good medical evidence that outcomes aren’t compromised if X-rays are ordered only when the patient’s condition appears to be worsening.

For too long, there has not been enough attention paid to the bottom line in health care,” Brotman says. This isn’t about rationing care to hold down costs, he says, but about choosing tests a little more wisely.

health-care-costEven though price transparency didn’t influence the way physicians ordered imaging tests in this study, financial considerations may play a role in other circumstances if tied to clinical evidence.

If you show a provider that he or she is ordering four times as many CT scans as a colleague whose patients have similar outcomes, it could change the decision-making calculus for the better.

Cost transparency must be part of the solution to solving fiscal challenges in medicine,” Brotman says. “Providers have no idea how much they’re spending. Patients don’t know either. Having everyone understand more of the economics of health care is a great place to start cutting costs in medicine.”

Seems logical to us.

SRxA-logo for web

A quarter of patients do not fill new prescriptions

As our regular Word on Health readers will know, I’ve had more than my fair share of trips to the pharmacy recently.  Painkillers, antibiotics, anti-inflammatories…the list goes on.  It’s not that I like taking tablets, I needed them.  Having taken time out of my busy life to see a doctor and get a prescription it would never occur to me to leave it languishing in the bottom of my purse.  However, according to a new study almost 1 in every 4 American’s does just that.

The study, published in the November issue of the American Journal of Medicine, evaluated more than 423,000 e-prescriptions written in 2008 for more than 280,000 patients. It was conducted by researchers at Harvard University, Brigham and Women’s Hospital, and CVS Caremark, who matched e-prescriptions with resulting claim data or those who did not claim prescriptions within 6 months.

What they found was that 24% of patients given a new prescription did not fill it. This percentage is higher than that seen in earlier studies.

While some recent research has used e-prescribing data to evaluate primary non-adherence, we were able to study a nationwide sample of patients. Our finding that 24% of patients are not filling initial prescriptions reflects slightly higher primary non-adherence than seen in earlier studies,” said Michael Fischer, MD, MS, with Brigham and Women’s and Harvard Medical School, and lead author of the study.

Most prior research about medication adherence could not review prescriptions that were never filled by patients. However, the advent of electronic prescribing has provided an opportunity to track initial prescriptions that may have been previously undetected and gives healthcare providers a broader look at patients who never fill their prescriptions.

Researchers said the factors that are predictive of primary non-adherence include:

  • the out-of-pocket cost of medications
  • socioeconomic factors
  • the integration of doctors’ health information systems
  • the types of medications.

Prescriptions that are sent directly to mail-order systems and pharmacies are more likely to be filled than e-prescriptions that doctors print out and give to patients, according to the study. The researchers found that medications for hypertension and diabetes resulted in primary non-adherence rates in excess of 25%, while prescriptions for antibiotics and medication for infants were almost always filled.

SRxA works closely with a number of leading health outcomes experts and specializes in providing effective patient adherence programsContact SRxA today to learn more.

Putting an “i” in adherence!

Poor adherence to medications has been a bugaboo in the healthcare system for a long time. When sick patients don’t take their meds, they often get even sicker and end up in the hospital.  According to the New England Healthcare Institute, patients who don’t take their medicine when they’re supposed to cost the U.S. healthcare system a mind-boggling $290 billion per year.

This problem caught the attention of entrepreneurs from MIT and physicians affiliated with Harvard Medical School and has led to the creation of several innovative solutions. Among these is an electronic pill box called “Maya” that uses wireless technology and sensors to alert patients with chronic diseases when they don’t take their pills on time.

Another medication-reminder technology is GlowCaps.  These “intelligent” caps fit onto standard pill bottles and use light and sound to signal when it is time to take a pill. They also sense when the bottle is opened and wirelessly relay their status to a secure network. If the bottle is not opened after two hours, the user is automatically reminded with a telephone call.  Additionally, each week, a report summarizing progress is emailed to the user or care-giver. The caps can even call with refill reminders and connect the patient to their pharmacy as pills deplete.

Other solutions include iPhone apps such as MediMemory.

One company has even developed pills that deliver wireless signals after they are swallowed.

Even though such systems have shown to be effective, there’s still a question of who should pay for the technology. “The way that the economic models are currently set up,” says Joseph Kvedar, director of The Partners Healthcare Center for Connected Health , “it’s the patient’s responsibility to take their medication, and nobody will give them a cash subsidy to cover a program like this.”

Given that costs increase dramatically when patients don’t take their drugs, Word on Health suggests it’s about time insurers started paying attention to initiatives such as this.

In the meantime, SRxA’s Health Outcomes group are standing by to help pharmaceutical companies improve patient adherence to their drugs.  Contact SRxA for more information.

Pharma’s Missing Millions

As Word on Health has previously reported, patients not taking or refilling medications on time costs the pharmaceutical industry billions each year.  The recent global economic crisis has helped write a whole new chapter in the adherence story.  Higher numbers of new prescriptions simply go unfilled because patients either cannot afford, or are unwilling, to pay for them.

In the U.S., the total number of prescriptions filled grew a modest 2.7% last year. Yet the rate of prescriptions submitted to a pharmacy but never picked up rose 24%.

According to Dea Belazi, a consulting practice leader for Wolters Kluwer Pharma Solutions,  “What’s peculiar is that the rate of increase among patients walking away is almost unprecedented. Over the last two years, pharma has been trying to understand the abandonment situation, particularly in which parts of the country patients tend to abandon more.”
Among commercial health plan patients, the abandonment rate for new prescriptions at the pharmacy reached 6.3% in 2009. The abandonment rate for new prescriptions of brand-name drugs alone was 8.6%, up 23% from 2008 and nearly 70% since 2006.

Rising co-pays are one reason.  However, macroeconomic factors such as the housing crisis, subsequent recession and lower household incomes are thought to be the main culprits behind rising price sensitivity and soaring abandonment rates.
Health plan denials compound the problem.  Taken together, patient abandonment and payer denials resulted in 14.4% of all new, commercial-plan prescriptions going unfilled in 2009, a 5.5% increase from 2008.
Where can pharma go from here? Abandonment varies geographically. It is highest in Delaware, North Carolina and Florida, whereas denial rates for new prescriptions of brand-name meds are highest in California, Delaware and Florida.

SRxA’s team of world class Health Outcomes experts can help create tactics and strategies to help pharmaceutical companies address abandonment, denial and compliance. Contact us to find out more.