Proportion of Days Covered (PDC) CMS Adherence Measure Explained.

I received a letter the other day from  MedicareBlue Rx (a Medicare Prescription Drug Plan) titled as an Adherence Improvement Opportunity. According to the letter I received:
The Centers for Medicare and Medicaid Services (CMS) recently added medication adherence measures to their reported patient safety measures.  CMS uses the Proportion of Days Covered (PDC), developed by Pharmacy Quality Alliance, to calculate adherence.  Based on this, a patient who has a PDC rate of at least 80 percent is considered to be adherent.
Here's a good link describing the methodology of the medication adherence measure using pharmacy claims data to calculate the proportion of days covered.  In other words, as I understand it,  CMS is trying to define how adherent you as a patient are to your prescription medications based on how often you fill them (using drug claims data linked with medical claims and enrollment data).

CMS currently calculates and reports on several patient safety measures, including Part D medication adherence to treatment for cholesterol (Statins), hypertension drugs (ACEi or ARB) and oral diabetes medications (Sulfonylureas, Biguanides and Thiazolidinediones).   According to the first link above, the medication adherence rate for all beneficiaries in Part D plans was just over 60%.  That's 60%.  That's not surprising to me given that research has shown just 10% of patients given free heart medications after an MI continued to fill them one year later. 

The letter I received continued:
In an effort to promote adherence, we used our pharmacy claims database to identify patients on select chronic medications with a PDC less than 80 percent for whom you have prescribed medication.  A profile for each of your patients is enclosed.

Lower medication adherence is a major cause of hospitalization, poor health outcomes (including death) and increased overall health care costs.  Higher adherence rates have been associated with lower health care costs and better health care outcomes.  One study found that patients with diabetes, hypertension or hypercholesterolemia with high medication adherence (80-100%) had reduced hospitalizations and lower health care costs compared to less adherent patients.

Reasons for non-adherence may include side effects of the drug, cost of the drug, lack of perceived benefit and/or forgetfulness.

In addition, studies have found that lower member cost share is associated with improved medication adherence.  When prescribing therapy, please consider the use of a generic drug.  Generic drugs cost less.  Your patients may benefit directly; most have a lower cost share for generic drugs.  This is especially true for patients who may enter the Part D 'Coverage Gap' and struggle to pay high prices for brand-name medications.

Medication adherence is an important factor in maintaining patient safety and containing health care costs.  Please evaluate the adherence rate of your patients in the attached profiles.  If  non-adherence is a significant issue, please discuss solutions to address non-adherence with your patient.

Note:  this information is not intended to replace your clinical judgement. Prescription claims data do not include many other patient-specific variables needed to completely interpret the appropriateness of a drug regimen.  Only you, in direct consultation with your patient, may determine a patient's true adherence to medication.


Signed with a signature stamp

David E. Pautz, MD, FACP  Senior Medical Director, Government Programs
Along with this letter I received notification of one patient who had last filled their lisinopril over 6 months ago.  I presume this patient was  flagged for my review as not being adherent to their medication regimen.  I presume I was notified because I probably ordered this blood pressure medication when they were discharged from the hospital at some time in the past.

This letter was intriguing on so many levels.  The most concerning to me is that I am a hospitalist.  I am left wondering if Dr David Pautz needs to ask himself what a hospitalist is because where I'm sitting in the peanut gallery, hospitalists are not involved in the month to month management of medication adherence after the patient gets their formal hospital summary of discharge sent to the primary care physician.  I'm sure most hospitalists have never heard of proportion of days covered (PDC).  And I'm pretty sure most hospitalists have no ability to counsel their discharged patients about medication adherence.  I can guarantee with 100% certainty that the only action most hospitalists will take with this letter is to throw it in  the trash.

In fact, I'm probably sure most primary care physicians will as well.   They simply  don't have the labor intensive time to discuss  the dozens of potential reasons why Mrs Smith was flagged by CMS for not taking her lisinopril as prescribed.  And CMS just doesn't want to pay for the time intensive resources necessary to adequately provide this consultation.  Between the ten complicated chronic  medical problems, the list of 25 medications and the last minute complaints of  "Oh, by the way  I'm tired, I have no energy and  I've been dizzy", outpatient internists and family medicine doctors simply don't have the time to pursue these labor intensive discussions being requested by David E. Pautz, Md, FACP, Senior Medical Director, Government Programs

What are my concerns with CMS tracking patient medication adherence rates?  It's Big Brother at its finest.  While the federal government investigates Google and Facebook for privacy concerns, they are deeply involved in their own crusade to define everything about you.  And you probably have no idea it's happening.

 Of course, the first question I must ask is who will have access to this data?  You may not know it but data about you is worth its weight in gold to someone somewhere. Whether you are in the category of 80% or higher in proportion of days covered or whether you are in the 20% is important to someone somewhere.  And whether we like it or not, that data will be bought and sold like anything else that carries intrinsic value.

What are some possible repercussions for you, the patient or for doctors carrying for these patients when this data does get into the hands of businesses who can use it to make or break their business model?  Someday, this data, like all data, can be used against you (or for you if you are determined to be compliant with your doctor's recommendations).  And if you think this data stops with Medicare, think again.  It will be used by your private medical insurance as well and sold as a revenue opportunity for insurance companies looking to increase alternative sources of revenue:

Consequences For Patients with low patient medication adherence and proportion of days covered. 
  • You may be charged more for your Medicare or private insurance premiums or be required to pay higher copays and deductibles.
  • You may be denied certain medications, treatments, procedures or surgeries, based on expected algorithmic complications of poor medication adherence.   
  • Businesses may use this to increase collections efforts or to write it off as expected bad debt.
  • You may be denied as a patient in doctors offices who will be financially penalized for having an overall patient population with low medication adherence rates.
  • You may be denied health insurance (I would not expect medication adherence to be considered a preexisting medical condition), life insurance, credit cards, car loans, mortgages or you may even be denied opening a bank account based on your medication adherence rates and their actuarial defined association with credit risk.  
  • You may be denied the right to foster children or gain custody of your children if you are considered unable to take your medications appropriately.
  • You may be denied parole  or be considered a high risk re-offender for being a high risk of failing to comply with the rules.
Consequences for Doctors with low patient medication adherence and proportion of days covered.
  • Doctors may be penalized by Medicare or their private insurance companies and receive lower payment for services provided if patient adherence rates are suboptimal
  • In a bundled care and or  accountable care organization model, patients with lower medication adherence will require a higher utilization of resources  with a potentially higher risk of failure to meet defined thresholds of success and overall reduced profit potential when these goals fail (and they will because patients don't live in an ACO bubble).
  • Physicians may get fired from their hospital owned jobs for having suboptimal patient medication adherence rates which will threaten hospital revenues. 
  • Physicians may open up clinics on more affluent areas of a city to avoid being penalized with  low patient medication adherence rates, reducing critical access to inner city populations.
Consequences for Hospitals with low patient medication adherence and low proportion of days covered.  
  • Like other ORYX measures, it may someday be used as a factor to determine how hospitals get paid by Medicare.  Look for hospital profit margins from Medicare to continue their assault downward.  
  • Patient medication adherence rates may someday be used to deny payment for 30 day hospital  readmissions.  
  • Hospitals may use this data to increase collections efforts or to deny assistance for their outrageous medical bills.
  • Hospitals may close for their inability to control what patients do outside of the hospital.
When you have data like this that has profound implications across many aspects of American business, I can assure you that eventually, whether you are labeled as a patient with good medication adherence characteristics or not, will be used either to your benefit or to your detriment.  Discrimination against smokers and patients with morbid obesity is just the beginning.  Be prepared for the next wave of making patients pay for the right not to accept personal responsibility for their actions.  Unfortunately, it's going to drag doctors and hospitals through the mud in order to get there. 

Facebook education:
This is from my files:  I got a letter from a company called "Prescription Solutions". They apparently administer an opiate drug utilization review program for a Medicare prescription drug plan with the goal to improve outcomes and promote the safe use of medications. What did I discover? On that letter was the name of a patient I saw over six months prior. Apparently, I had prescribed opiates to the patient, one of over a dozen doctors to do so in a three month period. 
December 2009 Hydrocodone/APAP 5/325 #40 Dr #1 Pharmacy #1
December 2009 Hydrocodone/APAP 7.5/500 #50 Dr #2 Pharmacy #2
December 2009 Hydrocodone/APAP 5/500 #50 Dr #3 Pharmacy #2
December 2009 Hydrocodone/APAP 7.5/500 #30 Dr #4 Pharmacy #2
December 2009 Hydrocodone/APAP 5/325 #20 Dr #5 Pharmacy #3
December 2009 Hydrocodone/APAP 2.5/500 #40 APRN #6 Pharmacy #4
January 2010 Hydrocodone/APAP 2.5/500 #50 Dr #7 Pharmacy #2
January 2010 Oxycodone 5 #60 Dr #8 Pharmacy #3
January 2010 Oxycontin 40 #60 Dr #8 Pharmacy #3
January 2010 Oxycontin 20 #20 Dr #9 Pharmacy #2
January 2010 Hydrocodone/APAP 5/500 #30 Dr #10 Pharmacy #2
January 2010 Hydrocodone/APAP 7.5/500 #30 Dr #11 Pharmacy #2
February 2010 Oxycontin 10 #20 Dr #12 Pharmacy #2
February 2010 Oxycontin 10 #20 Dr #13 Pharmacy #2
February 2010 Percocet 5/325 #12 PA #14 Pharmacy #3 
That's what you call doctor shopping. That's over six tablets a day, every day, for three months straight. Assuming one sleeps eight hours a day, that's one tablet every three hours, for three months straight. 
And guess what. Opiates are a regulated drug. Is this what you call regulation? Makes you wonder how much worse it could be if opiates weren't regulated. Lends strength to the argument of deregulating all drugs, prescription or otherwise...
Because it doesn't work... 
At the end of the day, these kind of programs don't work because I'm a hospitalist and the data is 6 months old. And like all these forms it get every day, I say, why would I care? What can I do with this information? 

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