PROVIDERS: Medicare coverage represents a significant source of revenue and patients for healthcare providers. The management of chronic conditions constitutes key therapeutic strategies that rely heavily on the use of medications, so expanding our understanding of drug use in this population is important. Medicare Advantage plans have grown and are continuing to grow in popularity among Medicare-eligible patients. Medicare Advantage plans typically offer broad coverage of services and reduced or no-cost medications, depending on the geographic plan area. For chronic obstructive pulmonary disease (COPD), medication use remains a cornerstone of disease management, yet the sustained use of drugs and the appropriate use of short-acting versus long-acting therapies remains problematic in this patient population, as suggested in the study by Xu and colleagues.1 Future studies are needed on this subject, but the studies will need to reach beyond typical clinical metrics–based or traditional care visit–related outcomes to drive market-based solutions more effectively.
Despite the study limitations noted by Xu and colleagues,1 key trends in recent years continue to show a lack of progress in successfully addressing appropriate and sustained adherence with drugs for COPD. Such under- or misutilization of treatments needs to be addressed by healthcare providers as part of shared-risk arrangements with various Medicare plans that are currently on the market. Such collaboration and information sharing would be beneficial to all parties, especially patients in the Medicare population.
PATIENTS: Although the appropriate prescribing of medications has improved the ability to manage COPD better in elderly patients, patient adherence issues persist. Healthcare providers from multiple disciplines could work more effectively with their patients regarding appropriate medication use, but providers also need involvement from patients to manage their COPD effectively. Counterintuitively, health plans have made it easier to get low-cost or no-cost drugs in Medicare Advantage plans, but they have also raised patients’ deductibles, increased the use of tiers and coinsurance, or selected brand-name drugs based on other considerations that collectively have resulted in the underutilization of appropriate drugs by their members. Making coverage simpler, in addition to less costly, would be a welcomed change for patients to optimize the therapeutic outcomes that can lower the total costs of care and out-of-pocket expenses.
Further study of these cost and compliance issues needs to include the patient perspective and input from healthcare providers. Studies that examine different perspectives on these issues will further enhance the possibility of addressing the persistent long-term trend of medication nonadherence.
PAYERS: The study by Xu and colleagues has limitations, as is acknowledged by the investigators,1 yet it continues a long-time trend of medication use issues in the treatment of chronic diseases that have been increasingly managed with prescription medications. For plan sponsors who insure the risk of healthcare (ie, third-party insurance carriers, employers, unions, or municipalities), it remains important to balance the economics of drug coverage with clinical outcomes. Several shifts occurred over the years in Medicare and in commercial plans regarding what factors are driving coverage decisions beyond safety and efficacy.
Economic factors were diverting attention to the end goals of a plan sponsor that includes a fiduciary responsibility. Today, we are seeing a resurgence in consumerism and a shift in Medicare toward a more balanced fiscal approach that includes full transparency of economic considerations. How fast that transparency is implemented remains to be seen, as well as how factors, such as rebates, dissipate from coverage consideration, yet the importance of appropriate medication use remains significant.
The appropriate use of medication, including adherence, could have exaggerated effects on health plan performance and fiduciary responsibility in delivering the promise of the appropriate use of funds to support the health of a covered population. This type of strategy resonates today with third-party administrators and health plan sponsors, but may be lacking in pharmacy benefit managers who have no responsibility for risk or for the health of the population.
F. Randy Vogenberg, PhD, FASHP, is Principal, Institute for Integrated Healthcare, and Board Chair, Employer-Provider Interface Council, Greenville, SC.
1. Xu Q, Laxa SS, Serna O, Sansgiry SS. Medication use before and after hospitalization for chronic obstructive pulmonary disease in a cohort of elderly patients with a Medicare Advantage plan. Am Health Drug Benefits. 2020;13(1):32-42.