Thinking Outside the Pillbox? Scary implications.

This New England Journal of Medicine article has scary implications limiting personal freedom for everyone. This plan would attempt to mandate drug compliance, extend availability of your electronic health records to related industries such as pharmacies, follow-up by nurses for adherence, and the use of Health Care Courts, denying your access to due process. Any HCP in the system can diagnose you. For example: "Finally, there needs to be greater use of proven screening and assessment tools to identify and target the patients who are at the greatest risk for nonadherence. Treatment guidelines for chronic conditions, for instance, should recommend screening for depression, which can be an indicator of poor adherence."

Thinking Outside the Pillbox — Medication Adherence as a Priority for Health Care Reform
As many as half of all patients do not adhere faithfully to their prescription-medication requirements, and the result is more than $100 billion spent each year on avoidable hospitalizations. David Cutler and Wendy Everett discuss how to improve medication adherence.

April 7, 2010 (DOI: 10.1056/NEJMp1002305)

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Thinking Outside the Pillbox —Medication Adherence as a Priority for Health Care Reform

Posted by NEJM • April 7th, 2010 • Printer-friendly

David M. Cutler, Ph.D., and Wendy Everett, Sc.D.

Poor adherence to treatment regimens has long been recognized as a substantial roadblock to achieving better outcomes for patients. Data show that as many as half of all patients do not adhere faithfully to their prescription-medication regimens — and the result is more than $100 billion spent each year on avoidable hospitalizations.¹ Nonadherence to medication regimens also affects the quality and length of life; for example, it has been estimated that better adherence to antihypertensive treatment alone could prevent 89,000 premature deaths in the United States annually.²

What is less clear is why adherence to the 3.8 billion prescriptions written every year is so poor. Out-of-pocket costs for medication clearly affect adherence; people use more drugs when the prices of the drugs are lower. But even if drugs were free, nonadherence would persist: one recent study showed that even among patients who have health plans with no cost sharing for medications, rates of nonadherence were nearly 40%.³

Lack of coordination of care is another major factor. There is much more that could be done at the time a physician prescribes a medication to optimize and tailor regimens for individual patients. For patients with coexisting conditions who take multiple medications prescribed by multiple physicians, there is a vital need to reconcile the prescribed regimen with what a patient is actually taking and to understand why there is a difference between the two. But optimizing and reconciling medications require substantial investments of time by a skilled health care practitioner, as well as electronic data sharing among practitioners — neither of which is widely available in today’s model of health care delivery.

There are also numerous factors that affect adherence at the individual level, including lifestyle, psychological issues, health literacy, support systems, and side effects of medications. Indeed, patients’ personal attributes probably have the strongest influence on adherence. Engaging and supporting patients in improving their adherence are critical to improving health outcomes. In today’s system, however, there are neither the incentives nor the support systems to do so.

Taken together, these findings suggest that improved adherence will require changes in health care delivery, particularly in the area of primary care, along with continued investment in information-technology systems and new health plan designs that focus on achieving improved health outcomes. Fortunately, there are a number of real-world examples that teach important lessons about how to improve medication adherence. For instance, two well-known integrated health care delivery systems, Geisinger Health System and Group Health Cooperative, have made adherence a priority and have begun to tackle the problem through multidimensional approaches. The Community Care of North Carolina program has a similar objective (see Current Integrated Approaches to Promoting Adherence and Their Effects). And studies point to improved adherence and outcomes among patients with particular conditions, such as HIV infection, AIDS, and heart failure. The success stories are there, though they are still scattered.

All these programs leverage information technology and patient-level data. They focus on understanding the patients’ attributes and tailoring interventions to those attributes. In addition, they offer follow-up and patient support provided by health care professionals who are trained and empowered to work closely with patients to improve adherence.

We believe that there are four lessons to be learned from the successes in the field. First, measures for improving adherence must address financial barriers, especially the copayments that patients must make for medications. Given the growing evidence showing a strong link between reducing copayments for medications for chronic conditions and improving adherence, the movement by many large employers toward value-based insurance design (tailoring cost sharing to the value of the service provided) is an excellent first step. But more can be done. For example, patients could be given financial incentives or other rewards for appropriate adherence to medication regimens. Research shows that the more frequent the reward, the better; thus, smaller amounts provided regularly are likely to be more effective than bigger amounts provided sporadically.

Second, data and data infrastructure that support interventions to boost adherence need to be a high priority in the country’s new investment in health information technology (HIT) and electronic health records. The guidelines promulgated by the Obama administration for “meaningful use” of HIT are promising. But the country’s HIT strategy should not only recommend the incorporation of accurate medication data (e.g., medication histories and rates of filling and refilling of prescriptions) into electronic medical records but also encourage data sharing across care providers and care settings, including physicians’ offices, hospitals, pharmacies, home health care agencies, and others.

Third, payment reform will be essential. Shifting from a fee-for-service model to payment systems that reward care providers for better patient outcomes and encourage coordination of care is critical to providing the incentives and investments that are required for improving adherence. Recent shifts to paying for medical homes and care transitions are trends that should support improved adherence. But to ensure that adherence actually improves, goals for medication adherence should be explicitly written into the performance measures for medical homes, accountable care organizations, and care transition teams. In the short run, efforts aimed at increasing adherence to medication regimens will require funds to be allocated up front. Over time, there should be savings. Thus, the structure of reimbursement must create an inducement for investment (typically by providers) that is financed by the groups that will save (usually insurers).

Finally, there needs to be greater use of proven screening and assessment tools to identify and target the patients who are at the greatest risk for nonadherence. Treatment guidelines for chronic conditions, for instance, should recommend screening for depression, which can be an indicator of poor adherence. In addition, assessment tools can broadly predict a patient’s proclivity to adhere to treatment,⁴ which is valuable information for providers to use in encouraging adherence both at the point of prescribing and in follow-up contacts with patients.

Once the right patients are targeted, there is still a lot to learn about tailoring adherence interventions to individual patients. Although we know about many common features of adherence programs, it is more difficult to determine the best possible combination of such features for any given person. New investments in research, including efforts associated with the government’s expanded program of comparative-effectiveness research, could dramatically enhance the evidence base for effective adherence interventions.

The bottom line is this: We’ve known for some time that improved adherence can lead to improvements in health outcomes and reductions in health care spending. What we haven’t known is where to start. With the new federal health care reform law moving into implementation, the existing movements toward deployment of HIT, improved coordination of care, and payment reform together create a desire and an infrastructure for improving health outcomes through improved adherence. Now we just need to get moving.

Current Integrated Approaches to Promoting Adherence and Their Effects.

Community Care of North Carolina (CCNC), a loose affiliation of 14 physician networks serving Medicaid and uninsured patients, has launched the Pharmacy Home Project, a plan that pays participating physicians a monthly fee for coordination of care. Adherence is promoted through the use of case managers who are embedded throughout the networks and clinical pharmacists who serve multiple physician practices on a rotating basis and through the collection of data on patient medications from multiple sources including medical charts, claims records, and records of prescriptions filled to provide prescribers with complete and accurate data for use in reviewing medications. Under this program, CCNC has achieved a 5 to 7% increase in adherence rates.

Geisinger Health System, in Pennsylvania, has begun implementing multiple programs to address adherence. One approach is to collect patients’ medication preferences through an electronic survey completed before a physician sees the patient. As part of Geisinger’s medical home model, nurses actively follow up with patients to monitor medication use and address any questions or concerns the patient might have. The health system has also made changes to its own employee health benefits by reducing copayments and deductibles for medications for chronic conditions. Geisinger reports that it has achieved a 5 to 7% reduction in monthly costs.

At Group Health Cooperative, in Washington State and northern Idaho, the approach to adherence relies on nurse case managers who interview patients to assess whether they are managing their medical conditions and to increase patients’ adherence to their medication regimens. Case managers also educate patients about their conditions, create action plans with patients, and refer patients to programs that help them find more affordable medications. The Group Health Cooperative reports that the results have included annual savings — representing avoided health care costs — of more than $476 per participant.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Source Information

From Harvard University (D.M.C.) and the New England Healthcare Institute (W.E.) — both in Cambridge, MA.

This article (10.1056/NEJMp1002305) was published on April 7, 2010, at NEJM.org.

References

1. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-497. [Free Full Text]
2. Cutler DM, Long G, Berndt ER, et al. The value of antihypertensive drugs: a perspective on medical innovation. Health Aff (Millwood) 2007;26:97-110. [Free Full Text]
3. Doshi JA, Zhu J, Lee BY, Kimmel S, Volpp KG. Impact of a prescription copayment increase on lipid-lowering medication adherence in veterans. Circulation 2009;119:390-397. [Free Full Text]
4. Mosen DM, Schmittdiel J, Hibbard J, Sobel D, Remmers C, Bellows J. Is patient activation associated eLIZABETH lA

"Good Life. Good Death. Your Choice."

Assisted suicide group Final Exit Network plans billboards for N.J. and California

By The Associated Press

March 10, 2010, 1:47PM

Scott Strazzante/Chicago Tribune/MCTJerry Dincin is the new president of the Final Exit Network which offers counseling and assistance to people with medical conditions who want to end their life. He faces trial on a charge of helping a cancer patient kill himself.The leader of assisted suicide group Final Exit Network plans to put up billboards in New Jersey and California, as means of validating the group's work.

Jerry Dincin discussed the planned billboards as his group, Final Exit Network, prepares for a trial in Georgia after helping a 58-year-old man with cancer kill himself.

Dincin said Tuesday they have been preparing for the trial for more than a year, and is "glad it's moving along."

He became the group's leader after then-president Ted Goodwin and three other members were arrested in February 2009. The four members and the group itself were indicted Tuesday by a Forsyth County grand jury.

Dincin said the billboards planned for New Jersey and California will read:

"Good Life. Good Death. Your Choice."

Final Exit Network - Georgia Four will be indicted on April 1

Friday March12, 2010

On Tuesday the Georgia prosecutor announced that the Georgia Four, arrested 14 months ago will be indicted on April 1. This is something we have been waiting for so that we can finally have our day in court.

To see the announcement which appears on CBS TV news click on:

Georgia Four Finally indicted

You will have to wait a moment for a TV ad but it will come on immediately.

Watch our web page for updates Final Exit Network

Regards

Jerry Dincin, President

"To establish that a mentally competent person, suffering from irreversible illness or intractable pain, has the right to end his or her life, and the right to choose the timing, method, help, and companion, free of any restrictions no matter how well intentioned"
The Ultimate Human Right of the 21st Century
Visit our new web site at Final Exit Network

Conspicuous And Invidious Consumption

From The Motly Fool

The economist Thorstein Veblen is best known for the expression "conspicuous consumption" which describes the kind of lavish spending which is primarily performed for the purpose of displaying income and wealth. Veblen was arguably the first economist to look at luxury goods in any detail and he showed that a great deal of spending on luxury goods is for what he describes as "invidious consumption" where the purchaser intends to display the goods to create feelings of envy in those who see their purchases.

If you've sat through someone's wobbly videos and badly-shot photographs of their expensive holiday, it probably wasn't to give you any great insights into the local architecture and culture. Part of the reason for taking the holiday was for invidious consumption and the holidaymakers must tell others to make them envious! :-) Invidious consumption can be seen everywhere from people flashing their "bling" to telling your friends about your new pair of shoes ;-)

Someone who spends £500 on a bottle of wine does so, in part, to convince themselves that they are in an elite club. Just don't show them the research published in the April 2008 issue of the Journal of Wine Economics which showed that that the vast majority of wine consumers cannot tell the difference between cheap and expensive wines :-) Most people are better off with a £4.99 bottle from Tesco.

Conspicuous consumption and housing

In the U.S., a trend in 1950s towards large houses began, with the average size of a home about doubling over a period of 50 years. This trend has been compared to the rise of the SUV, also often a symbol of conspicuous consumption. **Such large homes can also facilitate other forms of consumption, in providing extra storage space for vehicles, clothes, and other objects. (!!)

** I find this both hilarious and sad at the same time. Just MHO.

Virtual Revolution: The Cost Of Free

~Listen online to BBC documentaty ~
Virtual Revolution: The Cost Of Free
How commerce has been transformed by the online market.

The Virtual Revolution: The Great Levelling?

From BBC Documentaries:

In the first in this four-part series, Dr Aleks Krotoski charts the extraordinary rise of blogs, Wikipedia and YouTube, and traces an ongoing clash between the freedom the technology offers us, and our innate human desire to control and profit.

Whistle-Blowing Nurse Is Acquitted in Texas

By KEVIN SACK

A West Texas jury took but an hour Thursday to acquit a nurse who had been charged with a felony after alerting the state medical board that a doctor at her hospital was practicing unsafe medicine.

The uncommon prosecution had ignited deep concern among health care workers and advocates for whistle-blowers about a potential chilling effect on the reporting of malpractice.

But after a four-day trial in Andrews, Tex., a state court jury quickly found that the nurse, Anne Mitchell, was not guilty of the third-degree felony charge of “misuse of official information.” Conviction could have carried a prison sentence of up to 10 years and a fine of up to $10,000.

The prosecution said Mrs. Mitchell, 52, who had been a nurse at Winkler County Memorial Hospital for 25 years, had used her position to obtain and disseminate confidential information — patient file numbers — in her letter to the medical board with the intent of harming Dr. Rolando G. Arafiles Jr. The prosecutor argued that state law required that reports of misconduct be made in good faith, and that Mrs. Mitchell had been waging a vendetta against Dr. Arafiles since his arrival at the hospital in April 2008.

Witnesses testified that they had heard Mrs. Mitchell refer to Dr. Arafiles, a proponent of alternative medicine and herbal remedies, as a “witch doctor.”

But other nurses vouched that Mrs. Mitchell’s concerns were legitimate, and that internal complaints were not dealt with adequately by the hospital’s administration.

The jury foreman said the panel of six men and six women voted unanimously on the first ballot, and questioned why Mrs. Mitchell had ever been arrested.

“We just didn’t see the wrongdoing of sending the file numbers in, since she’s a nurse,” said the foreman, Harley D. Tyler, a high school custodian.

Mrs. Mitchell, who did not testify in her defense, said after the verdict that she had been trying only to protect her patients.

“It’s a duty to every nurse to take care of patients,” she said, after wiping away tears of relief.

The prosecution has so polarized the small town of Kermit, where the hospital is located, that the judge moved the trial to a neighboring county. The case was investigated by Sheriff Robert L. Roberts Jr., a friend and admiring patient of Dr. Arafiles, and tried by the county attorney, Scott M. Tidwell, a political ally of the sheriff and, according to testimony, Dr. Arafiles’s personal lawyer.

Sheriff Roberts said he was disappointed in the verdict but did not regret the prosecution.

“The defense had to spin this as a reporting issue, that nurses were not going to be able to report bad medical care, and it’s never been that,” he said. “We encourage people to report bad medical care. But I encourage public servants to report it properly.”

Mrs. Mitchell and Vickilyn Galle, a co-worker who helped her write the anonymous letter to the medical board, were fired by the hospital last June, shortly before being indicted. The charges against Mrs. Galle, 54, were dismissed late last month at the prosecutor’s discretion.

After the verdict, the nurses’ lawyers pivoted quickly to the lawsuit they have filed in federal court against the county, the hospital and various officials, charging that the firings and indictments amounted to a violation of due process and their First Amendment rights.

“We are glad that this phase of this ordeal has ended and that Anne has been restored to her liberty,” said Mrs. Mitchell’s lawyer, John H. Cook IV, “but there was great damage done in this case, and this does not make them whole.”

Mr. Cook presented broad evidence that the nurses’ concerns about Dr. Arafiles, 47, were well founded, and that Mrs. Mitchell had violated no laws or regulations in alerting the governmental body that licenses and regulates physicians. He walked the jury through a series of questionable cases involving Dr. Arafiles, including one in which the doctor performed a skin graft in the hospital’s emergency room, despite not having surgical privileges, and another where he sutured a rubber tip to a patient’s crushed finger for protection.

Some watchdog groups worried that the prosecution would stifle reporting of improper medical care, regardless of the outcome. But Rebecca M. Patton, president of the American Nurses Association, called the verdict “a resounding win on behalf of patient safety.”

Ms. Patton said, “The message the jury sent is clear: the freedom for nurses to report a physician’s unsafe medical practices is non-negotiable.”

Jim Mustian contributed reporting from Andrews, Tex.