Tuesday, May 29, 2018

Radar on Drug Benefits, a subscription-based publication of AIS Health, interviewed L.A. Care's Chief Pharmacy Officer, Yana Paulson, in "To Boost Medication Adherence, 'Think Outside the Box'". The piece looks at health insurer strategies to encourage patients to take their medications as prescribed. 

To Boost Medication Adherence, 'Think Outside the Box'

Encouraging patients to take their medications as prescribed is a key priority for health insurers, as nonadherence can fuel costly complications, hospitalizations and emergency room visits. To improve medication adherence, insurers are employing tactics like reaching out when prescriptions aren’t refilled and offering mail-order services. But some are also thinking outside the box to overcome barriers that are unique to their patient populations — namely, cultural and language barriers.

One of those insurers is Minnesota-based UCare, which serves members of the Hmong community in the Minneapolis/St. Paul metro area. The Hmong began coming to the state in 1975 to flee wars in their homelands in Laos, and today the Twin Cities are home to the largest concentration of Hmong in the United States, according to the Minnesota Historical Society.

Of the more than 12,300 members in UCare's Minnesota Senior Health Options (MSHO) dual-eligible plan for members 65 and older, about 18% are of Asian descent, Director of Pharmacy Patrick Mitsch, Pharm.D., tells AIS Health. And among them, about 1,200 speak Hmong as their primary language.

"Some of the things that we encounter with engaging with our Hmong community is our traditional methods of communicating with them don't work for whatever reason," Mitsch says. "Whether it's a print letter that we send out to give them information about their drug benefits or that they're late on a refill for their medication, that doesn't register with them because that's not necessarily how they consume information."

But something else that the insurer learned about the Hmong proved to be the key to engaging them: their penchant for relying on community-based pharmacies with Hmong-speaking staff to serve as health care guides. UCare's Hmong members, Mitsch says, will often go to those pharmacists "with a piece of paper from their health insurance company and they say, 'Tell me what this is,' or 'Tell me what I need to know about this.'"

"They feel a certain level of comfort, obviously, being able to speak to somebody in their native language who can explain things in a manner that's understandable and convey the importance of the message that we're trying to get across," he adds.

Knowing that, UCare began reimbursing community-based pharmacists to conduct outreach that promotes medication adherence, Mitsch explains. That includes encouraging members to take their medications, calling them with refill reminders and explaining the benefits of the medication being prescribed — which is particularly important for conditions like high cholesterol or high blood pressure that have "silent" symptoms, he adds.

"A lot of it is empowering the pharmacists to really take what they know and pass that along to members and explain to them how their medication works and how even though you may not feel sick, these medications will ultimately keep you on a path to better health," he says.

UCare's efforts appear to have paid off. For the insurer's overall dual-eligible population, it saw a 5% increase in adherence from 2015 through 2017 for blood pressure, cholesterol and diabetes medications, according to Mitsch.

"We’re really proud of that number, because ultimately it speaks to the fact that our initiatives are having an impact — members are getting the medication that they need, and ultimately for some of these members, they're going to be avoiding the consequences of not taking their medication," he says.

L.A. Care Stresses Education

At L.A. Care, which serves residents of Los Angeles County, a significant portion of the insurer's membership prefers to converse in a language other than English, says Chief Pharmacy Officer Yana Paulson.

L.A. Care addresses this by employing Spanish-speaking staff who can communicate directly with members who prefer that language. And for members who speak other languages, the insurer uses a translation service to help communicate with them.

The bigger issue for L.A. Care when it comes to promoting medication adherence, Paulson says, is not so much language barriers as it is cultural barriers.

"We know, for example, that the Hispanic population, they sort of have this cultural belief that taking medication means they're weak and they can't cope without medication," Paulson says. "So we try to overcome that by just educating them about the disease and that it doesn't have anything to do with willpower."

L.A. Care also holds quarterly meetings with its medical groups, during which the insurer and providers discuss, among other topics, cultural barriers that may get in the way of medication adherence among demographics where the physicians are practicing, she says.

And for its entire member population, the insurer has employed a "high-touch initiative" that targets patients who fail to refill their medication for a chronic condition, according to Paulson. L.A. Care's pharmacy technicians call these patients to both assess the reasons why they're not refilling their medication and take steps to help.

"For example, they may not have any refills on their medication, so we reach out to the doctor's office to make sure they call the pharmacy to authorize more refills," she says. The insurer also assists patients in converting a 30-day-supply prescription to a 90-day one; offers transportation resources to help members get to a pharmacy; helps facilitate medication delivery; provides tips on how to remember to regularly take medication; and connects patients with clinical pharmacists who can answer their questions about their medications.

Effort Saw Boost in Statin Refills

Overall, L.A. Care fielded 3,500 calls and reached nearly 2,000 members last year as part of the high-touch medication adherence program, Paulson says. The insurer also saw a 10% improvement in refills of high-cholesterol medication and a 5% improvement for hypertension and diabetes medications.

"Even though these numbers [5% and 10%] sound small, it's actually a very significant improvement. They're all statistically significant improvements in adherence for these chronic medications," Paulson says.

For insurers seeking to improve medication adherence among a diverse group of members, Mitsch says the ideal approach is to figure out what resonates best with different populations. "You can’t paint the broad brush and say, 'This is going to work for everybody' — you really need to understand the intricacies of each subset of the population that you're serving," he says.

Insurers must also recognize that it's not always as simple as "translating something into somebody's native language because there's a good chance they may not even be able to read their native language," he says. "So you really just need to think outside the box in terms of how you engage with them."

Provider Engagement, Data Are Key

Data also play a vital role, suggests Greg Hanley, UCare's vice president of quality management and pharmacy.

"It all starts really with data, and being able to drill down and identify the segments of the population that may be struggling with medication adherence, and identifying not only who they are but where they are," he says.

UCare exchanges data with pharmacists to help identify and prioritize members who are falling behind on taking their medication, Mitsch adds.

Paulson says that while high-touch programs like L.A. Care’s are important, "not everybody has those resources." In that case, even small steps like mailing pillboxes or daily planners to patients can help encourage medication adherence, she says.

Encouraging provider-patient communication is also key to boosting adherence, she points out. "Even a five-minute talk or a two-minute talk to patients about how important it is to the doctor that the patient takes the medication makes a huge difference," Paulson says.

Contact Mitsch and Hanley via Wendy Wicks and Paulson via Penny Griego.

by Leslie Small
AIS Health


About L.A. Care Health Plan

L.A. Care Health Plan is a public entity and community-accountable health plan serving residents of Los Angeles County through a variety of health coverage programs including L.A. Care Covered™,  Medi-CalL.A. Care Cal MediConnect Plan and PASC-SEIU Homecare Workers Health Care Plan. L.A. Care is a leader in developing new programs through innovative partnerships designed to provide health coverage to vulnerable populations and to support the safety net. With more than 2 million members, L.A. Care is the nation’s largest publicly operated health plan.


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