HERC Cyberseminar Department of Veterans Affairs - 1 -

Department of Veterans Affairs

HERC Health Economics Seminar

Medication Adherence in Chronically Ill Veterans: Copayments, Other Potential Barriers, and Health System Factors to Potentially Mitigate Cost Burdens

John E. Zeber, PhD, MHA

February 15, 2012

Moderator: I just wanted to welcome everybody to the February edition of the HERC Cyberseminar. Today I'm very pleased to introduce John Zeber. John finished in 2004 at the University of Michigan, where he got his degree in health services and worked with a lot of the VA people up there: Marcia Valenstein and Fred Blow, looking at cost issues as they were related to medication and psychiatric issues. So his talk today is: Medication Adherence in Chronically Ill Veterans that carries forward that thread. He's been very productive over the past few years, now he is down in Texas, where he is a Co-director of Health Outcomes for the Scott & White Healthcare system and also at the—I think it's the San Antonio VA, John, if I'm not mistaken?

John Zeber: Temple, Texas.

Moderator: I'm going to hand it over to you, John. We look forward to it, thank you so much.

John Zeber: Well, thank you very much, Todd. I hope you're feeling that way fifty-five minutes from now. I'd like to thank Todd, Heidi and Angela—and the others for helping me prepare for the session today, plus any time an audience doesn't actually have to see me in my first gray hairs is an all around plus. I did warn Todd that he was inviting a true amature to join this seminar at least in terms of economic experience, because I tend to fit better in the sociology, behavioral health policy realms, so I welcome the opportunity to share a collection of our work over the past several years.

Upon stitching these studies together, I am pleased that they do fit pretty well together in a logical and coherent trajectory, something I'm not accused of doing very often, but your suggestions for future efforts and even potential collaboration would be appreciated.

I have presented much of this material at different times at the HSR&D meetings, so many of you have probably seen parts of it and depending on time, I may skim through some of it, but I'm happy to share reprints or more information.

Now while most of these studies reflect Veterans with serious mental illness, some target other chronic conditions, with much relevance to many patients in healthcare systems. Since you are a semi-captured audience, it gives me a chance to share a few photos of our trips to Yellowstone and Yosemite.

I think there's a poll question here, which is just getting some general information about who is in the audience and your primary role.

Heidi: We have responses that are coming in, we're at about thirty percent right now, so we'll give it a few more seconds for people to respond here.

John Zeber: Okay. I'll kind of talk over that here a little bit. I'd like to first begin with a couple of our earlier projects, which I mentioned, here Marcia Valenstein, On Medication Adherence in Veterans with Schizophrenia, which then led to my dark dissertation days, where I focused on a significant policy change in VA Pharmacy Benefits.

So by way of introduction—

Heidi: We're actually only able to have the slides or the poll up at one time.

John Zeber: Got you.

Heidi: Here your poll is up.

John Zeber: So that's half and half health services, researchers and administration, great. We know that up to half of the patients with serious mental illness, not to mention other chronic health and mental health conditions tend to be poorly adherent. In fact, that's at a cross-sectional view, often in the short term or even up to a year period.

Now Marcia and her colleagues found that if you look over a three-year period, for instance, up to sixty-five to seventy percent of patients with schizophrenia are poorly adherent. So it's safe to assume that over the long illness course, most patients will at sometime experience adherence difficulty. Naturally these adherence problems lead to severe ramifications in terms of relapse, deteriorating symptoms, psychiatric admissions, ER visits, costs and so forth.

A couple of years ago [Marks, Fritz and Olsen] estimated the California Medicaid system alone could save up to $106 million a year by just reducing the adherence gaps in its schizophrenia patients.

No healthcare system is really exempt from this problem. If you see patients, adherence is going to be a problem. We know that there are also more vulnerable patients who may suffer greater burden from a variety of potential areas we’ll discuss, this includes older patients, chronic conditions, ethnic minority.

An entire day can be devoted to discussing how to define and measure medication adherence, plus the many different ways and lack of agreement among some, such as pharmacy claim data, patients don't report, family or provider assessment and blood level and we used a couple of these in our studies for both administrative and self-report, which we'll go over today.

I'd like to start with a couple of our favorite graphs from our earlier work with Marcia, perhaps suggesting I need to get outside more often. This first one covers the National Population of Veterans with schizophrenia from 1999 data and what it really shows is the distribution of medication adherence as defined by the MPR or Medication Possession Ratio. Now while my colleague, [Laurel Copeland] devoted six years of her life to the often complex coding of this, what the MPR really does is provide a percent of medications the patient should be taking. So you're aiming for about one or one hundred percent.

The appropriate cut point is debatable and they differ across chronic conditions. MPR of .08 has been validated as measuring good adherence. So on this graph, while most of the patients do tend to cluster around one or good adherence, you'll notice to the left of the arrow, the substantial proportion in there of below .08. In fact, in this population there's 41.5 percent to be exact. On the other extreme it's the ten percent to the far right who may be considered the over achievers of the adherence kingdom and they have MPR's of 1.5, 2 or even higher. We found these patients to be much sicker in terms of comorbidities and they represent a very distinct group.

Laurel created this second figure which remains a highly cited paper, which shows the almost suspiciously linear relationship between adherence and the risk of psychiatric admissions. So if you start to the far left of the worst adherers, they have MPRs around .1, nearly one-third of them are admitted during the course of a year. As you move towards the right, this risk steadily drops to about eight percent of patients with the best adherence before shooting up again in the high MPR group.

Now a little bit more background—we all know that there are an awful of discussions regarding rising pharmacy costs across all healthcare systems. In the late 1990s, early 2000s, these are increasing fifteen to twenty percent per year. So it's no surprise that many healthcare systems design a variety of cost restriction plans, benefits restrictions, formularies and other cost sharing such as copayment. It covered a variety of different types, including putting a cap on the number of pills, dollar amounts, also recent notions regarding value benefit design and so forth.

Then, of course, the simple fact of raising medication copayment. We all know that results in problems for the patient respective of cutting back on their medication due to cost. I believe that Todd Wagner in his work has worked with our former Michigan colleagues, John Piette and Michelle Heisler in a couple of papers that looked at the extent to which Veterans with diabetes cut back on their medication. At least twenty percent of them report they did at sometime, now that sets the stage for this talk today.

A quick recap of VA pharmacy copayments in case we're not aware of them. We have been gradually implementing this copayment plan since 1986 when Congress first declared that service connection percentage or priority status could be used to define eligibility. The first $2 copayment was implemented in 1990, where it remained until the 1999 Millennium Bill was passed, which then led to the $7 copayment increase in 2002. It was raised to $8 a couple of years later and I just read that it's actually $9 for some of the lower priority Veterans.

Okay. I think we're ready for the second poll? Here I'm just trying to get some awareness, if people are aware of what the current copayment policy within the VA or medication costs in general from their patients.

Heidi: Here are the results.

John Zeber: Oh, about half and half, great. I don't want to make too light of the situation, but this is often what patients feel when they encounter a cost for a variety of different medications. People with chronic conditions, including multiple comorbidities, often have eight to ten or more medications a month they're dealing with and it certainly leads to anxiety.

I don't want to cover too much about this, but we know from numerous past studies across a variety of healthcare plans and copayment restrictions that they work. There's been numerous data dating back all the way to the RAND experiment, across a variety of healthcare services, primary care specialty visits, such as psychotherapy, chiropractic, dentistry and so forth, even ER visits for urgent conditions, that when faced with higher costs, patients do cut back on all of these services and, of course, the evidence pertaining pharmacy use is also quite substantial and growing.

However, there is actually presently a few studies specifically targeting mental health conditions. Probably the biggest precursor to my study, was the mid 1990s work of Steve Summer and colleagues at Harvard, where they examined the Medicaid cap that was put on their program, when they looked at schizophrenia patients, they observed a nearly fifty percent drop in psychotropic drugs, with a sharp rise in ER visits and admissions.

In the second paper on older patients, they found a thirty-five percent drop in fills and increased number of nursing home admits. Once the cap was removed, things stabilized pretty quickly. In much the same as other things, there are some findings that certain patient population groups may be more sensitive to copays or cost sharing, such as ethnic minorities and the elderly.

Now turning to my dissertation topic, which I think I have recovered from the traumatic stress to revisit now. This is a visual representation of the study, starting with a baseline periods to define include criteria, we looked at a twenty-month period prior to the copayment increase and twenty months after, subdividing that into four ten-month periods to see if we can at least get some idea of trends prior to the policy change, a relatively simple logistic longitudinal approach, that we effectively controlled for time and numerous covariates.

We benefitted from a national population of all Veterans treated with schizophrenia in 1999, starting with about 100,000. We excluded eighteen percent for either dying during the study period, having a hundred or more inpatient days during a ten-month period and then not having valid service connection percentage. Even though that number of exclusions is fairly large, we did a detailed attrition analysis that revealed fairly minimal differences between those who were kept and those who were excluded.

The data came from the VA's National Psychosis Registry developed and still maintained by [inaudible], Twick and Ann Arbor]. I was fortunate enough as a graduate student to be part of the development team on this. It's a comprehensive database of all Veterans treated in the VA with schizophrenia or bipolar disorder. It contains the patient demographics, utilization pharmacy and cost information.

I looked at three different groups based on the service connection percentage and you'll see that in the slides to follow, but you can really combine Groups 1 and 2, which has a distinction between non-service connection and having 0-49 percent. We're really comparing those who did have a copayment against those who are completely exempt. In fact, that's a natural control group of patients who never faced a copayment. We used a longitudinal random effects model to look at each of the outcomes, which we'll describe in a second, there's one for demographics, substance abuse, illness severity, plus a new variable we've created for the Registry called "tenure", which get at how long and consistently a Veteran was using the VA services.

I thank my committee for limiting me to six outcomes. We first looked at pharmacy utilization, total, and subdivided into medical and psychotropics. Ideally, I probably should have sub divided the psychotropics into different sub classes, antipsychotics, mood stabilizers and others, but that can be done in the future.

We looked at both inpatient days, admits and outpatient visits as potential ramifications from lower adherence due to cost and then also total pharmacy costs from the VA's perspective. Out of a total final sample of over 80,000, almost a perfect split with fifty percent were exempt from copayment—I won't go too much into population, but it's fairly representative nationally of Veterans with schizophrenia during that time, primarily male, older, a high percentage of minorities and they're a very sick group.

The baseline difference is that we did find a little bit of difference between the copaying exempt that they tended to be a little healthier, that's no surprise since service connection is often used as a proxy for illness severity and need.

Then just turning to the results, the total of medical bills were approximately the same scenario, so I'll just present the medical. While the exempt patients continued to increase their utilization about fifteen to twenty percent, the brown triangle at the top, the two copayment groups at least stabilized over time after the copayment increased.

The more interesting finding was the psychotropic fills or the exempt patients more or less stabilized following the 2002 change. The copayment patients dropped their utilization by twenty to twenty-five percent and that's surely a significant drop there.

Then just turning to inpatient days, there was not a dramatic change, copayment patients increased their utilization about three to four percent and that reversed a decade-long trend of declining psychiatric admissions and days in the VA.

Now initially I had downplayed that small increase in the manuscript before a kindly reviewer pointed out—before rejecting the manuscript, that even a small increase in the population of this size could result in hundreds of extra admissions and percept thousands of additional inpatient days. So that's actually triggered one of the future studies we're going to look with cost offset. I'll just skip over the pharmacy costs as they reflect the total medication use pretty well.

So turning to the grounding of the findings in more of a sociological model, we find that I think health beliefs play a big role in this. Because when faced with the higher cost to the patient on their medications, they were choosing to give up the psychotropics rather than the drugs for medical conditions. Now a second point is the VA has long taken pride in caring for individuals with limited resource and treatment options.

The 1974 book, John Ayanianasserted that one key purpose of all healthcare benefits is to more equitable distribute scarce healthcare resources. So it seems at least within that context the 2002 policy change raises some equity issues.

Now regarding whether the copayment increase was a success, it certainly worked to cut back on higher cost medication, but as always one must consider other unintended consequences such as balancing objectives with the healthcare system's overall mission, patient needs and so forth. Even at the time, I was wondering, couldn't there have been a more softer option than immediately tripling the out-of-pocket expenses for these vulnerable patients with schizophrenia, who have very low income?

We must, of course, recognize that Veterans themselves are a vulnerable population and even more so in Veterans with schizophrenia and other serious conditions. So this policy impact will obviously affect them probably more than others, and though they may be more sensitive to the same policy change or decision that other patients may not find to be too burdensome. I think I'll pause here for the next question. I just like to see how often if your providers or administrators do often discuss or consider medication costs when discussing with your patients? I'm just going to turn to one sub analysis that we did conduct on this—

Heidi: I'm bringing up the results right now.

John Zeber: We do have a fair percent that do at least consider and discuss this with their patients, which is good. There's been many polls out there that indicate that providers really don't have any idea what medications cost or what the overall burden is to their patients.