Improving
Medication
Management
Stephen L. Axelrod, M.D.
121 South Madison St. Suite C
Denver, CO 80209
www.tabsafe.com
“Drugs don’t work
in patients who
don’t take them.”
C. Everett Koop, MD
Former US Surgeon General
The Growing Problem
MEDICATION NONADHERENCE
• 51% of all prescription medication in
the U.S. is taken incorrectly causing:
• 125,000 deaths per year
• 1,000,000 hospitalizations
• Among the elderly, nonadherence
accounts for 30-40% of all hospital
admissions
Medication Nonadherence
RESULTS IN:
• 23% of all nursing home admissions
•1/3 to 2/3 of all medication-related
hospitalizations
• An estimated 188.3 MM medical visits
wasted because patients do not follow advice
received
• Increased use of expensive,
specialized medical resources
How costly is it?
How much money is wasted annually in the
U.S on the direct and indirect costs
associated with medication nonadherence?
a.
b.
c.
d.
e.
$2,500,000,000,000.00
$177,000,000,000.00
$290,000,000,000.00
$258,000,000,000.00
$ 40,000,000,000.00
How costly is it?
•Estimated
direct costs
+
•Indirect costs
annually1
=
$177 Billion
1. National Council on Patient Information and Education. Enhancing Prescription
Medication Adherence: A National Action Plan. August 2007.
•Estimated
direct costs
+
•Indirect costs
annually2
=
$290 Billion
2. CVS Caremark, Harvard University, and Brigham & Women’s Hospital. August 2010
•Estimated
direct costs
+
•Indirect costs
annually3
3. Express Scripts, Reported in USA Today May 27, 2011
= $258 Billion
Demographics
“THE SILVER TSUNAMI”
Silver Tsunami
Demographic Shifts
• In the 2000, 35 million people, 13 percent of
the population, were age 65 and older - by 2030,
20 percent of Americans, about 70 million people
• The population aged 85 and above is the fastest
growing segment of the older population
• The number of centenarians was about 65,000 people
in 2000 by 2030 that is expected to grow quickly so
that there may be as many as 381,000 by 2030
Increased Longevity
1900 - 1950
Infectious Disease
Breakthroughs: antibiotics, immunizations
1950 - 2000
Acute Cardiac Care
Breakthroughs: early dx, CPR, defibrillation,
interventional cardiology
2000 - 2030? Chronic Disease Management
Breakthroughs: PCMH, patient engagement,
EMR, telehealth, medication management
Healthcare Continuum
•
•
•
•
•
•
•
Acute Care Hospitals
Subacute Hospitals (LTAC)
Skilled Nursing Facilities (SNF)
Assisted Living Communities
Independent Living Communities
Adult Day Care
Independent Seniors in the
Community
SNF & ALF Census
2,000,000
1,800,000
1,600,000
1,400,000
•Number
1,200,000
•of
•Residents
1,000,000
800,000
600,000
400,000
200,000
0
1998
2000
2002
Assisted Living
•Source – HSG, 7/02
2004 Est
Skilled Nursing
2006
Senior Housing Estimates
Senior Housing Estimates
86% of Seniors Live at Home
About 31% (11.2 million) live alone
Med Management Programs
Med Management Programs
Adherence Technologies
Adherence Technologies
• Simple pill boxes:
Simple medication organizers often
designed for seven-day supplies.
• Alerts:
Telephonic, text, email reminders to take medication at
the prescribed times
• Complex pill holders with alarms:
Medication organizers
that also have alarms or alerting for prescribed medication times
• Automated Dispensing:
An automated dispensing device
both prompts the patients to take their medication and dispenses the
medication to them.
• Monitoring Devices: Monitoring devices provide automated
tracking and reporting of a patient’s medication regimen in addition
to medication dispersal and reminders.
Integrated Technologies
“Developed more recently, integrated
medication adherence technologies integrate
pill dispenser and reminder systems with
general health monitoring or health
information storage.”
Results: Improved mean medication adherence
rates of over 92% compared to a 40% baseline
medication adherence rate.
Technologies for Optimizing Medication Use in Older Adults, Center for
Technology and Aging, Sacramento, CA, October 2009.
What is TabSafe?
─ Personal medication management system that
securely stores medications to be dispensed on a
specific time schedule
– Medications can be filled by pharmacies, by users,
their family members, or home care companies
– Sends visual and auditory reminders for medication
adherence with verification of completion
– 3 follow-up calls to prevent nonadherence
– Reminders for activities of daily living and for
medications not stored in TabSafe
TabSafe is Unique
– Manages “As Needed” meds and prevents over-usage
– Maintains each medication’s inventory, automatically alerts for
reorder, digitally downloads each transaction for reports and
analysis. When released, What med, quantity, Who released
– Web accessible reports allow for the management of
medications from any web browser
– Allows for interactive medication dose changes or
discontinuance when prescription changes
– Collects, records, and correlates vital sign and biometric data
to medication adherence data
Patented Technology
• Patent 7,129,819 B2

Patent issued October 2006

Mechanical design
 Application software
 Database software
 Electrical design
 Closed-loop Pharmacy Connectivity
 Vital signs correlated to medication adherence
Web-Accessible Reports
• Medication Report
• Release Report
• Inventory Report
•
Chronic Disease
“THE HEALTHCARE TSUNAMI”
Incidence of Chronic Disease
1. “20.9% of the population age 60 and
older--10.3 million people--have
diabetes.”
2. “By 2020, 81,000,000 people will have
two or more chronic conditions.”
3. “There are currently 8 million people
that suffer from five or more chronic
diseases and take ≥ 10 medications.”
1.
National Center for Health Statistics. Health, United States, 2005 with chartbook on trends in the health of Americans. Hyattsville, MD: Centers
for Disease Control and Prevention. 2005.
2.
Partnership for Solutions . Chronic Conditions: Making the case for ongoing care. Baltimore, MD: Johns Hopkins University. 2002
Unrelenting Burden
•
Blurring Lines in the Accountable Care Era, Fred Bentley, Managing Director,
Strategic Research, The Advisory Board Company September 2011
Cost of Chronic Disease
•
Blurring Lines in the Accountable Care Era, Fred Bentley, Managing Director,
Strategic Research, The Advisory Board Company, Sept. 2011
Focus on Reducing Waste
• 5% of all Medicare beneficiaries account for 50%
of the total Medicare healthcare expenditures
• Bottom 50% of Medicare beneficiaries only
account for 4% of Medicare healthcare
expenditures
• 50% of all lifetime healthcare expenditures are
spent in the last 18-24 months of life (70-80%
irrelevant)
• Patients with a Living Will save $5500 on end-oflife care with 70% passing away at home
Target Patient Populations
• Hospital Care Transition Process
• High Risk Patients
– Any admission where medication adherence has
been identified as a complicating issue
– Any hospital discharge for:
• Organ transplant
• HIV
• Schizophrenia
• Oncology
• Congestive Heart Failure (CHF)
• Diagnoses requiring anticoagulation
• Pain Management
• Frequent emergency transport
Reducing Readmissions
Care Transitions Interventions (CTI©)
•
•
•
•
Medication adherence (25-30%)
Medication reconciliation (15%)
Access to hospital records
Physician appointment scheduled within 7
days of discharge
• Patient emergency plan
• Transition coaching
Medication Monitoring and
Better Outcomes
Medication Dispensing Study
Machine
Pillbox
Hospitalizations per patient
0.09
0.42
ED Visits per patient
0.18
0.42
Prescriptions per patient
7.62
8.65
Buckwalter,KC et al, New Technology for Medication Adherence,
Journal of Gerontological Nursing, July 2004, p.5-8
 Study Conducted by University of Iowa School of Nursing and
Johnson County (Iowa) VNA
 Greatest success with the medication dispensing system was
seen in patients on warfarin therapy or those who had mental and
cognitive issues
Adherence in AL
Released
Taken
Missed
%Adherence
Assisted Living*
4802
3414
1388
71.10%
AL with TabSafe
312358
310286
2072
99.34%
Medication Errors (Missed Med Time) in Assisted Living
*Young H, Carley MM, AHCA/NCAL/MECF 58th Annual Convention and Exposition. White Paper:
Medication Management in Assisted Living, October 7-10, 2007
TabSafe Improves Adherence
Released
Taken
Missed
Independent
Guardian TabSafe
Customers YTD
%Adherence
49.00%
70414
67646
2768
96.07%
•Independently Living Individuals Using TabSafe vs. Nat’l Average
TabSafe Improves Adherence
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Without TabSafe
With TabSafe
Assisted Living
Independent
Living
Adherence for CHF Patients
• Clin Ther. 2007 Aug;29(8):1771-83.
• Bagchi AD, Esposito D, Kim M, Verdier J, Bencio D
• CONCLUSIONS: State Medicaid agencies and Medicare
prescription drug plans should consider designing
targeted interventions that encourage better
adherence among Medicaid beneficiaries with CHF,
particularly men, those aged <65 years, ethnic
minorities, and patients with poor overall health status.
Reducing Hospital Risk in HIV
• Mascolini M.
• Conclusion: Regardless of regimen type, people
attaining 95% adherence were significantly less likely to
get admitted to the hospital. For people taking one pill
daily, 6.6% with 95% adherence versus 11.4% without
95% adherence went to the hospital. For the two-pill
group, those proportions were 6.6% versus 15.2%, and
for the three-or-more-pill group 7.8% versus 12.1%.
Proper adherence lowers hospitalization risk
by 40% in patients with HIV.
Mental Health Hospitalizations
• Chris M. Kozma, PhD ; Peter J. Weiden, MD
• AHDB. 2009;2(1):31-38
• Conclusion: Small decreases in compliance
with antipsychotics are associated with
increased hospitalization risk among patients
with schizophrenia in a managed care population.
Reducing Relapses in Schizophrenia
• Ayuso-Gutiérrez JL, del Río Vega JM.
• Schizophr Res. 1997 Dec 19;28(2-3):199-206.
• Conclusion: Follow-up studies suggest that
noncompliance with medication, pharmacological
factors, psychosocial factors and alcohol and drug abuse
contribute to setting off new psychotic episodes. The
most important of these is noncompliance with
medication. The overwhelming majority of
schizophrenic patients who suffered a clinical
exacerbation and required hospitalization (73%) did not
comply with the treatment prescribed
Coordinated Care
Physician/NP
Pharmacy
Home
Healthcare
Families
Medical
Monitoring
Coordinated Care
• Physician
–
–
–
–
–
Comprehensive patient assessment
Evaluate caregiving resources
Medication reconciliation
“Patient-centric Medical Home”
Set parameters and select peripherals needed for
monitoring and alerts
• Home Care and Home Health
–
–
–
–
–
Arrange for TabSafe and selected peripherals (turnkey)
Check exception reports weekly
Facilitates caregiving with less labor intensity
Monitors adherence proactively and makes follow-up calls
Fill medication cartridges where allowed
Coordinated Care
• Pharmacy
–
–
–
–
–
Manages all medications incl. OTCs
Proactive medication reviews
Program and fill cartridges
Allows for “real-time” medication changes
“Pharmacy Home”
• Medical Monitoring
–
–
–
–
–
Provide 24/7 call center support
Monitor an array of peripherals, e.g. PERs, GPS
Data collection, analytics, and reporting
Program cartridges for self-filling
National distribution and installation
Coordinated Care
• Families and Caregivers
–
–
–
–
Facilitates remote caregiving
Provides “peace-of-mind”
Reduces caregiving burden
Monitor medication adherence without intrusive
phone calls and controlling behaviors
– Allows family engagement
• Patient
–
–
–
–
Utilize medication alerting and dispensing system
Maintain their independence
Reminders for activities of daily living
Provides a sense of self-control
Reimbursed Delivery Models
• Independence At Home Act
– Providing cost-effective care for homebound patients
– Utilizes Housecall provider visits
• Patient-Centered Medical Home
– Proactive care of patients at home
• Accountable Care Organizations
– Penalties for readmissions
– At risk for poor outcomes
• Program for the All-inclusive Care of the Elderly
• State Medicaid Waiver Programs
– Home and Community-Based Services
– “Money Follows the Person” programs
Continuous Care?
•
Blurring Lines in the Accountable Care Era, Fred Bentley, Managing
Director, Strategic Research, The Advisory Board Company, Sept. 2011
•
Blurring Lines in the Accountable Care Era, Fred Bentley, Managing Director,
Strategic Research, The Advisory Board Company September 2011
Blurring Lines in the Accountable Care Era, Fred Bentley, Managing
Director, Strategic Research, The Advisory Board Company September
2011
1. Adherence matters because physicians are
increasingly being held accountable for their
patients’ outcomes
2. eRx can identify patients that have not been filling
their prescriptions or aid in participant selection
3. Medication dispensing devices, electronic
reminders, and follow-up alerts can assist in
prompting patients to take their medications as
prescribed and improve adherence significantly
4. California has legislated a MDM Pilot with a
projected savings of $140MM and 110,000
caregiver jobs annually by utilizing 40,000 units
The Bowman Family
“Before TabSafe, I was making phone calls
twice a day. TabSafe provides peace of mind
and freedom for the family. I can go to the
movies without worrying about him.”
Claudia Bowman
Stephen L. Axelrod, M.D.
Chairman & CEO
TabSafe Medical Services, Inc.
saxelrod@tabsafe.com
www.tabsafe.com
303.399.1088