Has Your Health Insurance Really Got You Covered?
Your health insurance is paying for the wrong things.
According to both the World Health Organization and the Centers for Disease Control and Prevention, about 50 percent of people who are prescribed medication for long-term health conditions such as high blood pressure, high cholesterol or diabetes do not take their medications as prescribed.
The reasons are many and vary from person to person, but the result is the same: Many people are not getting the health benefits they need from their medication, either to maintain or improve their health, or to prevent worse health events down the road, such as heart attack or stroke.
As a result, insurers must pay for health care providers to deliver behavioral interventions and case management to improve adherence to medication regimens.
Over my 20 years as a nurse, I have seen many patients struggle to manage medications, often ending up hospitalized as a result. In my research, I have found ways to identify and help patients better manage their medications, but our current health care financing model does not reimburse for such care.
Medication nonadherence is estimated to cost the U.S. health care system between $100 billion and $289 billion in direct costs each year, according to research published in the Annals of Internal Medicine. The average total cost of a single heart attack ranges from $760,000 to about $1 million per person, depending on severity, according to an article from the National Business Group on Health reported by CBS News.
Research in the journal Stroke reports that total costs from a stroke range from $90,981 to $228,030, depending on the type of stroke. If we can prevent heart attacks and strokes, the savings to insurance companies, employers, patients and taxpayers is staggering.
We know that many people need help with managing medications for reasons such as forgetfulness, complex medication regimens, language barriers, inability to obtain medication, or symptoms from health conditions, yet health insurers do not provide coverage to pay for patients to get the help they need.
For instance, researchers have developed many programs through which health care providers can work with patients to improve medication management, but without a financial model to pay for it, such programs will not reach patients who need it. As one example, P. Michael Ho at the Department of Veterans Affairs and colleagues have shown that team-based approaches do lead to significant improvements in how patients use their cardiovascular medications.
Reimbursing health care organizations for medication adherence initiatives delivered by providers, such as registered nurses, nurse practitioners or pharmacists, would improve health outcomes and lower costs overall. While this approach would involve up-front costs, the result would be a net savings due to prevented hospitalizations.
Health care providers typically don’t have time during appointments to address whether patients are taking medications correctly, and research repeatedly shows that patients usually think they’re doing better with managing their medications than they actually are.
Reliant Medical Group, a network of over 500 health care providers in Massachusetts serving over 320,000 patients, has also demonstrated how a focus on adapting medication regimens to improve adherence in high-risk patients can lead to better rates of blood pressure control. These approaches can work when health care teams are able to devote the time and resources needed to partner with patients to address the obstacles in the way of improving each patient’s health.
To be sure, taking medication when required is not the only important behavior for maintaining and improving health. While other health behaviors such as diet and exercise are important, for most people with chronic health problems, adhering to a medication regimen is going to be the most important health behavior for keeping a person out of the hospital (or worse).
While many insurance companies have their own care management programs, patients tend to be more comfortable working with case managers and nurses from their own health care provider’s office. If these programs are housed in individual practices, there is also better continuity of care and ability to make modifications to medication regimens or detect changes in health status needing early intervention to prevent hospitalization.
Yes, this is a change in how we do things.
Having insurance companies pay for services that don’t fit the traditional model may be seen as radical. But the health of our nation and the growing cost of our health care system demand new approaches.
There can be no innovations to our health care delivery models if there is no change in how insurance reimburses for health care services and defines what is necessary in health care services.
It is far better in the short term and the long run to pay for proactive care up front for the portion of the population that needs it than to have all of society paying increased insurance costs to pay for health problems we could have prevented.