MACRA plays blame game when patients don't adhere

Non-adherence has been a problem for as long as physicians have been treating patients. But now it is an even greater concern because it can affect their Medicare Part B reimbursements under the new Medicare Access and CHIP Reauthorization Act (MACRA).

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MACRA brings with it a new set of initiatives, benchmarks and reporting requirements, accompanied by escalating financial incentives and penalties. The program is meant to strengthen the role of primary care and improve patient outcomes, but navigating the new reporting and reimbursement landscape can be problematic for physicians, particularly when patients don’t, or can’t, cooperate.

Patient engagement is a factor in three of the four reporting categories under what is expected to be MACRA’s most common track, the Merit-based Incentive Payment System (MIPS). Policymakers hope the increased coordination between providers and patients will lead to improved adherence. But some think it could be unfair to doctors.

“The performance measures are archaic and they hold physicians responsible for things that are systemic,” says Wendy Nickel, MPH, director of the American College of Physicians (ACP) Center for Patient Partnership in Healthcare, which promotes patient-centered care. “If you tie non-adherence to the physician alone, you’re losing the responsibility that everyone else in the healthcare system has.” 

Engaging patients 

There has been a long and vigorous debate in primary care about non-adherence and how much responsibility physicians should bear for patients’ failure (or inability) to follow medical advice, often to their own detriment.

Some physicians argue that adherence is not their responsibility. All they can do, they say, is prescribe the appropriate treatment; it’s up to the patient to follow through. However, the opposing point of view, which holds that physicians are obligated to do whatever they can to increase adherence, was gaining the upper hand even before MACRA tied reimbursement to results.

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One of the reasons for this is that physicians who might once have attributed non-adherence to patient indifference or laziness have become more aware of the reasons why patients might not follow advice or fill prescriptions, such as financial difficulties, depression, and language and education barriers. 

The key is partnering with the patient, says Amelia Coleman, director of practice management consulting for MBA HealthGroup, a firm with offices in New York City and Burlington, Vermont.

“Those doctors are going to have to find better ways to engage with patients; they’re going to have to take a more active approach’” she says. “A patient is going to be into a care plan if they believe in that care plan and can see how it benefits them.”

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There is no universal solution for improving adherence. It has to be addressed on a patient-by-patient basis, Coleman adds. 

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In many cases, physicians know that patients are non-adherent and even why, but don’t have the time or resources to address it, says the ACP’s Nickel. “Doctors are being pulled in so many directions. The problem is time. Who has time to provide all this information” to patients, she asks.

Some practices are adding care managers and other staff who can address non-adherence as part of their care coordination efforts. Others are using technology, such as secure messaging, texting and at-home medical monitoring, prompting and communication tools to improve adherence.

For Oak Street Health, a multi-site practice with clinics in Illinois, Indiana and Michigan, having current data and patient updates are key to improving adherence, says primary care physician Laolu Fayanju, MD. The organization receives reports from the Centers for Medicare & Medicaid Services (CMS) and commercial payers that show medication adherence (from claims on filled prescriptions), clinic by clinic and patient by patient. This allows doctors to identify and address problems. 

Oak Street Health uses registered nurses, nurse practitioners and social workers to follow up with patients following appointments to ensure adherence. Staff members who visit a patient’s home might even count pills to see if the patient is really sticking to the regimen and prepare for problems resulting from non-adherence, Fayanju says.

“My team and I are not flying blind,” he says. “We have the relevant information on our patients.”

Group effort

Physicians aren’t alone in tackling patient non-adherence. CMS, commercial payers, employers, pharmaceutical companies and medical technology firms have undertaken their own initiatives to improve adherence to make medicine more effective, cut costs and, in the case of pharmaceutical companies, increase revenues.

Some pharma companies are developing “smart pills” embedded with sensors that can send an alert when a pill is swallowed or when a dose is missed. Others are awarding gift cards to patients who refill prescriptions. And the industry has lobbied regulators for permission to pay third parties, such as pharmacists, to remind patients to take their medications. Also, manufacturers are creating medical devices, such as inhalers, that can record the time and date of their use.

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In addition, some employers are rewarding employees for taking part in wellness programs that can reinforce their physicians’ orders to lose weight, exercise more, stop smoking etc. And commercial insurers are experimenting with giving free medications and providing financial incentives for patients who stick to their treatment plans. Private payers also give information regarding non-adherence to doctors. 

Next: Playing to the measures

The emphasis among commercial payers has been on providing incentives to improve adherence and not taking punitive measures, such as increasing copays for non-adherent patients. However, penalties might not be far behind. For example, the Affordable Care Act allows insurers to charge smokers higher premiums,   

‘Playing to the measures’

By potentially penalizing physicians for poor outcomes caused by non-adherent patients, does MACRA provide an incentive for physicians to charge those patients more-or even discharge them?

Non-payment of bills and treatment non-adherence can be appropriate reasons for terminating a doctor-patient relationship, but discharging patients solely because their non-adherence could hurt reimbursements would seem to be unethical.

Though it is not addressed specifically in the ACP Ethics Manual, several of its sections do speak to similar issues. For example, the manual states that pay-for-performance programs “must be aligned with the goals of medical professionalism” and cites “deselection of patients and ‘playing to the measures’ rather than focusing on the patient” as dangers.

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The manual also cautions that in any case of physician-patient disagreement, the doctor is obligated to explain the basis for the disagreement, educate the patient and meet the patient’s needs for comfort and reassurance.

Oak Street Health’s Fayanju says he hopes doctors never drop non-adherent patients just to protect their metrics, but adds that “we are being asked to assume a lot of healthcare risks for our patients.” 

The ethics manual does not address whether it would be fair to charge non-adherent patients more to offset any Medicare penalties, though it does stress that providing the appropriate care should override any financial issues.

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It’s important that frustrated physicians not view non-adherent patients as obstacles or adversaries to be abandoned, says the ACP’s Nickel. “We really want to create space where this is a partnership,” she says. “You can’t have a patient walk into a visit and feel they failed because they will then continue to fail.”