Out of Physicians' Hands: TMA Challenges Unfair Quality Measures on Medication Adherence
By Joey Berlin Texas Medicine December 2019

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Only patients can pick up their own prescriptions, and only patients can propel that medication into their own bodies. Physicians can educate, emphasize, and admonish – but at the end of the day, they can’t restrain and “pill” a squirming, uncooperative patient like a dog or cat. It’s up to patients to do the right thing for themselves.

Yet, some health plans’ quality programs are putting that onus on physicians – through medication adherence metrics that determine whether physicians and accountable care organizations (ACOs) in value-based contracts receive bonus payments. And as Elizabeth Torres, MD, knows firsthand, myriad circumstances can lead to patients not taking their meds.

“Basically, the insurance company wants us to help control a situation in which we have no power to do so. We don’t have the ability to do that,” said Dr. Torres, an internist in Sugar Land. “I’m not at their house; I’m not calling every day to remind them if they took the medication or not. All I can do is impress upon patients the importance of taking their medication and make sure they understand how the medication works, as well as dosing instructions. But even with all that, there’s still no guarantee.”

At its 2019 annual session, the Texas Medical Association House of Delegates adopted a resolution for TMA to identify ways to address insurers’ medication adherence-related quality measures “in response to marketplace influences” that physicians can’t control. The resolution also called for TMA to work with health plans in that effort.

At press time, TMA’s Council on Health Care Quality began taking action on the resolution by drafting letters to the entities that develop quality measures, as well as the Centers for Medicare & Medicaid Services (CMS) and private payers that use the metrics, describing the problems physicians have encountered.

Problems with the measures

Dr. Torres wrote the House of Delegates resolution, in which she noted the vast majority of health plans use the Healthcare Effectiveness Data and Information Set (HEDIS) to assess physicians in value-based contracting. The 2019 HEDIS measures include benchmarks for controlling high blood pressure; annual monitoring for patients on persistent medications; and use of beta-blockers post-heart attack, all of which tie back to medication adherence.

Dr. Torres notes one particular medication adherence metric for which a health plan raised the passing score from 83% in 2018 to 90% this year, meaning patients must be getting their medication 90% of the time at scheduled intervals. She found that requirement quite unreasonable.

“Before, it was 80%,” she said, “and over time they have just kept jacking the percentage up.”

Problems with evaluating physicians on medication adherence abound. Start with the obvious one already noted: The act of getting that prescription, and taking it as directed, is out of the physician’s hands.

“I tell people, set your phones, take the medicine when the alarm goes off, get a seven-day pill box, or place a reminder on the bathroom mirror,” Dr. Torres said. “But people have two jobs, they have children, they have school and projects that are going on with the kids. They get distracted. So they have other things that take priority over their own health sometimes, and they don’t take the medication.”

Drug recalls also have made it difficult for physicians to meet medication adherence-related targets. As Dr. Torres’ resolution notes, recent recalls of blood pressure medications valsartan, losartan, and irbesartan have led “to patient non-compliance and medication shortages that impede an ACO’s ability” to hit medication adherence targets.

Laredo family physician David Cruz, MD, medical director of Seven Flags ACO, confirms that those particular recalls have created difficulties.

“The patients are taking it upon themselves to just stop the medicine. They’re coming in later on and then they’re saying, ‘Yeah, I’m not taking the medicine anymore because of those recalls,’ even [if] that particular medicine wasn’t recalled,” he said. “There’s a lot of confusion and that is going to affect our numbers, without a doubt.”

Even when patients are picking up their medications when they’re supposed to, in some situations physicians aren’t getting credit for it. Dr. Torres notes that insurers calculate medication adherence through claims submission methods that won’t track the various ways in which patients get their prescriptions — including cash payments, pharmaceutical assistance programs, and discounted medication apps such as GoodRx. Samples physicians give patients to cover medication gaps also should be accounted for, Dr. Cruz adds.

“I know it’s very difficult to do,” he said. “But we have to be able to submit that we are getting [patients] samples and they are taking their medications, so there is compliance without [insurers] actually knowing.”

Solutions sought

The cost of medications is also a factor, Dr. Torres adds. She says health plans not only set unreasonable targets, but also cause medication adherence shortcomings themselves because of what they will and won’t cover. She points to metoprolol as an example. The beta blocker is available in both a short-acting and long-acting formulation.

“You can take it to regulate blood pressure, heart rate, or post-[heart attack],” she said. “The short-acting drug is cheaper but you have to take it twice a day. But we know that with twice-daily dosing, there’s less adherence versus a regimen that’s once a day. So both drugs have the same effect. But the insurance company wants to cover the cheaper drug instead of the more expensive drug. But what’s more important – medication adherence or cost?”

Both she and Dr. Cruz acknowledge that medication adherence itself is important for patient care. Now that TMA is engaging payers on the issue, Dr. Torres wants to see the adherence benchmarks reduced to a reasonable, achievable level.

“Either that or get rid of [those] measures, but they’re not going to do it, because they see that it’s very important [to track it]. Insurers need to find an alternate means of reporting so that patients can report their medications that are done on a cash basis … and find a way for [insurers] to capture that data,” she said. “To hold physicians responsible for measures beyond our control is not helpful to our patients, and certainly not reasonable.”

The Texas Association of Health Plans did not respond to a request for comment. United Healthcare and Blue Cross Blue Shield of Texas both acknowledged Texas Medicine’s request for an interview but did not make anyone available.


Tex Med. 2019;115(12):30-34
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Last Updated On

December 04, 2019

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Joey Berlin

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Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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