advancing the responsible use of medicines: avoidable costs and considerations for...

Advancing the Responsible Use of Medicines: Avoidable Costs and Considerations for Korea’s Health System

Murray Aitken, Executive Director, IMS Institute

Sungkyunkwan University, School of Pharmacy

March 26, 2014

Today’s discussion

• Introduction to the IMS Institute for Healthcare Informatics

• Overview of our global research on the responsible use of medicines

• Considerations for Korea’s health system

Sungkyunkwan University School of Pharmacy 032614 Responsible Use of Medicines Seminar 2

Established in 2011, the IMS Institute has a research agenda around five areas

Effective use of

information

Performance of medical

care

Global role for

biopharmaceuticals

Innovation in health systems products, processes

and delivery systems

Developing nations

1 2 3 4 5

The Institute’s mission is to provide key policy setters and decision makers in the global health sector with unique and transformational insights into healthcare dynamics

derived from granular analysis of information


About the IMS Institute

Unbiased Information

Academic Research

Public Policy Support

4 Sungkyunkwan University School of Pharmacy 032614 Responsible Use of Medicines Seminar

Why focus on responsible use of medicines?

Medicines are an integral part of healthcare

But often managed in isolation from other parts of care.

Sungkyunkwan University School of Pharmacy 032614 Responsible Use of Medicines Seminar

$1 Trillion will be spent on medicines globally in 2014

5

Our technical report had four objectives

1 Establish a globally relevant framework of where the value from responsible medicine use can be gained

2 Develop a quantitative analysis for avoidable costs from a medicine and non-medicine spend perspective

3 Identify best practice policy options and case study examples of addressing lost value and realizing benefits

4 Provide a set of prioritized and pragmatic recommendations for health system leaders

Drawn primarily on middle- and high-income countries

though approach & implications should be relevant for all


Total global spending on medicines will reach about $1.2Tn in 2017, an increase of $205-235Bn from 2012

Global spending and growth, 2008-2017

2007 2008-2012 2012 2013-2017 2017

$731Bn

$234Bn

$965Bn

$205-235Bn

$1,170-1,200 Bn

Source: IMS Health Market Prognosis, September 2012


Annual spending growth on medicines will accelerate over the next five years, particularly in developed markets


Global Growth, 2008-2017

-10

0

10

20

30

40

50

60

70

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

ABSO

LU

TE G

RO

WTH

CO

NST $

USBN

Developed Pharmerging Rest of World

2008-12 Growth $217Bn

2013-17 Growth $230 -260Bn

Source: IMS Health Market Prognosis, September 2013

The responsible use of medicines places emphasis on the stakeholders

The responsible use of medicines implies that the activities, capabilities and existing resources of

health system stakeholders are aligned to ensure patients receive the right medicines at the

right time, use them appropriately and benefit from them


The focus of study was limited to six areas where there is opportunity to increase the value of medicines

Medicine access and pricing were not addressed


Medication nonadherence

Delayed evidence-based treatment

Medication errors

Suboptimal generics use

Mismanaged polypharmacy

Antibiotic misuse

Improvement in health outcomes

Decline in healthcare

costs

Increase in medicines value and

health system

performance

10

We applied a five-step process for the global quantification effort

• Step 1: Consolidated existing data across countries on the avoidable cost opportunity across six levers in countries

• Step 2: Assessed the drivers of differences in the avoidable cost opportunity across countries with a focus on measurability, global relevance and comparison. This resulted in five factors supported by global datasets:

• Health system infrastructure • Affordability • Medicine intensity • Elderly in the population • Non-communicable disease risk

• Step 3: We then assessed the relationship between these five factors and our six levers, developing a weight for each relationship.

• Step 4: Developed an algorithm to estimate avoidable costs for 186 countries using weights, existing avoidable cost figures and global data on the five factors

• Step 5: Identified error margins based on the differences between actual and modelled data for countries where it exists and the quantity of data requiring estimations

• Gray literature and peer reviewed articles • Government sources • IMS Health data

Process Source

• IMS Institute • IMS Health • WHO • World Bank

• IMS Institute • WHO

• IMS Institute

• IMS Institute


We drew on case studies and supporting evidence from a wide set of countries to inform what ministers can do

12

-19 country case studies -12 different geographies

-Supporting evidence from over 30 countries


We also consulted with over a dozen external reviewers to assess sections and specific recommendations

13


14

54

Criteria 14 Criteria Top 5

Factors relevant for Ministers’ of Health: -Leadership -Policy-making -Financing

• Peer-reviewed and “gray” Pragmatic literature review covering literature sources •Case study development • Primary interviews with different healthcare professionals

So

urces

We identified 5 ‘high impact’ recommendations out of 54 using a prioritization process

Factors relevant for health system leaders: - Level of spending -Health outcome improvement

- Time from initiation to impact

Coverage • 9 distinct levers • Stakeholder focus across physicians, pharmacists, nurses and patients

Coverage: • 5 distinct levers • Focus on non-adherence

• Multiple stakeholder focus

Coverage: • Focus on 5 levers with spillover effects on others

• Pharmacist focus

Prioritizing recommendations

Pro

cess

#


Annual avoidable costs were estimated for each of the six areas




Medication errors



Antibiotic misuse

$269 Bn

Annual Avoidable Costs (2012)

$62 Bn

$54 Bn

$42 Bn

$30 Bn

$18 Bn

Total Annual

Avoidable Costs:

$475 Bn = ~8% THE

15

This opportunity exists across all health system, and ranges from 4 to 9% of total healthcare expenditure

Latin America & Caribbean15 Bn or ~5% of THE

North America 234 Bn or ~9% of THE

EU5 100 Bn or ~8% of THE

Africa & the Middle East 7 Bn or ~4% of THE

Western Europe 34 Bn or ~8% of THE

Asia Pacific 25 Bn or ~5% of THE

Japan 38 Bn or ~9% of THE

Central and Eastern Europe 19 Bn or ~7% of THE


THE = Total Healthcare Expenditure

These costs represent avoidable healthcare services utilized by millions of patients


14045

22

6

10 million hospitalizations

78 million outpatient visits

246 million prescriptions

4 million emergency room visits

Source: Avoidable Costs in U.S. Healthcare Study

Millions of lives affected $213 Bn

Avoidable Costs, US ($Bn)

Utilization

17

Nonadherence is the biggest area of opportunity, multi-faceted in nature and can be improved

Nature of the challenge Possible interventions References/Examples

• Apply a patient-centered approach

• Multi-faceted: Several risk factors that

operate in combination • Relies on behavior

change: Patients’ belief system matters yet that is often beyond the control of healthcare professionals

• Simple tactics: peer sup-port groups, self-initiated reminders

• Support data collection efforts to enable targeted interventions

• At the point of prescription and during medication intake

• Adopt cross-disease learnings

• Cardiovascular disease and HIV

• Strengthen role of healthcare professionals, particularly pharmacists to support adherence interventions

• Pharmacy-based management programme can trigger a return on in investment (e.g., 3 USD for every 1 USD spent) and improve adherence levels


A few countries track adherence progress in spite of existing challenges

Brazil monitors adherence for TB and HIV medicines

Denmark tracks adherence among asthma, elderly and other at-risk patients

Recent CMS reform mandating adherence tracking as key components of quality care

Examples

Various terms: Adherence, compliance, persistence?

Inconsistent definitions: thresholds, dichotomous methods

Lack of reliability in self-reported methods

Current challenges


A number of cross-country learnings can be leveraged to foster improvement across other levers

Ensure timely medicine use

Optimise antibiotic use

Prevent medication errors

Use low-cost generics where available

Manage polypharmacy

Primary recommendations Country evidence

• Leverage economic evaluations

• Thailand

•Develop patient education programs and public campaigns

• France

• Implement technology-supported solutions

•Sweden

•Ensure supply-side measures •Germany

•Risk-stratify patients at high risk of inappropriate use of concurrent medicines

•US


Our global research developed five top recommendations based on outcome impact, timing and cost

1 Support greater role of pharmacists to own medicines management

2 Invest in medical audits targeting elderly patients

3 Implement mandatory reporting of antibiotic use

4 Encourage a “no blame” culture towards error reporting

5 Support targeted disease management programs for prevalent non-communicable diseases


Pharmacists can play critical roles in a large number of potential improvement areas

Examples of high value pharmacist role




Medication errors



Antibiotic misuse

• Direct and meaningful patient engagement • Tailored programs in support of segments of patients likely to be nonadherent

• Availability of low barrier/cost diagnostics • Medication therapy management programs

• Patient awareness of appropriate antibiotic use • Monitoring and reporting of atypical utilization

• No-blame culture of error reporting • Systematic approach to developing corrective actions

• Active substitution efforts where permitted

• Medication therapy management programs • Priority for elderly patients

22

There are other qualitative factors that affect the suboptimal use of medicines

Description

Oth

er f

acto

rs

The use of medicines and assessment of whether it is optimal or not is not systematically tracked within or across countries, making it difficult to understand the value of medicine use in the broader health system context and how countries can improve

Regulation and its enforcement

• Policies exist to support responsible use of medicines across different stakeholders

• Incentives underpin activity related to medicine use to support policy implementation

• Particularly key for antibiotic use, generic use and polypharmacy • Most relevant for low and middle income countries

Coordination in the health system

• Healthcare professionals are supported in ensuring treatment is provided an aligned fashion between different clinicians and pharmacists

• Information is shared between clinicians on patient health progress and medicine use

• Particularly key for timely medicine use, antibiotic use, polypharmacy and adherence

Ability to track metrics related to medicine use

• Information collection is encouraged and supported to ensure tracking of progress and setbacks with respect to medicine use issues

• The use of existing data is optimized to track medicine use even if it is not a perfect mechanism

• Key for all areas

23


The most effective and innovative approaches are possible only through collaboration among multiple healthcare stakeholders


PROVIDERS

PATIENTS PAYERS

PHARMACEUTICAL MANUFACTURERS

POLICYMAKERS

Areas of Avoidable

Costs

PHARMACISTS

24

We see a set of common principles applied to successful improvement programs

Consistent focus on high-risk patients most vulnerable to suboptimal medicines use and require costliest interventions


Steadfast engagement with patients as responsible and capable partners

Rigorous assessment of impact and ROI in design and implementation of interventions for optimum avoidable cost reduction

Continuous measurement and accountability as basis for multi-stakeholder approaches

Alignment of compensation/incentive models with new healthcare delivery models

25

We identified five success factors which can also be supported by Ministers of Health for implementation

Policy

Regulations or laws that

support improvements in medicine

use downstream

among prescribers, dispensers

and patients.

Collaboration

Engagement between

healthcare professionals and patients in the public and private

sectors.

Education and Capacity-

building

Education efforts

directed to healthcare

professionals and patients

through training

and/or public awareness campaigns.

Informatics

Applied data collection or medicine use monitoring to

inform decision making,

including the application of information technology

(IT) and non-IT based methods.

Incentives

Alignment of incentives

among healthcare

professionals to drive

change in clinical and/or

dispensing practice.


The report offers messages for all stakeholders across the health system

Consolidate experiences on how stakeholders in the health system improve medicines management and impact the nonmedicine part of the health system

1

2

3

There is an overall need to... Key stakeholder relevance

• Pharmacists • Pharmaceutical industry

Ensure mechanisms are in place to support the responsible use of medicines in countries where healthcare service and medicine access is increasing

•Governments • Payers •Wholesalers

Revitalize discussions on what works to improve adherence and health outcomes given new interest, supporting information and evidence

•All, ideally in a multi-stakeholder approach

27


2.9 1.7 0.98

0.3

0.98

0.1

Nonadherence (39%)

Mismanaged polypharmacy (3%)

Medication Errors (7%)

Suboptimal generic use (15%)

Antibiotic misuse/overuse (13%)

Untimely medicine use (23%)

Annual magnitude of the opportunity across the health system Total KRW Tn

This quantification effort is intended to trigger a meaningful discussion on how to assess the impact of responsible medicine use and not on the exact figures

Our modelling suggests there is an avoidable cost opportunity of 7.8% of total health expenditure in Korea or KRW 7.5 Tn

These are nonmedicine and medicine-related avoidable costs

21

South Korea’s health system has some distinctive factors that likely affect medicine use

29

75.12 101.64

28.10

84.10 94.40

S. Korea has fewer physicians

compared to the average

While obesity rates are lower in S.

Korea, alcohol and tobacco use are

higher

S. Korea has more medicines /capita

including new chemical entities and antibiotics

S. Korea has a lower elderly population

Healthcare infrastructure

NCD Risk factor

Affordability Elderly Medicine intensity

Are policies in place to ensure appropriate use?

S. Korea indexed to high-income country average

Affordability for healthcare is very high in S. Korea with much lower

OOP on healthcare

A combination of factors make the health system more or less vulnerable for suboptimal medicine use


The risk of suboptimal medicine rises as countries have greater availability of medicines

30

0

1

2

3

4

5

6

7

8

9

10

11

0 100 200 300 400 500 600 700 800 900 1,000 1,100 1,200

S. Korea

Morocco

Indonesia

India Ghana

Egypt, Arab Rep.

Cameroon Cambodia Bangladesh

United States

United Kingdom

Netherlands

Dominican Republic

Spain

Saudi Arabia

Oman

Japan

Ireland

Germany

Finland

France

Austria Canada

Australia

Thailand

South Africa Russian Federation

Jordan

Costa Rica

Switzerland

Colombia China

Brazil

Zambia

Vietnam

Source: IMS MIDAS, 2009; World Bank and WHO indicators, 2009; IMS Institute for Health Informatics, 2012; Select countries invited to the Ministers Summit

Suboptim

al m

edic

ine u

se r

isk s

core

The more medicines there are in the health system, the greater the risk for suboptimal use without mechanisms in place to ensure appropriate use

Suboptimal medicine use risk score vs medicine intensity

Oral standard units per capita


30

Considerations for Korea

• What level of attention is given to the responsible use of medicines?

• Are mechanisms in place to track responsible use of medicines? e.g.

− Medication adherence levels by patient segment and therapy area

− Timeliness of diagnosis and initiation of treatment for key diseases

− Efficiency of the generics market

− Level of inappropriate use of antibiotics

− Medication safety levels in hospitals and community care

− Proactive management of polypharmacy

• What programs have been highly successful at improving responsible medicine use and avoiding healthcare costs?

• Do healthcare stakeholders collaborate effectively to improve medicine use?


For more information

• www.imsinstitute.org

• Apple iTunes store/IMS Institute

• [email protected]


http://www.imsinstitute.org/

Advancing the Responsible Use of Medicines: Avoidable Costs and Considerations for Korea’s Health System

Murray Aitken, Executive Director, IMS Institute

Sungkyunkwan University, School of Pharmacy

March 26, 2014

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