Article Date: 8/1/2009

Glaucoma Medication Adherence Vs. The Economy
glaucoma

Glaucoma Medication Adherence Vs. The Economy

You're likely to overcome the ever more prevalent cost issue by following these seven tips.

MICHAEL CHAGLASIAN, O.D., F.A.A.O. AND RONALD CARR, O.D., F.A.A.O., Chicago

Getting our patients to adhere to their glaucoma drugs is an ongoing challenge. (See "The Importance of Instilling Adherence," below.) Among other reasons, motor skills, side effects, lack of education about therapy, forgetfulness, lack of and improvement in symptoms and cost have all been implicated as reasons for non-compliance (See "Reasons For Non-Compliance," below).1,2

Unfortunately, the current economic environment has greatly strengthened the cost reason. But, you have an excellent chance of overcoming this even greater obstacle by following these seven tips. (See "LEAPS: Enhance Practitioner Patient Communication to Strengthen Adherence," below.)

1 Navigate the Medicare Part D benefits

Medicare Part D covers most glaucoma medications. As part of Medicare Part D, for the 2009 plan year as an example, patients pay premiums which are approximately $544 a year.3,4 Once an individual has met the $295 deductible, Medicare Part D covers approximately three-quarters of the cost — provided you select a Medicare-preferred agent. Thereafter, the patient receives coverage until the individual and one's plan reaches the $2,700 limit. Beyond this threshold is the "donut hole," or coverage gap, that requires full payment until the patient spends approximately $4,350. Once the patient reaches this limit, the government picks up 95% of the expense of drugs.

Low-income seniors covered under Medicaid also receive Medicare Part D. These "dual eligible patients" don't pay monthly premiums or deductibles, they have low co-pays and aren't subject to the "donut hole."

A myriad of Part D drug plans are currently available. Having such a broad variety of plans can create confusion, which can lead to poor adherence. For instance, plans with the same "Brand" name, such as AARP (American Association for Retired Persons), can offer several plans that have different premium levels, deductibles and benefits. Thus, while one AARP patient may pay a certain amount per month for a specific glaucoma drug, the next patient may not have the same benefit and may not even be covered at all. The bottom line: Make sure both you and your staff know which Part D drug benefit plan to which your glaucoma patient belongs.

The Importance of Instilling Adherence
Getting patients to cooperate with chronic medication therapy is critical to minimizing glaucoma progression and blindness. Most patients will be taking one to two drops daily for the rest of their life, with almost 50% of patients requiring multiple agents.6
In managing glaucoma, getting patients to comply with prescribed therapy can be far from ideal. Medication adherence, or the degree to which a patient follows prescribed instructions during a defined time, in these patients is a significant issue.7,8 Rates of adherence with glaucoma medications are not impressive. One seminal study showed a rate of 76% compliance with an electronic eye drop monitor, and 55% of patients overstated compliance by more than 10%.9

2 Mind the gap

Be mindful that the aforementioned "donut hole" occurs during the final quarter of the year. As a result, build a plan with your patients and insurance plan company representatives to address potential issues related to medication access during this time. This is particularly important for those individuals who use multiple medications.

3 Always request the separate drug card

Be aware that your patients' drug and healthcare coverage aren't always the same. Therefore, become familiar with the coverage of the major glaucoma medications in the largest plans locally. (visit: www.fingertipformulary.com), and obtain current coverage information from drug company representatives.

Several practices copy the patient's Medicare card for services; yet fail to request the separate drug card. So, the medication you decide to prescribe may not be covered or may cost more than another covered medication that's appropriate for the patient. The result: The patient may decide stretch out his medication or not fill the prescription.

To keep abreast of your patient's coverage, always have a staff member make a copy of the patient's drug card. Further, designate the staff member who already handles refills or reimbursements as the practice specialist on medication coverage. This is particularly important for dual eligible patients who may not fully know the extent of their medication coverage.

Note: E-prescribing software can provide the "real time" ability to acquire information about formulary coverage as well as expedite and assure the dispensing of the proper medication at the pharmacy.

4 Assess quantity limits

Double check the quantity limits of the patient's drug plan, so you can assess whether the plan offers a mail order option (a 90-day, or three bottle-supply, for only two co-pays) or allows for large bottles.

5 Determine whether a generic drug is suitable

Although some generic versions of topical ophthalmic products may have some limitations due to a lack of testing for bioequivalence and potential decreased tolerability as the result of different buffering agents in the formulation, this isn't the case for all generic drugs. Therefore, if a generic glaucoma drug makes sense clinically, consider prescribing it.5

6 Be aware of step-edits

Be knowledgeable of step-edits, or treatment protocol requirements, in coverage coming down the line. Being proactive regarding these payer policies enables you to eliminate unnecessary pharmacy callbacks.

7 Use indigent care programs

Take advantage of the various drug company indigent care programs. These support programs are designed for underinsured and uninsured patients. For further information, check the Pharmaceutical Manufacturer's Association (PharMA) Partnership for Prescription Assistance at www.pparx.org/Intro.php, www.rxhope.com — a guide to patient assistance — or the Web site of the respective manufacturer indigent care program.

Because most glaucoma patients are already on a fixed budget, a struggling economy can greatly worsen the cost reason for non-adherence to medications. So, it's crucial we find ways to increase the likelihood these patients comply with our prescriptions. By following the outlined seven tips, you increase your chance of accomplishing this very important goal. Further, these seven steps will likely create several word-of-mouth referrals, as following them shows your patients you genuinely care not only about their ocular health but also their finances. OM

LEAPS: Enhance Practitioner Patient Communication to Strengthen Adherence.10,11,12
LISTEN. During each patient visit, listen more and speak less. To do this, ask more questions. Ask the patient how often he takes his medication and to show you how he physically instills the drops. If he says he's been unable to instill the drops or you notice that all the drops are not entering his eye, ask the patient what he believes is causing the problem and how he thinks the problem could be solved.
EDUCATE. Take time to educate the patient. Start by determining the patient's understanding of glaucoma: "Can you tell me what you already know about glaucoma?" Fill in gaps, and correct misinformation. Patients who have a full understanding of their disease and of the risks of not taking their medication (e.g. vision loss, blindness) are more likely to adhere to the medication(s) you've prescribed.13
ASSESS. Monitor and evaluate compliance in a non-judgmental way. If after listening, the patient reveals he's not taking his medication 100% of the time, empathize that complying 100% of the time is difficult for everyone, and ask him what ideas he has to make adhering easier. Establishing a close bond and trust with the patient opens avenues for communication and practitioner influence.
PARTNER. Partner with the patient. After listening and assessing, offer suggestions based on his response (signifying the partnership). Such suggestions may include a calendar, log book or alarm clock.
SUPPORT. Being supportive is critical. Make it easy for patients to share their issues. Empathy can go a long way: "It looks like having glaucoma is hitting you pretty hard. Anyone would feel overwhelmed by it all at first; and I'm here to help you through this period."

1. Tsai JC, McClure CA, Ramos SE, et al. Compliance barriers in glaucoma: a systematic classification. J Glaucoma. 2003 Oct;12(5):393-8.
2. Patel SD, Spaeth GL. Compliance in patients prescribed eye drops for glaucoma. Ophthalmic Surg. 1995 May-Jun; 26(3):233-6.
3. Medical News Today. Medicare- PartD.com Brings 2009 Medicare Prescription Drug Plan Information Online, USA. www.medicalnewstoday.com/articles/123255.php. Accessed July 17, 2009.
4. Centers for Medicare and Medicaid Services. Medicare and You 2009. www. medicare.gov/Publications/Pubs/pdf/1-0050.pdf. Accessed July 17, 2009.
5. Cantor LB. Ophthalmic generic drug approval process: implications for efficacy and safety. J Glaucoma. 1997 Oct;6(5):344-9.
6. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002 Jun;120(6):701-13.
7. Schwartz GF, Quigley HA. Adherence and persistence with glaucoma therapy. Surv Ophtalmol. 2008; Nov;53 Suppl:S57-68. Review.
8. Garber MC, Nau DP, Erickson SR, et al. The concordance of self-report with other measures of medication adherence: a summary of the literature. Med Care. 2004 Jul;42(7):649-52.
9. Kass M, Gordon M, Meltzer DW. Can Ophthalmologists correctly identify patients defaulting from pilocarpine therapy? Am J Ophthalmol. 1986 101:524- 30.
10. Roter DL, Hall JA. Strategies for enhancing patient adherence to medical recommendations. JAMA. 1994 Jan 55; 271(1):80.
11. Roter DL, Hall JA. Communication and Adherence: Moving From Prediction to Understanding. Med Care. 2009 Jul 10. [Epub ahead of print]
12. Roter DL, Frankel RM, Hall JA Sluyter D. The expression of emotion through nonverbal behavior in medical visits. Mechanisms and outcomes. J Gen Intern Med. 2006 Jan;21 Suppl 1:S28-34.
13. Cochereau I. Increasing compliance in glaucoma patients through education. J Fr Ophtalmol. 2007 May;30(5 pt 2):3S79-81.

Dr. Chaglasian is chief of staff at the Illinois Eye Institute and associate professor at the Illinois College of Optometry in Chicago. E-mail him at MChaglas@ico.edu.
Dr. Carr is in private practice at Midwest Eye Professionals in Palos Heights, Ill. Also, he's a member of the adjunct clinical faculty at the Illinois College of Optometry in Chicago. E-mail him at roncarr@mweye.com.


Optometric Management, Issue: August 2009