Perspectives of Older Patients on the Complexity of Medication Use from Dutch colleagues clarifies the components of the Medication Regimen Complexity Index (MRCI) and makes a compelling argument for the inclusion of patient perspectives in order to make the tool more effective 1. While reviewing the article, I could not help but think about how refreshing it was to focus on simplifying medication administration instead of spending so much time on medication costs in the United States. The basic questions we often face when trying to help older adults navigate their medications in the United States are (1) can they afford what is prescribed? ; (2) if generic, will there be a shortage or need to switch to a new manufacturer due to production cessation because of the very low prices we pay for generics? ; (3) if brand, can the pharmacy afford to dispense the medication—as acquisition costs can exceed their reimbursement? 2-5. The appropriate use and administration of medications should be front and center; however, it is often given short shrift. Pharmacists are not considered providers and cannot directly bill Medicare for medication therapy management services. In addition, due to siloed funding sources and numerous contributing factors that confound proof of causation to health outcomes, demonstrating that pharmacists are valuable care team members is challenging. Unfortunately, the promise that medication therapy management would be the cornerstone of the Part D benefit and reward pharmacists for engaging in clinical interventions was never funded beyond administration fees to Part D plans that usually create call centers. Plus, improving access to medications due to high costs in America continues to take center stage. There is growing concern that the annual cap on the Medicare D beneficiary payment (2100 for non-low income subsidy individuals in 2026) might increase polypharmacy, and possibly unnecessary spending due to a loss in price sensitivity by Medicare beneficiaries 6. In contrast to some other healthcare settings, in the Netherlands, the affordability of medication is generally less of a concern because of comprehensive health insurance coverage. While the system reduces financial barriers, patients may still face challenges in managing the complexity of their regimens. In settings with less regulation and stronger market orientation, affordability may further contribute to medication-related complexity. Dusetzina et al. found that in 2019, a stunning 27. 2% of total spending for individuals enrolled in traditional Medicare was for medications 7. Since then, the Inflation Reduction Act has capped annual spending for beneficiaries, expanded “extra help, ” implemented single-source drug price negotiations, and captured manufacturers' rebates if they raise prices faster than inflation 8. The current administration is threatening tariffs on some imported medications and making deals with some drug manufacturers to lower prices—the results of which we are waiting to see. This is all while new biologics and specialty medicines, which are heavily advertised to the public, come with eye-popping prices. Concurrently, researchers and policy makers are grappling with understanding how medication “value” needs to be considered in light of production costs, government regulation, and how we need to shift to a more competitive and transparent market 9. Fortunately, geriatrics expertise is shared across continents, and we have much to learn from others working in different environments. Dr. Falke and team provide a wonderful graphic describing the MRCI that examines form and route of therapy, dosage frequency, and additional instructions for both prescription and over-the-counter medications. They describe qualitative interviews that led to four major themes when considering the patient's perspective of complexity and found that routine can be a tremendous asset, which we know from other research 10. The Ishikawa diagram delineates other findings (Falke, Figure 2). Wimmer et al. conducted a systematic review of clinical outcomes associated with medication regimen complexity a decade ago and found inconsistent results. However, the review did not focus on studies that included patients' perspectives; one study included family caregiver medication administration hassles 11. In addition to medication regimen complexity and payment concerns in the United States, challenges include medication switches not based on clinical decisions but insurance coverage and ever-changing formularies. It is also common—and infuriating—for insurers to steer patients to certain pharmacies as vertical integration drives incentives with consolidation in the medication supply chains (i. e. , insurers owning a PBM and pharmacies). Plus, drug distributors when bidding for the cheapest generic may switch manufacturers, sending medicines to pharmacies that contain the same active ingredients—but they look and possibly affect people differently—depending on the quality of manufacturing 5. When focused on medication appropriateness, we have several tools that help guide treatment decisions for older adults. The explicit American Geriatrics Society Beers Criteria (c) and STOPP-Start in addition to the implicit 10-item Medication Appropriateness Index, which includes a metric “are the directions practical” 12-14. And yet, these useful tools are not geared towards the context of patients' lives, including their knowledge, attitude, and beliefs. Within each of these categories of medication-related problems, older adults often described medication-related problems in ways that were inextricable from the broader, socioemotional context of their lives. This marks a major contrast from existing taxonomies for categorizing medication-related problems, which focus almost exclusively on discrete and highly tangible problems such as non-adherence or adverse drug effects, and lack attention to problems articulated by patients related to fear, communication, and the social and emotional impacts of medication use. These researchers encourage clinicians to get curious about the context of the lives of the individuals using the medications 16. And, while it is critical to understand the “customer's perspective, ” in most markets, fast-paced healthcare environments tilt towards clinical guidelines, process, and surrogate measures 17. For example, measures for the Medicare Part D star ratings program have been heavily weighted towards adherence, which can lead to “auto-fills, ” especially from mail order pharmacies. To top it off, these star metrics measure dispensing rates not actual adherence 18. Falke and team clearly outline the importance of medication characteristics, how individuals prepare to administer the medications, and the actual administration itself, in addition to the attitudes and beliefs of the individuals taking the medications. All of these concepts come together nicely in a health program planning and evaluation model—the Precede-Proceed Model (PPM) from Green and Kreuter 19-21 (see Figure 1). While this model is meant to support program design and evaluation, its application can place medication use in the larger context of individuals' lives. As pharmacists seek to demonstrate their impact on health outcomes since surrogate clinical measures aren't viewed as enough “return on investment”—it is critical to start with the “end in mind. ” An example of how to use the PPM is below and features Senior PharmAssist in Durham, NC, a nonprofit created in 1994 to help older adults with limited incomes obtain and better use their medications of which I am the founding director 22-24. Over the years, Senior PharmAssist (SPA) has grown to include tailored community referrals, Medicare insurance counseling, and advocacy 8, 25, 26. While SPA does not measure medication regimen complexity, addressing the complexity is a critical focus for our pharmacists. They work with others to simplify medication regimens focused on the participants' perspectives as much as possible and ensure that all care team members are on the same “medication page. ” Employing motivational interviewing and building trust over time have been essential to better understanding what “matters most. ” Participants' perspectives might not always be “correct” (“I believe drug X causes Y, ” when it is highly unlikely) ; however, understanding where they are coming from, and subsequently how they use their medications, should be our starting point. The planning phase of the PPM is focused on quality of life. As we established SPA, we learned from older adults, care partners, providers, and pharmacists that the outcome of medication optimization would facilitate older individuals being as functional as possible for as long as possible. While SPA does not address everything that supports function, we knew a pharmacy/social care model could address function and well-being in meaningful ways. Figure 2 illustrates issues we consider critical to our model. This planning and evaluation model helped the designers of SPA “think outside” of our clinical boxes and consider the perspectives of the older adults we wanted to serve, their family members, and the local pharmacists and providers who comprise our participants' health care teams. This goal-concordant care is in-line with the 5 M framework of AGS (what matters, medications, mentation, mobility, and multicomplexity), and the Institute of Healthcare Improvement's 5 R framework in safe medication practices (right drug, right patient, right dose, right route, and right time) 27, 28. While not every problem needs a full-scale program design, clinicians thinking outside of our usual “boxes” can be enlightening. Falke et al. have provided useful context for decreasing the complexity of drug regimens, let's hope that market forces in the US don't continue to drive “more medicines” and “more expenses, ” while sacrificing the quality of life for our older neighbors. Gina Upchurch is solely responsible for the concept, design, and composition of this article. Views or opinions expressed in this article are solely those of the author and do not represent those of the Medicare Payment Advisory Commission. The author has nothing to report. There was no funding or sponsorship for this work. Gina Upchurch is the founding executive director of Senior PharmAssist and serves on the Medicare Payment Advisory Commission. The views presented are those of the author and do not reflect those of the Commission. This publication is linked to a related research article by Falke et al. To view this article, visit https: //doi. org/10. 1111/jgs. 70311.
Gina Upchurch (Fri,) studied this question.