Continuation Appropriateness in Managed Care: The Missing Measure

In managed care systems, a critical gap has emerged in the long-term maintenance phase of patient treatment. While significant oversight exists at the start of a therapy, there is a lack of systemic evaluation regarding whether a medication remains necessary, safe, and effective over time, a concept known as continuation appropriateness.

Continuation appropriateness refers to the ongoing assessment of a patient’s treatment to ensure that the therapy continues to provide clinical value. This differs from initial prescribing, which is typically heavily scrutinized through clinical guidelines and prior authorization processes.

The Gap in Quality Frameworks

Existing quality frameworks often fail to capture the necessity of long-term medication use. For example, the Healthcare Effectiveness Data and Information Set (HEDIS) is designed to measure if a patient received the correct drug at the point of initiation. Meanwhile, Star Ratings focus on whether the patient is continuing to take the medication.

Neither of these measures evaluates whether the medication is still the most appropriate choice for the patient as their health status evolves. Clinical pharmacists are uniquely positioned to provide this missing measure of continuation appropriateness, which is not currently produced by existing quality frameworks.

Therapeutic Inertia and Patient Risks

The absence of rigorous oversight during the maintenance phase can lead to therapeutic inertia. This occurs when patients remain on a specific therapy long after its clinical utility has peaked or after more appropriate alternative treatments have become available.

Ignoring continuation appropriateness increases the risk of adverse events. Patients who remain on inappropriate long-term medications are more susceptible to experiencing therapeutic failure or side effects.

The primary goal of managed care systems is to provide appropriate care to prevent expensive emergency department visits and hospital stays, as noted by the Medicare and Medicaid Payments Advisory Commission (MACPAC). However, the failure to re-evaluate long-term therapies can undermine this goal.

Economic and Structural Drivers

The oversight of continuation appropriateness is tied to the structural incentives of managed care organizations (MCOs). Unlike the traditional fee-for-service model, where providers are paid for each individual service, MCOs generally operate on a capitation basis.

Under capitation, a payer or state provides a fixed dollar amount per member per month to cover a defined set of services. This creates a tension between cost-containment and clinical quality.

In an environment where financial incentives are linked to cost-reduction and capitation rates, there is a risk that efficiency is prioritized over the periodic clinical re-evaluation of a patient’s medication regimen.

Broader Implications for Care Continuity

The challenge of maintaining appropriate care is further complicated by issues with data integrity. Missing data in healthcare databases can disrupt the continuity of care and hinder the ability of providers to make informed clinical decisions.

Research into All-Payer Claims Databases has shown significant gaps, including missing principal diagnoses in 6.3% of claims and missing race classifiers in 30.6% of enrollment data. A 2021 federal Government Accountability Office (GAO) study found that Medicaid T-MSIS data was inaccurate and incomplete.

These data omissions can lead to a breakdown in information flow, potentially resulting in inappropriate treatment plans or the failure to recognize chronic conditions. When combined with a lack of systemic measures for continuation appropriateness, these gaps can compromise patient safety and the overall effectiveness of managed care.