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Medication Adherence: Why Now?

Medication nonadherence is one of the largest problems facing not only the United States as a whole, but community pharmacists in particular. In recent years, costs associated with patient medication nonadherence have taken a particular toll, as the number of people living with chronic diseases in the United States has risen steadily since 1995 (The Growing Crisis of Chronic Disease. . .) and costs associated with caring for this population also continue to climb with an estimated $1.7 trillion spent annually on the treatment of chronic diseases alone (Clifton et al 2018). So how does this affect community pharmacists? As per PBMs themselves, “DIR is a form of pay for performance” and “DIR payments encourage pharmacists to operate efficiently through certain activities such as generic dispensing, cost-effective dispensing, improving medication adherence, and reducing inappropriate drug use” (DiLoreto, Pilch & Hauser). In summary; poor medication adherence, among a number of other things, can directly impact the amount of DIR fees a pharmacist is required to pay. Better medication adherence means lower DIR fees.

Woman examining medication vials

Considering that there are many strategies to combat medication nonadherence, improve STAR ratings, and decrease, the sometimes crippling, DIR fees, it can be hard to decide where to begin. For any community pharmacist there are steps that can be taken today with relatively little time and financial burden. Two effective strategies that are easily put into place are adherence strip packaging, and comprehensive medication reviews. Considering the growing desire and expectation amongst patients to “age in place”, or remain in the residence of their choosing for as long as possible, it can be difficult to make sure that they have everything they need. Below is an excerpt from a recent publication in The American Journal of Managed Care that studied the efficacy of telephonic CMRs on patient outcomes:

“There was no significant difference between the 2 groups for any outcomes in the initial analysis. However, a planned post hoc analysis separated the participants into 4 groups based on baseline risk of hospitalization from the CMS risk score. An analysis of patients in the lowest-risk quartile found that those receiving a CMR were more than 3 times less likely to be hospitalized within 60 days, were more than 6 times less likely to be hospitalized within 30 days, and had a significantly longer time to first hospitalization compared with those not receiving a CMR” (Dezeeuw PharmD, Coleman PharmD, Nahata PharmD 2018).

While overall, the examination found little difference in the group as a whole, it’s important to note that the lowest-risk patients, those most likely to frequent a pharmacy for a long time, saw an enormous decrease in their risk of hospitalization. The study also notes that because these patients are frequently unwilling, or unable to visit the pharmacy in-person, telephonic CMRs make their pharmacist suddenly accessible, and more in-depth reviews of their medication suddenly possible (Dezeeuw PharmD, Coleman PharmD, Nahata PharmD). The study further elaborates, stating that:

“The primary purpose of this study was to determine the impact of a telephonic MTM program on 180-day mortality as well as on inpatient hospitalizations, emergency department (ED) visits, and the cost of Medicare Part D covered drugs. Beneficiaries receiving MTM services were 50% less likely to die in the 180 days after the intervention compared with controls” (Dezeeuw PharmD, Coleman PharmD, Nahata PharmD).

Considering the drastic reduction in patient mortality, and the ease of telephonic CMRs on the side of the pharmacist, which typically take less than half an hour to complete (Pattah 2015), it is a resource worth implementing in any pharmacy’s day-to-day.

The second proposed solution is to implement adherence strip-packaging or other, similar adherence packaging. These solutions can often be implemented with little time cost to the pharmacists via a variety of automation options and the results can be viewed as objectively positive. Considering that today in 2018, nearly half of the population of the United States lives with a chronic condition (Growing Crisis of Chronic Disease. . .) it is this patient group that should be considered especially closely. An analysis conducted in 2010 found that patients with congestive heart failure, chronic pulmonary disease, and diabetes had rates of adherence up to 40%, up to 26%, and up to 35% higher respectively when participating in MTM programs as compared to those who were not (Center for Medicare and Medicaid Innovation). Further, profits per chronically ill patient increased dramatically when they were given their prescriptions in strip packaging rather than bottles. These strip packaging systems, often automated time-savers for a pharmacy, increased the mean profit per patient from $1208.01 per year to $1561.82 per year (Clifton et al).

In today’s world of health care, it’s essential for community pharmacists to take advantage of all the tools at their disposal. Two of the most effective methods available today are CMR or MTM appointments, either in-person or over the phone, or implementation of adherence packaging such as strip packaging or “bubble packaging” that display the time, dosage, and medications that are to be taken. These methods decrease patient mortality, increase profits per patient, and have the potential to positively affect a patient’s health, longevity, and day-to-day comfort.

Sources:

Center for Medicare and Medicaid Innovation. (n.d.) Evidence Supporting Enhanced Medication Therapy Management. Retrieved from https://innovation.cms.gov/Files/x/mtm-evidencebase.pdf

Clifton, C. L., Branham, A. R., Hayes, H., Jr., Moore, J. S., Rhodes, L. A., & Marciniak, M. W. (2018, July). Financial impact of patients enrolled in a medication adherence program at an independent community pharmacy. Retrieved from https://www.japha.org/article/S1544-3191(18)30195-X/fulltext

DeZeeuw, E. A., PharmD, Coleman, A. M., PharmD, & Nahata, M. C., PharmD, MS. (2018, February 17). Impact of Telephonic Comprehensive Medication Reviews on Patient Outcomes. 

DiLoreto, M., Pilch, S., Hauser, R., & NCPA. (n.d.). Pharmacy DIR Fees; A National Landscape. Retrieved from https://www.papharmacists.com/events/EventDetails.aspx?id=854723

Partnership to Fight Chronic Disease.  (n.d.) The Growing Crisis of Chronic Disease in the United States. Retrieved from https://www.fightchronicdisease.org/sites/default/files/docs/GrowingCris…

Pattah, V. (2015, June). MTM and the CMR Completion Rate: What Community Pharmacists Need to Know. Retrieved from http://www.ncpa.co/pdf/pqm-cmr-completion.pdf

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