Study examines impact of voluntary, mandatory mail on medication adherence

NEW YORK — Mandatory mail seems to cause some patients to prematurely discontinue therapy, especially among those patients without previous mail-service pharmacy experience. At least, that’s what a recent study on mandatory mail suggested.

The CVS Caremark-funded study, “Adherence to Medication Under Mandatory and Voluntary Mail Benefit Designs,” recently was published in the American Journal of Managed Care.

It is no secret that a challenge in designing pharmacy benefits is to find the ideal balance between access to essential medications and cost management. It is a balancing act that is becoming increasingly difficult and, in an effort to help curb costs, employers increasingly are offering a mail-service option. According to the study, in 2010, nearly 96% of all employers offered mail pharmacy services to their employees. The majority of plan sponsors offer voluntary mail, while nearly 19% of employers implemented mandatory mail.

However, the impact on adherence rates under voluntary and mandatory mail benefit designs remains murky. The study — which focused on adherence rates in the first year of therapy — aimed to help clear the waters.

The study examined seven therapeutic classes for either anti-diabetic or cardiovascular therapies. The data came from employer-sponsored pharmacy insurance plans that offered either mandatory or voluntary mail pharmacy benefits managed by CVS Caremark between July 1, 2008, and March 31, 2010.

“Participants with a mandatory mail pharmacy benefit design were less likely to remain persistent during the first year of therapy. Most impacted were those who had no previous mail use and thus were most likely to have been unfamiliar with the requirements of mandatory mail,” the authors wrote. Some of the authors are current or former employees of CVS Caremark.
According to the results, persistence rates were similar through the first 60 days of therapy; however, the mandatory mail cohort experienced a “notable” drop in persistence by the 90th day of therapy.

“The lower persistence in the mandatory mail cohort beginning between days 60 and 90 indicates potential barriers to access during the period of time when the prescription must be transferred from a retail pharmacy to a mail-service pharmacy,” the authors wrote. “The substantial drop in adherence occurring at this transition point suggests an important target for improved processes at mail-service and retail pharmacies to facilitate transitions between distribution channels — a transition that can require several steps.”

Several key takeaway points:

  • By restricting pharmacy choice and access, mandatory mail appeared to cause some members to prematurely discontinue therapy;

  • When members chose to discontinue, rather than switch pharmacy channels, the unintended consequence was a reduction in medication adherence and the potential for increased medical expenses; and

  • Individuals without previous use of mail-service pharmacy are particularly sensitive to this plan design and are an important population to target for interventions to support adherence.

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