“Drugs don’t work in patients who don’t take them.”
Sounds simple enough. But that obvious truism, voiced by former U.S. surgeon general C. Everett Koop, fails to convince tens of millions of patients that they should take their prescription medicines through the full dosage regimen. And in too many cases, patients aren’t even filling the script to begin with.
The battle to improve adherence has been joined. Chain and independent pharmacies — along with hospitals, health plans and public and private health plan payers — are engaged in a massive effort to educate patients about the critical importance of initiating and sticking with their drug therapies, and pharmacy technicians are on the front lines of
The toll taken by medication nonadherence is well-known. The New England Health Institute estimates that approximately half of Americans take their medications incorrectly, resulting in approximately $290 billion in avoidable costs every year. More than half of all Americans “live with at least one chronic condition,” noted the National Community Pharmacists Association, but many of their prescriptions don’t even get filled. Citing one study, the National Association of Chain Drug Stores Foundation reported that “nearly 1-in-4 newly prescribed prescription medications was not collected by patients,” especially among patients with chronic diseases like hypertension and diabetes.
The result is predictable: more lapses into serious illness and more hospitalizations. More than 1-of-every-3 medication-related hospital readmissions is linked to poor adherence, according to Ateb, a pharmacy technology provider.
“You can see why medication adherence has become so prominent, when you consider the fact that pharmaceuticals are the No. 1 intervention,” said Kathleen Jaeger, SVP pharmacy care and patient advocacy for NACDS and president of the NACDS Foundation. “The vast majority of older Americans are taking five or more meds. We need to look at what we can do to keep these folks on their medicine.”
A tech’s leverage ability to influence patients directly on adherence is limited. But changes in both the pharmacy workplace and in health care are expanding techs’ direct contact with patients and pushing them into more and more duties formerly held by pharmacists — including discussing adherence with patients and, increasingly, monitoring it via dashboard technology that opens a real-time view into the patient’s record for refilled prescriptions and drug utilization.
“You have a situation where, for the first time, you have the big insurers, the plans, the employers, all focusing on medication adherence and what can be done to improve patient outcomes and move the needle in terms of care and costs,” Jaeger asserted. “Everyone is looking at adherence as an opportunity to make a difference.”
“The stars are aligning,” she added. “It’s a huge win for patients because for the first time everyone is focusing on them. And all the parties have to come together — the primary care doc, the specialists, the nurses, the pharmacists and techs — all have to work together for the first time to improve the outcome for the patient.”
Mark Conklin, director of quality innovations for the Pharmacy Quality Alliance, said technicians would be called on to play a front-line role in the effort to reach patients and improve their medication adherence rates.
“From a process standpoint, pharmacy technicians become very important in helping to target [patients] who are at risk,” Conklin said. “Patient screenings can be done by technicians, and they can alert pharmacists to those at risk for being adherent. That’s where technicians become crucial, either by supporting [adherence] or by taking on more of the dispensing process so pharmacists can be freed up for things like
“It requires a change at the pharmacy level, and that includes all staff,” said Conklin. “I see techs as being critical with this shift going on, because pharmacists are strapped for time as it is, and they’re going to need to do more. I think it’s the technician that allows this to get done at the end of the day.”
Chris DuPaul, director of strategic development for CVS Caremark, breaks the nonadherence problem into three leaky buckets where patients can drift away from prescribed drug regimens:
Nonfulfillment, when a patient “elects to not pick up a new prescription initiated by a prescriber;”
Poor compliance, when a patient takes less of his or her prescribed medication; and
Nonpersistence, “when a patient elects to stop taking prescription medication without consulting his/her prescriber.”
David Nau, PQA’s senior director of quality strategies, said primary medication nonadherence or prescription “abandonment,” in which patients don’t obtain their prescribed medications or a prescription is filled by a pharmacy but never claimed by the patient, can lead to “billions of dollars of waste or untapped revenue.” He cites research estimates showing that “each prescription that is returned to stock will cost the pharmacy about $10.”
Pharmacy techs should be aware of some “factors predictive of primary nonadherence,” DuPaul said. Among them, the cost factor. “Compared to preferred medications, nonformulary medications were 17% less likely to be filled and noncovered medications were 86% less likely to be filled, as those medications translated into higher out-of-pocket costs for patients,” he noted.
Thus, it’s no surprise that “patients who live in higher-income areas [are] more likely to fill prescriptions for new medications,” DuPaul added.
Also tied to adherence rates is the type of medicines being prescribed, noted the CVS strategist. For instance, he said, “prescriptions written for infants are almost always filled, and antibiotics are filled at a rate of 90%,” while “medications for hypertension or diabetes saw primary nonadherence rates in excess of 25%.”
Another critical adherence challenge is that drug regimens can be extremely hard to follow. In a presentation to chain pharmacy leaders in August, DuPaul cited a 90-day study of adherence rates among statin users that “showed massive complexity,” both in the number of drugs required for their therapy, and in the number of times patients visited multiple pharmacies for their meds.
“The average statin user takes 11 medications … and makes five pharmacy visits” to have them filled each month, DuPaul said. And 1-in-10 of those patients, he added, “take 23 or more medications” prescribed by four or more doctors, and “make 11 or more pharmacy visits to two or more pharmacies” every 90 days.
“Simplifying therapy can improve adherence,” he asserted. “Adherence is greater when patients synchronize refills and fill all their prescriptions at a single pharmacy.”
Indeed, one of the most promising developments in driving higher adherence rates is the move by some pharmacies to give patients the option of refilling all their maintenance medications on the same day each month. The process, called medication synchronization, simplifies prescription refills for patients and makes it easier for them to adhere to their drug therapy by merging all their prescriptions to a single fill each month.
Among the drawbacks, synchronization can reduce monthly pharmacy visits, potentially impacting sales. Synchronizing refills also takes time, since pharmacists have to coordinate with prescribing physicians in order to cycle through a patient’s monthly medication schedule and sync up the refill schedule for all chronic medications. It also requires “identifying and focusing on patients that require intervention,” according to Frank Sheppard, CEO of Ateb, as well as a process for monitoring and managing changes within the patient’s monthly drug regimen.
Pharmacy techs can play a big role in that process, both by alerting patients about the program and in monitoring its progress via dashboard automation and other technology making its way into more
Among the drug chains offering synchronized refills are Rite Aid, which reportedly is testing in several markets, and Minnesota-based Thrifty White. The 83-store operator has emerged as a leader in medication adherence with innovations like an electronic timer cap on prescription vials and Ready Refill, an opt-in system that manages patients’ refills automatically.
With Ready Refill, said Dave Rueter, EVP personnel for Thrifty White, “when the patient comes in to pick up the script, our technician can review it with them, and the patient can choose those meds they’d like to have in the program. Then our system manages those refills, and we go ahead and refill each one for them and have it ready and waiting for them. They won’t have to call to have it refilled. So the tech does a lot of the explanation of that program to the patient.” Medication synchronization “is really just the next step beyond Ready Refill,” Rueter told DSN Collaborative Care.
“That program is all about adherence,” he explained. “We synch those scripts up so that instead of making five trips to the pharmacy over the month, patients can come in and have them all filled on the same day. The technicians do a lot of the education about what that program is, answer questions and explain its value to patients. They’re involved firsthand in educating patients about it.”
Technicians now also staff Thrifty White’s centralized patient care and pharmacy support center. “They’re doing a lot of the synchronization there, manning the phones and talking with patients,” he said.
Since its launch early this year, synchronization is showing a “very promising” and even “dramatic” impact on patient adherence, Rueter noted.
Other pharmacies are looking at offering the option. On behalf of its independent pharmacy members, the NCPA launched Simplify My Meds, its own version of medication synchronization. NCPA calls it “a personalized coordinated refill program that facilitates improved adherence by aligning a patient’s prescriptions to be filled on the same day each month.”