Pharmacy techs play front-line role in campaign to boost adherence rates
“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.”
NACDS ed sessions discuss medication adherence, travel meds
Among the highlights of the National Association of Chain Drug Stores’ annual Pharmacy and Technology conference are the educational sessions, for which pharmacists earn continuing education credits while learning about the latest trends in pharmacy practice and care.
One of the biggest trends in the retail pharmacy industry is the expansion of services it offers, ranging from health screenings to medication therapy management to vaccinations and immunizations. In August, one education session at the NACDS Pharmacy and Technology show in Denver — the last of its kind as the trade organization prepares to combine its Pharmacy and Technology, Marketplace, and Supply Chain and Logistics shows into one Total Store Expo in Las Vegas in August 2013 — focused on one particularly new and growing vaccination and immunization service.
For most pharmacy retailers, vaccinations are usually of the routine variety, but for a growing number of pharmacy retailers, it also means immunizing travelers against diseases they may risk acquiring while abroad, such as hepatitis A and B, and yellow fever. Seattle-based regional chain Bartell Drugs has offered comprehensive travel clinics at several of its stores for a few years now, and other retailers are doing the same; still others, such as Sam’s Club, offer travelers vaccinations against such conditions as hepatitis. But an education session at the Pharmacy and Technology Conference presented some of the opportunities and challenges involved in travel medicine.
Travel medicine requires expertise on a number of subjects, such as patient education, immunization and pharmacology. “These are things pharmacists are already very skilled at or can easily become skilled at,” the session’s presenter, University of Southern California pharmacy professor Jeff Goad, said. Vaccines are only part of it, he added.
Pharmacy retailers looking to get involved with travel medicine also should consider carrying products travelers will need, particularly if they’re going to developing countries. These include water purification tablets, mosquito nets and insect repellents. In addition, pharmacists consulting prospective travelers should know ways to deal with noninfectious conditions, such as jet lag and altitude sickness.
Travel medicine requires some investment on the part of the retailer, such as setting aside an area to provide services, necessary education for the pharmacist and stocking up on travel-related products, Goad said, as well as collaborative practice agreements with physicians that may be needed for certain vaccinations and medications, travel medicine software and in many states, a special stamp that certifies a pharmacy for delivering yellow fever vaccinations.
Other education sessions attended by DSN Collaborative Care included “Winning Strategies for Medication Adherence and Community Pharmacy,” hosted by CVS Caremark director of strategic development Chris DuPaul, Ateb president and CEO Frank Sheppard and Pharmacy Quality Alliance senior director for quality strategies David Nau. The presentation detailed numbers that should be familiar to many pharmacists: Nearly 3-in-4 patients don’t take their medications as directed; more than one-third of medication-related hospital admissions are related to poor adherence; 1-in-3 patients never fill their prescriptions; and almost 45% of the population has one or more chronic conditions requiring medications. All this adds up to the $290 billion per year commonly cited as the cost of medication nonadherence — though a study by pharmacy benefit manager Express Scripts earlier this year put the figure at more than $300 billion.
The speakers discussed common causes for medication nonadherence and how it affects health outcomes, how to differentiate primary medication nonadherence from secondary nonadherence and various strategies to improve adherence. These included Ateb’s “Time My Meds,” a medication-synchronization strategy that allows pharmacists to focus on patient-centered care by creating “appointments” to manage interactions between the patient and pharmacist, enabling close collaboration between the two and targeting patients with chronic diseases. Next to take the stage was CVS Caremark’s DuPaul, who discussed the causes and related issues of medication nonadherence, drawing on the extensive research the company has conducted on the subject.
On Aug. 28, the last day of the show, Walter Reed National Military Medical Center pharmacist Li Chengqing delivered a session titled “Expanding Pharmacy’s Role in New Care Models: Case Study of Pharmacists as Members of Patient Centered Medical Home Teams,” in which she discussed ways that pharmacists communicate with patients and physicians through bidirectional secure messaging to ensure patients are more engaged in their care. In addition, she described how pharmacists can use the system to see lab results, also identifying ways pharmacists can send condition-specific lab results through the system and offer customized medication counseling for patients with chronic diseases.
While generics benefit from patent cliff, branded drugs turn to innovation
Despite the patent cliff rendering entire therapeutic categories generic-only, numerous opportunities exist, according to a speech delivered in August at the National Association of Chain Drug Stores’ 2012 Pharmacy and Technology Conference in Denver by IMS Health VP industry relations Doug Long.
“Right now, there’s plentiful generic opportunities,” Long, who won the NACDS’ Harold W. Pratt Award at the conclusion of the conference, told DSN Collaborative Care in an interview before the show. “It’s almost a who’s who list of patent expiries.”
Usage of generics has skyrocketed, and they currently account for about 80% of dispensed prescriptions, according to IMS data. Spending on branded drugs increased in 2011 by 2.1%, to $235 billion, while branded generics saw a 2.8% increase and generics experienced a 13.8% increase. “Obviously, generics are doing better than brands and better than branded generics,” Long said. “I think this is a symptom of what I call the commoditization of oral solids.”
Oral solids, meaning capsules and tablets, especially primary care drugs, have seen tremendous erosion in sales due to loss of patent protection, with many classes, such as lipid regulators, set to lose their places among the top-selling drug classes because so many are going generic.
2012 has been a peak year for patent expiries, with $35 billion worth of drugs coming off patent, and 2014 will be an important year as well. Pfizer’s cholesterol drug Lipitor (atorvastatin) is a prime example: The drug lost patent protection in November 2011, and Ranbaxy launched its generic version; after Ranbaxy lost its own exclusivity period in May 2012, atorvastatin became fair game for any generic drug company that can win Food and Drug Administration approval.
“We’re in the teeth of the patent cliff,” Long said, speaking of what he called the “cone of commoditization.” This includes such drug classes as cholesterol medicines, antidepressants and others that have become essentially dominated by generics, compared with classes outside the “cone” that remain relatively safe from generic competition, such as drugs for HIV, hepatitis C and diabetes. The result is that new small molecules ripe for generic competition will gradually dry up. “If they weren’t invented in the first place, then there’s nothing to be genericized,” Long said.
Many drug makers have sought to protect themselves by moving up the value chain, Long said. For generic companies, this has often meant branching out from oral solids and into more complex methods of delivery, such as transdermal patches, injectables and follow-on biologics. While the Patient Protection and Affordable Care Act created an abbreviated approval pathway for follow-on biologics, the regulations are still not in place, prompting some companies looking to make them, such as Teva Pharmaceutical Industries, to seek approval through the same means used by makers of branded biologics.
For branded companies, resisting commoditization means innovation. Long said much of the innovation occurring today is happening in treatments for cancers, autoimmune disorders, orphan diseases and chronic viral infections. “Innovation has picked up in specialty, [but it’s] not quite there in primary care,” Long said.
Biologics have seen higher spending growth than small-molecule drugs, having increased by 6% to $69 billion, while small molecules have increased by 2.9% to $250 billion; spending on traditional drugs increased by 2%, while spending on specialty drugs increased by 8.8%. Overall, $319.4 billion was spent on medicines in 2011, according to IMS Health. Of that, 3.6% of spending growth went through retail channels, while institutional channels accounted for 3.7%.
The growth of specialty drugs and biosimilars opens some opportunities for pharmacy retailers. According to IMS, retailers command only 8.6% of the market for many cancer drugs. But in such areas as HIV and other antivirals, they largely dominate, and Long said there is potential in autoimmune disorders as well. Indeed, many pharmacy retailers, ranging from such national chains as Costco Wholesale, Walgreens and CVS/pharmacy to such regional chains as Hy-Vee, already have branched into specialty pharmacy. “Maybe the focus shouldn’t be on cancer and EPOs and ECGFs — it should be on other classes,” Long said.
Pharmacy retailers also have a role to play in offering primary care services, Long said. “You can play a big role in this as retailers, with your retail clinics and preventive efforts,” Long said, noting opportunities to increase adherence and compliance — especially among elderly patients — and citing a recent medication synchronization study conducted by Thrifty White Pharmacy and Virginia Commonwealth University that tested such efforts as advertising and packaging designed to boost adherence, such as the digital Rx Timer Cap.
Long’s speech followed the presentation of an award presented by Boehringer Ingelheim Pharmaceuticals national accounts director Colin Carr-Hall to Costco Wholesale SVP pharmacy Vic Curtis. Curtis’ award consisted of a plaque and a $10,000 contribution in his name to the NACDS Foundation. Additionally, Matthew Machado, a professor of pharmacy at the Massachusetts College of Pharmacy and manager of patient care services for Walgreens in the Boston area, was awarded the Apotex Preceptor of the Year Award by Apotex director of trade sales and pharmacy relations Sam Boulton.