A Spoonful of Medication Adherence Policy

“Drugs don’t work in patients who don’t take them” C. Everett Koop, MD

With the popularity of the hit musical Mary Poppins on Broadway, new generations of Americans are once again reminded that “just a spoonful of sugar makes the medicine go down.”  While sugar may help in the movies, medication synchronization and a prohibition on unreasonable out-of-pocket costs are real ways we can ensure that patients take their medicine as prescribed.

Non-adherence, meaning patients not taking their medicine as prescribed or not taking it at all,  leads to wasted resources north of $200 billion annually in avoidable medical services and hospitalization and poor health outcomes for patients. To put this figure in perspective, consider that it is more than the U.S. spends for all of the oncology, respiratory, mental health and diabetes medicines combined.

Researchers have underscored this point for the past several decades. Every year, a multitude of papers demonstrate the extent of poor medication adherence and potential consequences to patients and the healthcare system. Supporting data show that 50% of patients are not taking their medicines as prescribed by their provider and that non-adherence drives up hospitalizations and emergency department visits. One study published in 2011 found that medication adherence was associated with significantly lower annual inpatient hospital days, ranging from 1.18 fewer days for patients with high cholesterol to 5.72 fewer days for congestive heart failure. There are also studies that highlight the impact of non-adherence on non-medical outcomes, such as worker productivity, in specific disease states like rheumatoid arthritis.

Given the broad consensus around the benefits and consequences of medication adherence, building consensus for solutions should be achievable. What are the interventions that offer the best patient outcomes without burdening the individual, the provider or overwhelming the healthcare system?

One way to address non-adherence is to develop a rational policy for the out-of-pocket costs paid by patients for their medications. According to CMS-published data, patients pay less out-of-pocket for pharmaceuticals today than at any time in the past 40 years. This is the result of expanded access to insurance and the proliferation of generic drugs following a strong period of innovation in the 2000’s. However, this is probably news to those patients who are seriously ill and require therapies that do not have a generic alternative. In those cases, patients are often asked to pay a significant amount of their own money for their medicines. If they find that they eventually can’t afford those out-of-pocket costs, they don’t take their medicine, leading to higher health costs elsewhere in the system. But treatment for a severe illness is exactly what should be covered as an insured benefit. In fact, for the past decade employers have been eliminating or significantly reducing out-of-pocket costs for therapies in select disease states. This trend began when employer Pitney Bowes found savings of more than a $1 million after reducing copays for diabetes drugs and asthma drugs in 2001. Later in the decade, the company reduced copayments for statins and found that this new policy was associated with a 7.1% monthly increase in the number of statin prescriptions filled. The result of improved medication adherence?  Employees had fewer physician visits, hospitalizations, and emergency department admissions. More recently, Prime Therapeutics, a pharmacy benefits manager, found that if patients require treatments for rheumatoid arthritis or multiple sclerosis, they are more likely to abandon their therapy if the out-of-pocket cost exceeds $250 per claim. Part of the solution to the out-of-pocket cost dilemma may  be a more rational insurance design where patient cost sharing for various health services is based on the value of the intervention rather than price, as formularies should help patients and doctors make the best treatment choices, not forgo treatment all together.

Another way to address non-adherence is to allow a pharmacist to synchronize a patient’s chronic medicines. Medication synchronization is not a new concept; pharmacists across the country have synchronized refills for patients on multiple chronic medications for the past decade, ensuring that all a patient’s refills are ready on the same day every month. They have also operationalized the concept of an appointment based model the practice by which a pharmacist makes an appointment with a patient once a month or more to pick up their medications and to discuss other issues pertinent to their care such as over the counter medicine usage or vaccinations. These practices have helped reduce the number of trips a patient has to take to the pharmacy and lessened the administrative burden on pharmacists and physicians who no longer have to accommodate last minute refill requests. Most importantly, it has led to better patient adherence. In a paper published last year in the Journal of the American Pharmacists Association, patients who used the appointment based synchronization model had a 70% better chance of staying adherent to their therapies than those who continued to pick up their medications whenever they ran out.

For synchronization services to become a broad reality, pharmacists have to be allowed to partially fill prescriptions to ensure that they can get all of the refills to align on the same pick-up day. In addition, to be fair to the patient, payers ought to allow pro-rated copays for the impacted prescriptions and thus avoid potentially putting too much financial burden on the patient all at once, paying the same amount for a smaller number of pills . The pharmacy should also not be penalized with a lower dispensing fee for dispensing pursuant to medication synchronization since the pharmacy overhead costs remain the same.

Support for medication synchronization is growing. In 2014, the Centers for Medicaid and Medicare Services (CMS) decided that patients enrolled in Medicare Part D plans should have the opportunity to synchronize their medications if they choose to and if it is deemed appropriate by their physician and pharmacist. The American Medical Association House of Delegates has supported a resolution that implements prescription refill schedule strategies to reduce the burden on patients of having to travel numerous times to the pharmacy to pick up prescriptions. This year, the American Pharmacists Association has created an educational initiative which includes a zip code locator so patients who are interested in synchronizing their medicines can identify pharmacies that provide the service. Ultimately, synchronization and the appointment-based model may also help address other issues beyond patient adherence such as a reduction in inappropriate use of medicines including opioid abuse and a reduction in pharmaceutical waste due to potential changes or discontinuation in therapy. Clearly, it is time for payers to take the lead from CMS and promote policies, regulations and legislation that would allow synchronization.

While we can’t set these solutions to music, we can encourage policymakers around the country to adopt policies that support medication adherence for the benefit of patients and  economics of the healthcare system overall.

Morning Consult