CATALYST CORNER: September/October 2013

In my last column I described several key issues facing the profession and noted that the pharmacy IT community is truly going to be front and center as the pharmacy profession seeks to fulfill its vision for 2015 and beyond. That vision, for pharmacists as “the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes,” was crafted by the Joint Commission of Pharmacy Practitioners (JCPP) in 2004. The three issues I noted that may impact achieving that vision are:

      • Achieving provider status for pharmacists so they may more fully integrate their services into current and emerging healthcare structures such as accountable care organizations (ACOs) and patientcentered medical homes and have these services reimbursed. This will include defining a standard process of care.
      • Achieving integration of pharmacy clinical and dispensing data with electronic health record (EHR) systems and progress on the pharmacy HIT collaborative’s roadmap.
      • Addressing medication adherence issues, especially in patients with chronic disease, which is now estimated to cost the nation up to $200 billion annually.

In the column, I addressed the first two issues. This time, I’d like to turn to adherence. In June, CVS Caremark released an analysis of medication adherence within four chronic conditions: diabetes, hypertension (high blood pressure), dyslipidemia (high cholesterol), and depression. The 2013 State of the States: Adherence Report projects potential cost savings within each state by examining medication adherence rates and the use of generic drugs for these conditions by analyzing data from 2012. You can download a complete copy of the report at

The potential cost savings among the states range from $19 million to $2.1 billion, based on state member characteristics. Some interesting trends were found as well, including:

      • Across all market segments (health plans, employer-sponsored plans, and Medicare Part D plans), patients with depression generally had the lowest adherence rates, while patients with
      • hypertension were the most adherent.
      • Medicare beneficiaries had the highest adherence rates across the three groups.
      • Ninety-day dispensing rates were generally highest among members of employer-sponsored plans.
      • Regional variations were apparent across the groups. The lowest adherence rates for health plan members with diabetes and depression occurred in the Midwest, while the lowest rates for patients with any condition in employer-sponsored plans and Medicare Part D occurred in the South.

Also supporting the lack of adherence is a report issued in late June by NCPA. That report, Medication Adherence in America: A National Report Card, finds that Americans 40 and older with a chronic medical condition earn a troubling C+ on average when it comes to taking their medications correctly. Additionally, one in seven members of this group received an F, which equates to 10 million adults, according to an NCPA press release dated June 25, 2013.

The report card was based on a survey of 1,020 adults conducted by Langer Research Associates and represents an average of answers to questions on nine nonadherent behaviors. The survey measured whether or not, in the past 12 months, patients:

      • Failed to fill a prescription.
      • Failed to refill a prescription.
      • Missed a dose.
      • Took a lower dose than prescribed.
      • Took a higher dose than prescribed.
      • Stopped a prescription early.
      • Took an old medication for a new problem without consulting a doctor.
      • Took someone else’s medicine.
      • Forgot whether they’d taken a medication.

Specifically by grade, 24% earned an A grade for being completely adherent. Another 24% achieved a B by reporting one nonadherent behavior out of nine. Twenty percent earned a C and 16% a D for being somewhat nonadherent (two or three behaviors in the past year). Finally, 15% are largely nonadherent (four or more behaviors), earning an F grade.

The Pharmacist’s Influence

The research also found that the biggest predictor of medication adherence was patients’ personal connection (or lack thereof ) with a pharmacist or pharmacy staff. Patients of independent community pharmacies reported the highest level of personal connection (89% agreeing that pharmacist or staff “knows you pretty well”), followed by large chains (67%) and mail order (36%).

In his executive update accompanying the announcement, NCPA CEO Doug Hoey said a surprise to him was that consumers said they know their mail-box pharmacist “pretty well.” He went on to say, “This is a huge opportunity for pharmacy and one we need to seize. It makes health and economic sense for patients to take their medication appropriately. As pharmacists, we are the last healthcare professional patients see before going home and taking their medications.”

I agree with Doug. I also wondered in reviewing the CVS report if higher adherence rates among Medicare beneficiaries may be impacted by the availability of pharmacist-provided medication therapy management (MTM) services. Pharmacists have been targeting adherence through new avenues for the last few years, including providing MTM services.

One of the key services is medication synchronization, where the pharmacy staff works with a patient and the patient’s insurer to synchronize refills for all their medications at the same time each month. Additional co-pays can apply during the initial process. But results have been very positive. Thrifty White Pharmacy released results from a 12-month study of its medication synchronization program in January 2013. Conducted with Virginia Commonwealth University, it found the program lifts the medication adherence rate well above the industry average for patients with chronic disease states. According to their press release, study patients were selected based on having at least two fills for one of six chronic medication classes — ACEIs/ARBs, beta blockers, dihydropyridine calcium channel blockers (CCBs), thiazide diuretics, metformin, and statins — after they had enrolled in the chain’s appointment-based model (ABM) program. Patients must have had at least two fills of the chronic medication on or after enrollment, with at least one fill occurring within the 30-day period prior to the enrollment date. “Depending on the drug class, patients enrolled in the program had 3.4 to 6.1 times greater odds of adherence as controls during the evaluation period,” the study reports.

These programs are growing because of the positive results, and are being supported by many organizations. For example, NCPA has introduced Simplify My Meds for its members, an adherence program that provides pharmacies with tools and training to implement a medication synchronization program. And many pharmacy management system vendors have been very supportive of these types of programs and are helping pharmacists address medication adherence challenges with new innovations as well. It is a win-win situation for all involved: patients, pharmacists, and their vendor partners. CT

Marsha K. Millonig, R.Ph., M.B.A.,
is president of Catalyst Enterprises, LLC, located in Eagan, Minn. The firm provides consulting, research, and writing services to help industry players provide services more efficiently and implement new services for future growth. The author can be reached at