Association Between Narrow Pharmacy Networks and Medication Adherence

There are narrow or preferred pharmacy networks included within many insurance plans that have in-network pharmacies with reduced prescription prices based on negotiations with the insurance company. These types of insurance plans offer their members reduced cost sharing to incentivize them to use the in-network pharmacies. In 2014, 75% of Medicare Part D (drug coverage plans) and 70% of exchange plan enrollees were in a narrow or preferred network drug plan, so it’s clear that there are many patients who are enrolled in these types of insurance plans. Some professionals have expressed concern that narrow or preferred networks adversely affect medication adherence due to the fact that they might be hard for patients to access based on location. On the flip side, some believe that these types of networks are good for medication adherence because they encourage (and in some cases practically force) members to establish a pharmacy “home” where pharmacists can better support adherence and coordinated care.

The purpose of this study was to assess how narrow pharmacy networks effect plan members’ medication adherence. This study also looked at whether insurancd plans that implemented narrow networks and those that did not were different in the following 2 subgroups: plans with and plans without 90-day prescription programs. These subgroups were included because 90-day prescription programs have shown to be a positive impact on medication adherence.

Data was collected from January 1, 2012, through December 31, 2013, and each subject was studied for only one of the two years from Januray to December. Plans that implemented narrow networks in 2013 were considered intervention plans, while those that implemented them in 2014 were considered control plans. For all plans, CVS/Caremark was the pharmacy benefits manager. The main factors assessed were the differences in members’ medication-possession ratio (MPR) before and after network implementation separately for statins, antihypertensive medications, oral antidiabetic medications, and antidepressant medications. The MPR was defined as the days’ supply from the first through last times that the prescription was filled divided by the days between the first fill date and December 31 of that year. Two narrow network plans (having 67,906 members total) and 3 non-network plans (having 149,989 members total) were included in this study.

The results of the study were that individuals enrolled in narrow network plans had greater increases in MPR than individuals enrolled in non-network plans. In addition, it was found that the difference in MPR improvements before and after network implementation between network plans and non-network plans was greater for plans that had 90-day programs already in place.

This results of this study are really interesting to me because they show how outside factors can influence how patients take their medications. In this case, the outside factor is one’s insurance plan, and insurance definitely plays an important role in access to medications because it can essentially determine whether a person can afford their medications or not. It bothers me that some people miss out on lower prescription prices simply because they are not in narrow of preferred pharmacy network insurance plans, and I do not like that a person’s insurance plan can be a factor in the affordability of medications which can ultimately influence medication adherence. It is important that pharmacists understand how different insurance plans work so we can help our patients afford their medications in order to help them be adherent in sticking to their medication regimen.

My question posed to colleagues: What do you think about the results of this study? Are there ways in which pharmacists can help patients who are not in narrow or preferred networks afford their medications and also stay adherent?

Polinski, JM, Matlin, OS, Sullivan, C, et al. Association Between Narrow Pharmacy Networks and Medication Adherence. JAMA Intern Med. 2015;1850-1853.

Computerized Decision Support Improves Medication Review Effectiveness: An Experiment Evaluating the STRIP Assistant’s Usability

When physicians prescribe medications to patients with certain disease states, there is no way of determining whether the medication that is being prescribed will work for the patient. For example, obtaining adequate control of chronic disease states may involve a process of testing different medications on a patient until one can be deemed as an appropriate treatment option. There are different programs that have been established in the past to provide aid to physicians looking to initiate therapy options on a patient; however, they have not been proven to cause changes in care that lead to clinically significant improvement. For this reason, a new tool referred to as STRIP (Systemic Tool to Reduce Inappropriate prescribing) has been developed to optimize the prescribing process by conducting medication reviews in the primary care setting. This program is a computer-based technology that allows physicians to analyze patients medication histories and preferences to determine the best form of therapy.

In this study, 42 physicians were asked to optimize medical records of patients utilizing multiple medications by both the traditional manner and by the STRIP analysis. Utilization of the STRIP assistance program was linked to an increase in the number of appropriate medication decisions (to 76% from 58% without). Along with this, physicians on average spent more time meeting with patients and discussing treatment options using the program. The only major negative result gathered from the study was the fact that it received a below-average score by physicians examining the usability of the system. Therefore, the STRIP assistance program was determined to be an effective tool for providing medication reviews.

I believe this study is important because it shows how one of the main roles of a pharmacist (providing medication reviews) benefits the overall experience that a patient will have with their medication. I believe having systems like this in place to aid physicians in the process of decision making will allow pharmacists to eventually become more active in the process of prescribing medications. This is something that I think is important due to the amount of knowledge that pharmacists have about medications. Optimization of prescribing methods will not only benefit the health of the individual receiving the medication, but it will also ensure that we are limiting the cost that adverse effects from drugs have on the health care system. I believe that the role of a pharmacist will only continue to expand over the next couple of decades, and as a result, the profession will be more respected by the public.

Pharmacist initiation of postexposure doxycycline for Lyme disease prophylaxis

In an article published by Jackson, et al. it is reported that a community pharmacy has begun to successfully develop a program to dispense doxycyline to patients who have come into contact with the tick species known to carry Lyme disease. The pharmacy, which is located in Rhode Island, is independently run and wanted to increase the ability of patients to access this treatment for Lyme disease. Patients were asked to report any symptoms of the disease and to assess the performance of the pharmacy. Overall, the project was deemed a great success and was expanded to more pharmacies. It is also being used as a benchmark for treatment of Lyme disease in areas with high infection rates.

I feel that this article is important to pharmacy for a few reasons. First, an independent pharmacy was able to identify a problem in their community and develop a plan to solve it. Second, they successfully executed their plan and have plans for expansion. Third, they have shown the importance of not only independent pharmacists, but the importance of pharmacists in general. This is a great example of collaborative practice. I’m sure that PA, a state that has a fair amount of Lyme disease diagnoses, could benefit from similar programs. What do you think about this program?

Link to the article

Jackson, Anita N., K. Kelly Orr, Jeffrey P. Bratberg, and Frederic Silverblatt. “Pharmacist Initiation of Postexposure Doxycycline for Lyme Disease Prophylaxis.” Journal of the American Pharmacists Association 54.1 (2014): 69-73. Web.

Students as catalysts to increase community pharmacy-led direct patient care service

This study analyzed the effectiveness of an advanced pharmacy practice experience (APPE) elective at 5 colleges of pharmacy in the U.S. that promotes patient care in a community setting. Partner for Promotion (PFP) is an elective that provides student pharmacists with the chance to learn and build patient-centered practice skills that are most often used in community pharmacies.

Over the course of 3 years, 15 different patient care services were implemented, such as MTM, immunizations and prevention services, under PFP by 38 student pharmacists. Faculty at the schools of pharmacy were trained on the PFP program, who recruited local pharmacies to implement it. Each year a survey was completed by the faculty members at the school evaluating the program and its efficacy. The study found that the faculty thought components that were most successful were things such as ease of access to materials for the program and communication among the faculty networks. 100% of the faculty who completed the surveys found PFP to be “very useful” (highest on a scale from 1 to 4).

While the University of Pittsburgh does an incredible job preparing us student pharmacists to be patient care providers, many other schools of pharmacy do not do as much. Programs like this can help prepare more students to be patient-centered practitioners. By training as many student pharmacists as possible in a manner that promotes direct patient care, pharmacists and especially students can greatly help shift our health care from quantity to quality.

Rodin JL, Ulbrich TR, Jennings BT, et al. Students as catalysts to increase community pharmacy-led direct patient care services. J Am Pharm Assoc. 2015;55:642-8.

Cost analysis of a novel HIV testing strategy in community pharmacies and retail clinics

This study was conducted in six pharmacy sites in order to determine the cost of HIV testing in a retail or clinical setting.  The purpose of the study was to provide information to places who are planning on implementing HIV rapid testing so that they may plan and budget accordingly.  The results of the study found that the average cost of a test would be $47.21 per person.  Additionally, it found that the average counseling was two minutes pretest and two minutes posttest if negative or ten minutes posttest if positive. The average cost was comparable to data published in 2006 which stated that clinical testing would costing $28.05 per negative test and $86.84 per positive test. The study found that many factors could impact the actual cost of the tests including the quality of the tests, how many tests were ordered, and how many staff members would complete training for the tests. Additionally, the study was not allowed access to the sites’ overhead costs, including salaries and and utilities, and instead used median wage data so actual costs may be higher.

I was very surprised by the results of the study. I assumed such tests would be much more expensive and was why they were not already available to most pharmacies.  Pharmacies would be a great additional resource for individuals who want or need to be tested for HIV.  Pharmacies can provide the convenience of at-home testing while connecting people who are HIV-positive to the contacts and resources a clinical setting would also provide. With no increase in cost to other settings, pharmacies can become a medical source for patients with HIV to those who have limited access to other types of health care.

Lecher, Shirley Lee, Ram K. Shrestha, Linda W. Botts, Jorge Alvarez, James H. Moore, Vasavi Thomas, and Paul J. Weidle. “Cost Analysis of a Novel HIV Testing Strategy in Community Pharmacies and Retail Clinics.” Journal of the American Pharmacists Association 55.5 (2015): 488-92. Web.

Participant satisfaction with a community-based medication synchronization program

In a metropolitan area in Kansas City, a grocery store chain pharmacy decided to assess patient satisfaction with a new program they were offering. They called this program Time My Meds. Time My Meds was designed for patients taking 3 or more chronic medications to sync them to all fill on one day each month. The patients that were enrolled were asked to take a survey 3 months later to assess their satisfaction with the program. The survey collected demographic information and satisfaction based on the 5-point Likert scale. A total of 48 surveys were considered with no differences in trends based on age, education, income, or number of medications. Overall satisfaction was ranked very high with each question receiving a median score of 5 out of 5 on the scale.

This program was designed to benefit the patient. First, it helps reduce noncompliance. Three out of four Americans report not taking their medications as prescribed with long-term adherence rate at 50%. This can severely reduce the quality of life for an individual with an uncontrolled chronic disease. The results of the Time My Meds program showed patients had 3.4 to 6.1 times greater odds of adherence than unenrolled patients. This helps adherence because a patient is more like to come to the pharmacy if they only have to come once a month rather than once a week. Second, the study showed that pharmacy workflow would be improved because they could fill everything at once for a single pick-up date and reduce the unplanned and sporadic fills. By reducing these unnecessary fills, there will be more time for pharmacy staff to assist the patient.

From a patient’s perspective, this plan may be a great idea. It is extremely convenient to only make one trip to the pharmacy, easier to remember what medications are needed, and reduces the likelihood of noncompliance/nonadherence which improves the patient’s health. From a pharmacy technician/interns perspective, the program has many flaws. For example, some patients cannot afford to pick up all of their medications at once. Others like to manage their own medications and call them in when they are needed. The program may also take a few weeks to fully synchronize the “acceptable” medications, which can confuse an older adult that does not fully understand the program. Also, the only medications that can be enrolled in the program are those that are deemed “acceptable.” Patients may be on medications that are not deemed “acceptable” and would therefore, still need to manage some medications by themselves. Again, for an older adult, this may cause confusion as they would be expecting to pick up certain medications that may not actually be included in the synchronization. Overall, the idea of the program is great. I still believe there are kinks that need to be worked out to make the program the best it can be. Do you feel like a program like this would be easy to implement in a community pharmacy?

Butler K, Ruisinger J, Bates J, et al. Participant satisfaction with a community-based medication synchronization program. J Am Pharm Assoc(2003). 2015; 55(5):534-539.

Effectiveness of a pharmacist-physician collaborative program to manage influenza-like illness

The pharmacist-physician relationship is crucial to the collaborative efforts towards providing the best patient care as soon as possible.  This study is a prospective multicenter cohort study in which pharmacists working under collaborative practice agreements (CPAs) with a licensed physicians were able to administer simple physicals, and point of care rapid influenza diagnostic tests.  There were six overseeing physicians that signed the collaborative practice agreement, and fifty five pharmacies (both chain and independent) in Minnesota, Michigan, and Nebraska that volunteered to be a part of the study.  Those adult patients who showed signs of influenza like illness, and did not have an excluding condition were able to get screened.

There were 121 patients that volunteered for this study, but 45 were excluded due to predetermined exclusion factors.  Of the 76 patients eligible, one was sent to emergency care due to a systolic blood pressure of 83 mmHg.  Only 5 patients at CPA sites tested positive for influenza like illness, and they were given oseltamivir.  After treatment, 78% of all patients in the study were contacted within 48 hours, and reported feeling better.  A large third-party payer was found saying that treatment for upper respiratory tract infections at a physician’s office is on average $130-$180 whereas for emergency care treatment the cost is closer to $510-$635.  One important finding is that 35% of the patients in the study reported not having a primary care provider.

The study mentions that factors such as inconvenience, cost, and treatment delays add to a patient’s dissatisfaction with the health care system.  In the study the average time a pharmacist spent per patient was 10 minutes with a follow-up phone call lasting less than 2 minutes.  It also states that under this CPA model, the pharmacists were able to avoid the patient pressures for prescriptions that physicians often encounter.  The pharmacists were recorded saying that they felt they were able to better guide patients toward effective OTC medications instead of unnecessary prescriptions.  The final conclusion drawn from this study was that more exploration of collaborative models is warranted.

As a patient, would you feel comfortable seeing a pharmacist for treatment of what you believe to be the flu?  How would collaborative practice agreements impact the physician-pharmacist relationship?  Do you feel that a community pharmacist would be able to add this additional service to their day, or what changes to the current community setting would need to be implemented?

J Am Pharm Assoc. 2016;56(1);14-21. 

The adherence impact of a program offering specialty pharmacy services to patients using retail pharmacies

This study looks at a program called Specialty Connect utilized by specialty pharmacies in retail pharmacies. It looked at patient adherence over a 12-month period in 115 CVS Pharmacies in the Philadelphia, PA area.

Patients with “specialty conditions” such as cancer, cystic fibrosis, and pulmonary arterial hypertension were recognized in the Specialty Connect system and pharmacists were prompted to talk with such patients. The patient was given the option of utilizing the service and, if he or she agreed, the choice of having the medication delivered to their home or physician’s office, or available for in-store pick up. The patient was also told the pharmacist was available for counseling 24 hours a day, were counseled on their medications and adherence, and were given the option of refill reminders. The control group followed standard procedures for dispensing and counseling.

Refills of patients who were new to therapy were monitored over the 12-month period as well as those who had previously been receiving specialty medications. Compared to control groups, patients who were new to therapy had an increase of 17.5% in the rate of obtaining a refill on their specialty medications. Patients previously receiving specialty medications had an increase between 6.6% and 10.8% in refill rates.

This study shows how impactful a pharmacist’s interventions truly can be. Especially in the case of specialty mediations, adherence is very important in not only the treatment of the conditions but the costs of the treatments and resolving of issues related to nonadherence. A program like Specialty Connect can help patients with specialty conditions gain better access to and knowledge of their medications.

Moore JM, Matlin OS, Lotvin AM, et al. The adherence impact of a program offering specialty pharmacy serviced to patients using retail pharmacies. J Am Pharm Assoc. 2016;56:47-53.