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.

Using Medication Adherence as an Indicator of Cognitive Dysfunction Among the Elderly

Anyone who has been required to take a medication on a daily basis can attest to the fact that it is very easy to forget or skip a dose. Imagine having to remember to take 6 or 7 medications everyday at different times of the day. This undoubtedly requires a certain level of cognitive ability and a clear mind to be able to organize all of one’s medications and to proceed to remember to take them. While one can usually stay adherent to his medications if some sort of system is set up for him, a decline in cognitive function and the development of dementia may nullify all efforts to keep track of and remain adherent to his medications.

This study assesses the possibility of using medication adherence as an indicator of the development of cognitive dysfunction in elderly individuals. This was a retrospective cross-sectional study, which examined 3351 Japanese patients with a mean age of 78.9 years old. Participants completed a comprehensive cognitive function test and got their medication use checked by clinical pharmacists. The Lawton’s instrumental activities of daily living (IADLs) scale assessed participants’ abilities to carry out self-care tasks in 8 categories such as the ability to use a telephone, transportation use, ability to handle finances, and responsibility for own medications. The Barthel Index score assessed another 10 self-care categories and the MMSE (Mini-Mental State Examination) measured participants’ orientation in time and space, attention, memory, language, and constructive skills.

The results of this study demonstrated that those in the early stage of cognitive failure were unable to perform activities of daily living (ADLs) in the “shopping” and “responsibility for own medications” categories. Moreover, the data from this study showed that there was a significant association between poor medication adherence and many other factors such as the use of Alzheimer’s disease medication, advanced age, and low Barthel index scores. Of the 3351 patients in this study, 2753 had some sort of cognitive dysfunction, and almost all patients diagnosed with dementia demonstrated a lower adherence to their medications in this study.

This study reveals that IADL scores are an effective method of predicting cognitive dysfunction in elderly individuals. Medication adherence and the development of dementia are both extremely important issues that require immediate attention. Pharmacists can play a huge role in caring for the elderly by providing screenings to measure for cognitive dysfunction and, in doing so, monitoring the elderly’s medication adherence as well.

Mizokami F, Mase H, Kinoshita T, et al. Adherence to Medication Regimens is an Effective Indicator of Cognitive Dysfunction in Elderly Individuals. Am J Alzheimers Dis Other Demen. 2016; 31(2):132-36

http://aja.sagepub.com.pitt.idm.oclc.org/content/31/2/132.full.pdf+html

Motivational interviewing for medication adherence

Medication adherence is very important. Patients have to adhere to their medication regiment in order for the medications to produce the best therapeutic response. Medication adherence stems from patient’s internal motivation, which can be stimulated through motivational interviewing.

The study did a telephone survey in 2015 targeting adults over 40 years old, who are currently on at least one prescription medication for chronic illnesses. It was found that about 75% of the 1,020 respondents had engaged in at least one nonadherent behavior within the past year and 50% had multiple nonadherent incidents. The most common behaviors include missing a dose, not refilling the medication on time, self-initiate a lower dose than prescribed, and discontinuation of a prescribed medication without consulting the doctor. Medication adherence is a very common problem and contributes to 33-69% increase in medication-related hospitalization.

The article suggests that motivational interviewing may be the key to change patients’ nonadherent behaviors. Results from a meta-analysis show that there is a 19% increase in noncompliance in patients who has poor communication with their health care provider or pharmacists. The change talk in motivational interviewing is essential in brining about changes in patients. In the cases of patient brining up possible changes for better adherence, it is important to help the patient identify the pros and cons of adhering to the medication regiment. Through recognizing and affirming patients’ feelings and desires to make changes in order to better adhere to their medications, pharmacists can help develop patient’s motivation and reinforce their commitment to make good and healthy changes.

I agree that motivational interviewing allows pharmacists to better identify the barriers that are keeping patients from adhering to their medication regimen and helps encourages medication adherence. Although time remains as the primacy concern in regards to incorporating motivational interviewing into actual practice, I believe it is worthwhile to be implemented into pharmacist’s routine since it is very helpful in identifying and solving drug therapy problems.

Salvo MC, Cannon-Breland ML. Motivation interviewing for medication adherence. JAPhA. 2015;55(4).

Evaluating the Effects of an Interdisciplinary Practice Model with Pharmacist Collaboration on HIV Patient Co-Morbidities

HIV patients are likely to have certain medical co-morbidities at a higher prevalence than members of their age group and are more vulnerable to adverse events related to these problems. For this reason, monitoring of patients with this condition is highly utilized through primary care clinics that specialize in the treatment of the infection in association with chronic disease states. The disease states common among HIV patients over the age of 60 include hypertension (45% of people), diabetes (21% of people), and vascular disease (23% of people). Interdisciplinary practice models used in treatment of patients with this condition have been effective in managing these chronic disease states. Because pharmacists play a crucial role in how HIV patients adhere to medications and treatment guidelines, this study focused on determining if there is a benefit to adding pharmacists to this inter professional team.

This study found that pharmacists were able to help in the management of  lipid levels and the cessation of smoking. Along with this, pharmacists were found to significantly decrease the amount of money these patients spend management of their individual chronic co-morbidities (with average savings of $3,000). For this reason, pharmacists involvement in the primary care of patients with HIV should expand past the provision of medications to include counseling and other services.

I think this study is important due to the fact that it represents how the role of a pharmacist within the health system is constantly changing. We are not only trusted sources of information for medications and proper treatment techniques, but we are also crucial in providing adequate counseling to patients. This is something that I believe has been a major focus throughout our studies in pharmacy school over the course of the year, and as a result, a feel I will be well prepared to fill this role in my future profession. This article makes me want to learn specific ways that I can help patients from this population manage their condition.

Cope R, Berkowitz L, Arcebido R, et al. Evaluating the effects of an interdisciplinary practice model with pharmacist collaboration on HIV patient co-morbidities. AIDS Patient Care and STDs. 2015, 29(8): 445-453

Estimating the cost of unclaimed electronic prescriptions at an independent pharmacy

Electronic prescribing continues to expand across the health care system in the United States. A study was conducted in a Midwestern state independent pharmacy which estimated the cost of unclaimed electronic prescriptions towards the operational pharmacy practice. The study was organized in an area with a population of 6,000 over a six-month period. Researchers had to analyze the incurring costs to prepare, fill, and return the unclaimed prescription after 14 days In addition, the cost of personnel and contacting the patient were incorporated in the total expenditure.

The results showed that the unclaimed electronic prescriptions consisted of 0.44% of total prescriptions and 0.82% of the total electronic prescriptions. There were 147 unclaimed e-prescriptions and the cost ranged from 18.54 to 25.02 per unclaimed e-prescription depending on the cost of dispensing and staff.

I think that this study brought attention to the importance of medication adherence and obstacles the independent pharmacies face as they continue to operate on slim margins. Geographical location, patient population, and number of local competition factor into the success of the independent pharmacies. However, they do not have the capital of corporate community pharmacies to remain afloat from the decreasing reimbursement rates. Inflation of AWP contributes to the problem with single-source medications, drug manufacture mergers, and tighter regulations from FDA that increases the cost from inception to market. Areas with larger populations face potentially more unclaimed e-prescriptions leading to a greater cost without compensation.

Question: What can be done to curb this problem and maximize efficiency as electronic prescribing rises?

J Am Pharm Assoc. 2016;56(1):58-61.

Improving Adherence to Therapy and Clinical Outcomes While Containing Costs: Opportunities From the Greater Use of Generic Medications

Almost everyone in the United States can agree to the fact that medications are not cheap. Moreover, brand name medications are infamous for being unnecessarily expensive. The issue with expensive medications lies not just within the costs themselves but also within the fact that the costs affect patients’ medication adherence and willingness to receive treatment. Both health care practitioners and patients are often drawn towards brand name products without knowing that the equivalent generic medications may produce equally effective results.

This article describes a study in which researchers conducted a Google Scholar literature review, answering five questions regarding the usage of generic medications, effectiveness of generic medications, and barriers against using generic medications. Articles containing original empirical data that were relevant to each of the key questions were included in this review.

The results of this study demonstrated that many health care providers prescribe brand-name medications when generic versions are available. Furthermore, studies show that when managing common chronic conditions, physicians tend to choose medications that are newer and relatively expensive. “Therapeutic interchange” is the substitution of a similarly effective but less expensive chemical entity to treat the same condition and, when combined with generic substitution, studies have shown that Medicare could save $1.4 billion for patients with diabetes alone.

As I mentioned earlier, high costs are not the only issues in these situations because the impact high costs have on the patients’ medication adherence are just as important of an issue. In a study done on patients initiating therapy in long-term medications, results showed that patients beginning therapy with a generic medication had adherence rates that were 5-7% higher than those initiating therapy with a brand-name drug.

In response to the question, “What is the evidence that brand-name and generic medications have similar clinical effects?” there have been conflicting results. Bioequivalence is defined as “the absence of a significant difference in the availability of the active ingredient at the site of drug action”. While generic versions of bupropion were not found to be bioequivalent to the brand-name version, a meta-analysis of forty-seven studies comparing generic and brand name drugs in nine classes of cardiovascular medications demonstrated that the generic drugs were just as effective as the brand-name equivalents.

The future for generic drug use is still unclear because, while generic drug use has been increasing, there is still a lot of room for even greater use of these medications and for the improvement of health care quality and reduction of costs. The perceptions of patients and health care providers continue to heavily affect the use of generic medications. Many approaches to increasing the use of generic drugs have been proposed, the first one being the development of data demonstrating the safety and effectiveness of generic drugs relative to their brand-name counterparts. I personally am affected by the high costs of brand-drugs and am also guilty of misperceiving generic drugs as being not as effective as their brand-name counterparts. I believe that more concrete data and evidence would play an enormous in increasing generic medication use and medication adherence while substantially decreasing costs.

 

Choudhry M, Denberg T, Qaseem A. Improving Adherence to Therapy and Clinical Outcomes While Containing Costs: Opportunities From the Greater Use of Generic Medications: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2016; 164(1): 41-49

http://annals.org/article.aspx?articleid=2471597

 

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.