Strategies for Improving Medication Adherence
By Jason Turner, PharmD |
The impact of medication adherence derives from two interconnected realities: (1) nearly half of the patients in a typical pharmacy suffer from at least one chronic condition1 and (2) about one-quarter of a pharmacy’s chronically ill patients2 are at increased risk for complications and higher healthcare costs3 due to insufficient adherence to medication therapy.
Multiple studies reference 80 percent medication adherence as the threshold at which patients benefit from chronic medications to improve outcomes and reduce the risk of further complications.4
In practical terms, that equates to a patient taking his/her medication 6 of the 7 days of the week. At that rate, the pharmacy would fill a 30-day supply at least every 37 days or a minimum of 10 times per year.
The Medicare Star Ratings system uses the term “Proportion of Days Covered,” or PDC, to establish quality measures with a similar definition of 80 percent adherence targeted specifically to cholesterol, diabetes and hypertension therapy. The 2016 Star Ratings, which are based on 2014 claims data, show national average adherence rates that fall below the PDC threshold within Medicare Part C plans:
- 75 percent for cholesterol medications;
- 77 percent for diabetes medications; and
- 79 percent for hypertension medications.5
More recent performance reports, measured from July through December 2015 by the Electronic Quality Improvement Platform for Plans and Pharmacies (EQuIPPTM), indicate PDC averages rising to a range between 85 percent and 88 percent. Nonetheless, EQUIPP and other performance reporting platforms still offer plenty of opportunity for pharmacies to identify the patients who would benefit most from adherence-related services.
When looking at adherence levels it’s important to understand that PDC percentages do not reflect average adherence per patient. If we look at diabetes medications, for example, the Star Ratings figure indicates that 77 percent of patients are at least 80 percent adherent — not that individual patients average 77 percent adherence. The opportunity in this case lies with the 23 percent of diabetes patients who are not at least 80 percent adherent.
Overall, for the three Star Ratings-targeted classes of chronic medications, the goal is to improve adherence in about 1 in 4 patients. Let’s look at several key tools and programs that address adherence-related issues:
Data-mining reports. Data from EQuIPP, InSite (a proprietary AmerisourceBergen rel="noopener noreferrer" data analytics tool), Prescribe Wellness and additional subscription-based platforms identify patients who would benefit from adherence-related pharmacy services. Running reports from these platforms requires time and a plan to share results with the pharmacy team; however, the information gained may detect opportunities for better adherence currently missed in the prescription-dispensing process.
Medication synchronization. This process coordinates all of a patient’s chronic medications to be filled at the same time each month. It moderates barriers to adherence (e.g., forgetfulness, complex drug regimens, difficulty taking medications, patient’s understanding of either the medication or disease state), helps eliminate therapy interruptions, identifies non-adherence in the home or changes in therapy, reduces first-fill abandonment and improves patient-pharmacist interactions. At my two pharmacy locations, we proactively process about 55 percent of our total prescription volume through medication synchronization.
Medication therapy management (MTM). Two types of MTM — comprehensive medication review (CMR) and targeted interventions — identify patients with less-than-optimal adherence and address it through pharmacist-patient interactions. CMR involves real-time discussion of the patient’s medications (including prescriptions, over-the-counter medications, herbal therapies and dietary supplements). At the conclusion of the CMR, the pharmacist provides a summary to the patient in a standardized Medication Action Plan format. Targeted interventions focus on resolving and/or preventing the occurrence of one or more medication-related problems. MTM not only flags patients with poor adherence, but also establishes a purpose for counseling and pharmacy-provided services such as additional medications or immunizations.
Patient adherence counseling. We know that patients don’t want to be non-adherent. At the same time, they often look to the pharmacy to help them find a solution. While counseling is not an inherent skill — admittedly, my staff and I found it a bit unnatural at first — it definitely improves with practice and experience. Fostering a positive and productive conversation helps the patient realize why he or she needs to take their medication and become more adherent in that therapy. Start by asking open-ended questions along these lines: How do you take your medication? If you miss a dose, what is the most common reason why? How many doses do you miss per week? Would you like me to offer some recommendations?
Pharmacy-provided solutions. A community pharmacy should be able to offer an array of services such as medication synchronization, late refill calls, patient medication administration records, compliance packaging, prescription delivery, health or medication literature, and mobile apps/alarms — all with a role in improving adherence. However, bear in mind that not every solution will be right for every patient. The pharmacy should stand ready to help find the appropriate resolution or combination of offerings. Concentrate on services that are successful, sustainable and expandable, and be certain that staff members know how to offer and execute each solution.
As emphasized above, better medication adherence undoubtedly means healthier patients. But there are pharmacy business aspects to consider as well.
First, pay-for-performance programs or performance networks may include an adherence component. For example, a pharmacy could reduce direct and indirect remuneration (DIR) fees6 for network participation as a result of better performance on Star Ratings adherence measures.
Second, improving medication adherence translates to patients filling more prescriptions at the pharmacy. As shown in a landmark study, patient spending on chronic medications increased when they surpassed the 80 percent adherence threshold.7 Pharmacies shouldn’t feel guilty about generating higher revenue as a result of greater patient adherence.
Moving forward, pharmacies can significantly improve medication adherence in chronically ill populations. The highest performers will leverage existing services with easily accessible tools and technologies to develop best practices and achieve success.
1. CDC Public Health Grand Rounds. How pharmacists can improve our nation’s health. https://www.cdc.gov/cdcgrandrounds/pdf/gr-pharmacists-10-21-2014.pdf
2. Centers for Medicare and Medicaid Services. (2015, September 30). Medicare 2016 Part C & D Star Rating Technical Notes. http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html
3. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS (June 2005) Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care. 43: 521-530. http://www.ncbi.nlm.nih.gov/pubmed/15908846
4. Karve, S, Cleves, M, Helm, M, Hudson, T, West, D, & Martin, B (2009). Good and poor adherence: Optimal cut-point for adherence measures using administrative claims data. Current Medical Research and Opinion, 2303-2310. http://www.ncbi.nlm.nih.gov/pubmed/19635045
5. Centers for Medicare and Medicaid Services. (2015, September 30). Medicare 2016 Part C & D Star Rating Technical Notes. http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html
6. National Community Pharmacists Association. Frequently asked questions about pharmacy DIR fees. http://www.ncpa.co/pdf/faq-direct-indirect-remuneration-fees.pdf
7. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS (June 2005) Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care. 43: 521-530. http://www.ncbi.nlm.nih.gov/pubmed/15908846