Putting Medication Adherence Back into the Hands of Patients

Patricia Crawford - President/Founder, LTCPCMS; Terrence O’Neill - Director, Business Strategy, Covectra.

“Drugs don’t work in patients who don’t take them”

C. Everett Koop, MD, US Surgeon General, 1985.

The statement seems obvious on its face; however, medication non-adherence continues to plague healthcare in the U.S. It has been reported that annually medication non-adherence accounts for up to 50% of treatment failures, approximately 125,000 preventable deaths, and $500 billion in avoidable healthcare costs. How can something that seems to be so clear-cut endure amid the information age and the evolution of personalized medicine?

The World Health Organization defines medication adherence as how well a patient takes their prescribed medications according to the dosage and frequency recommended by their provider. Again, rather straightforward, it is the patient’s timely and accurate consumption of the medication. Yet when asked how they measure patient adherence, pharmacy representatives at all levels generally use one of two metrics:

1. Medication Possession Ratio - the ratio of the number of days a patient is stocked for their medication to the number of days a patient should be stocked for their medication, and

2. Proportion of Days Covered - the proportion of days in which a person has access to a medication.

Crucial factors no doubt; however, both measure the availability of the drug supply, not whether the patient is taking their drug in accordance with their provider’s expectations. Unfortunately, like in many business cases, retailers have invested and aligned people, processes, data, and technology in support of the metrics in which they are measured and are missing the mark when it comes to patient medication adherence.

When asked how they help patients with medication adherence, pharmacists across the board point to auto-refills, medication synchronization, text messages, and phone calls. Again, important interventions for getting drugs to patients, but those services fail to help patients take their medications as recommended by their providers. A study researching prescription pickup lags and automatic prescription refill programs found that ‘prescriptions in the automatic prescription refill programs were associated with a significantly longer amount of time in the pharmacy before being picked up by the patient’.¹ If patients were truly adherent, could they afford to leave their medications behind the counter for those extended periods? Might the pharmacy resources spent preparing medications that sit behind the counter longer be utilized more productively elsewhere? Particularly since there is a greater likelihood that time and resources will be spent reworking those drugs back into inventory. Those unclaimed refills are a byproduct of the compounding effects of medication non-adherence over time when a patient misses a dose here and there or goes on a drug holiday. In addition to the patient not receiving the medical benefit of the drug, it delays the urgency for refills which impacts the pharmacy’s bottom-line and operational efficiency. Interestingly, the same study found that manual refills initiated by the patient had a median pickup lag of one day, and 35% were picked up on the intended day. Many pharmacies have tried to address this issue by text messaging patients that prescriptions are ready for pickup; however, the effectiveness of those reminders has been uncertain, with one study concluding that ‘messages to refill medications may facilitate improvements in adherence, which in turn can improve chronic care’.² This certainly is not a ringing endorsement. Real patient medication adherence is a win-win when both the pharmacy and the patient are effectively engaged and coordinated.

While many are holding out hope that technology or artificial intelligence will solve this problem, we believe the answer rests in the hands of the patients. Rather than dispensing medications in bottles that are merely a means of conveyance, they can be packaged in calendarized adherence blister packaging that helps patients who often have no idea of how adherent they truly are. Each dose taken activates a patient engagement experience, the calendarized blister is a user interface prompting the patient to be compliant and immediately alerts them when they have not been, which enables them to modify their behavior. Physical cues are also integrated to remind patients to order refills. Unlike bottles, the abundant amount of billboard space on both sides of the carton enables QR codes to be consistently placed and prominently displayed, creating a convenient gateway to lead patients to virtual pharmacy resources or seamlessly connect patients to other e-commerce solutions. All of which can increase foot traffic at brick-and-mortar locations and eyeballs to the online marketplaces.

During ten years of producing over a billion adherence packages across various disease states and medications, our retail customers commissioned peer-reviewed studies to determine the business benefits of adherence packaging compared to bottles. The studies found that dispensing medications in the calendarized adherence blister packaging led to a prescription lift of up to 1.6 refills per patient, per drug, per year. That equates to a potential increase of 15% additional refills annually. Customer retention rates increased by up to 4%, and prescription loss rates decreased by up to 4%. Several operational efficiencies were realized from the prefilled adherence packages as pharmacists needed only to verify the drug and apply the pharmacy label. This reduced the amount of labor time required for dispensing and released staff to focus on other tasks that created more value for customers.

While it was determined that adherence blister packaging provided significant value for many patients and pharmacies, it was by no means a silver bullet or a perfect fit for everyone. We did experience a small number of patients, most over 65, who took six or more medications and used manual pill organizers and preferred bottles. For those patients, an uncomplicated pharmacy process needed to be in place, so medications are dispensed the way they want them. Understandably, patients who communicated their preferences and continued to receive medications in a different package became frustrated and a pharmacy challenge, which defeated the whole purpose of the adherence packaging program.

Another lesson learned was that patient awareness is paramount, and the lack thereof resulted in many questions. This serves as a golden opportunity for the pharmacy to engage with patients and further enrich relationships. Trust can be built by explaining to patients how the new packaging works and that it is being offered because the pharmacy cares about their well-being and will help them self-monitor their medication adherence. This is the very type of consultative interaction retailers are looking to establish today as they evolve pharmacies from medication dispensaries to healthcare service centers.

We learned in the past that most patients were accepting of the adherence packaging, but would patients appreciate the value and is there interest in it today?

In August 2023, Covectra commissioned Wiser Solutions to conduct an online consumer insights survey with 1,225 respondents across the US. The respondents were pre-qualified: 21+ years old, have taken a prescription medication as well as those who administer prescription medication to family members or as a healthcare professional. Listening to the voice of the patient after the pandemic, which altered the way healthcare is delivered and changed the patients’ service preferences are critical factors that influence patient medication adherence today.

In terms of medication non-adherence, despite the vast implementation of auto-refill, medication synchronization, and text message technologies retailers have adopted to virtually communicate directly with patients; doses, refills, and prescription reorders are still being missed at surprisingly high rates as illustrated in the next chart. This is also occurring while 88% of the respondents continue to obtain their prescriptions in-store at brick-and-mortar pharmacies. Precisely when opportunities are afforded to discuss, display, or in some other way reinforce medication adherence, which 98% of the survey respondents indicated was important to them.

The survey methodology included asking key questions upfront and then informing the study respondents about the definition of medication adherence, the adherence package and bottle features, and commonly reported costs of non-adherence. Afterward, those key questions were asked again to determine if the patient’s sentiments changed. When initially asked if they preferred the adherence package or bottle, the ratio was 45% to 55% in favor of bottles. After providing the basic medication adherence information, participants’ preferences changed to 72% in favor of the adherence package.

This is consistent with our experience and belief that with just a little education, patients will value, desire, and adopt the adherence package. Then as we investigated deeper into the respondents’ sentiments, the data became even more compelling.

When questioned about the benefit of the blister package calendarization feature, almost 9 out of 10 respondents indicated that the package enables patients to complete the prescription and stay on treatment, which is truly self-evident and difficult to dispute when one holds an adherence package and bottle in both hands.

The medication adherence package is a patient interface that can be integrated with other technology such as QR codes, which were also highly valued by patients. 73% indicated they would scan QR codes on the package to access additional pharmacy services, easy refill options, and rewards programs. Again, a great opportunity to build convenient, seamless connections with other healthcare programs or e-commerce solutions. 85% also responded it would be important to them to be able to utilize the QR code to access web-based medication information. Another touchpoint to further build trust with the patient as the go-to source for healthcare information and potentially create patient communities for patients to connect and share experiences about their disease.

Additionally, new data points can be created by leveraging simple and convenient smartphone applications to further track the patient’s adherence providing pharmacies with evidence-based information that can improve patient engagement and enrich relationships. These data and technologies also open a new frontier of exciting opportunities for pharmacies to establish partnerships with physicians to work together on Remote Patient Monitoring (RPM) and Remote Therapy Management (RTM) to improve patient outcomes.

Furthermore, many payors have recently been struggling with lower CMS Five Star Ratings that negatively impact reimbursement. The overall rating is heavily weighted by medication adherence, almost one-third, for targeted treatments addressing diabetes, hypertension, and high cholesterol. Payors can directly benefit from adherence improvements by guiding members to pharmacy networks or primary care providers that incorporate this type of packaging into their standard of care. The improved visibility and transparency of the patient’s actual medication adherence lead to fact-based decision-making during periodic follow-up assessments. Consequently, the packaging can be a foundational component to improve medication adherence in member populations across all age groups which can lead to higher CMS quality bonus payments, increased rebates, and lower member premiums.

Study after study has concluded that despite all the latest technology being applied to patient medication adherence, the challenges continue, costs are rising, and negative outcomes that could be avoided, are not being circumvented. To turn this trend around, a blend of technology and common-sense, convenient solutions must be laser-focused on the needs of the patient and provide access to affordable solutions that empower them to self-monitor, facilitate engagement, and build trust. If thoughtfully implemented, a medication adherence packaging program can generate benefits across the stakeholder spectrum from improved patient outcomes, pharmacy revenue, and cost benefits, and reducing the overall burden medication non-adherence places on the healthcare system and our society.

References

1. Lester CA, Chui MA. The prescription pickup lag, an automatic prescription refill program, and community pharmacy operations. J Am Pharm Assoc (2003). 2016 Jul-Aug;56(4):427-32. doi: 10.1016/j. japh.2016.03.010. Epub 2016 Jun 3. PMID: 27263422; PMCID: PMC4958552.

2. Waughtal J, Luong P, Sandy L, Chavez C, Ho PM, Bull S. Nudge me: tailoring text messages for prescription adherence through N-of-1 interviews. Transl Behav Med. 2021 Oct 23;11(10):1832- 1838. doi: 10.1093/tbm/ibab056. PMID: 34080636; PMCID: PMC8686108.

Author Biographies

Patricia Crawford serves as President/Founder of LTCPCMS. She can be reached at Pattychaneycrawford@gmail.com.

Terrence O’Neill serves as Directory Business Strategy at Coventry. He can be reached at toneill@covectra.com.

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