Improving adherence: Logan sees complex issue, pinpoints best interventions for patients


Innovations

Several years ago, L&S Pharmacy in Charleston, MO, began 
developing a hybrid adherence program.


The program L&S created—and eventually began marketing to other pharmacies through a consulting company—is rooted in medication therapy management, in which a patient’s medications are assessed for appropriateness, safety, and efficacy first. Adherence is built in by finding the best method of adherence intervention for the individual patient. 


“Everyone wants an easy button, but there is no easy button,” Tripp Logan, PharmD, who practices alongside his father at L&S Pharmacy, told Pharmacy Today . The interview took place at the 2015 APhA Annual Meeting & Exposition in San Diego, where he copresented an education session on adherence.


Like many community pharmacists, Logan sees an array of barriers that patients face adhering to their medications—everything from cost-sharing barriers in plan benefit design to a lack of understanding about why it’s important to take a medication. 


“People have their own reasons for why taking their medication doesn’t have meaning to them. Those reasons are sometimes three to four layers deep,” Janice Pringle, PhD, an epidemiologist at the University of Pittsburgh’s Center for Policy and Prescribing, told Today. 


From star ratings to tech solutions


A single person or technology solution will not be able to improve medication adherence rates alone. Such a complex issue requires an all-around effort, which stakeholders are beginning to recognize. Today, medication adherence is being addressed in health care settings, senior centers as well as other community settings, state legislatures, and academic institutions. As a result, more research is being done, and consumer awareness is gradually building.


In addition, health plans are being rated on a set of performance measures, which include medication adherence. Health plans, pharmacy benefit managers, physicians, and pharmacists are now accountable for medication adherence rates for their patients as the U.S. health care system transitions to a value-based system of care. 


“Adherence is the Achilles heel for plans achieving star ratings,” said David Nau, PhD, BSPharm, FAPhA, President of Pharmacy Quality Solutions, during a presentation at APhA2015.



Tripp Logan, PharmD

CMS rates Medicare Part D prescription drug plans on a number of different metrics between one and five stars, depending on quality and performance, with a five-star rating being the best. The program is more commonly known as the CMS star ratings program. 


Three measures focus on medication adherence and are heavily weighted compared with some of the other metrics in the program. Developed by the Pharmacy Quality Alliance, the measures also are beginning to show up on the state health insurance exchanges under the Affordable Care Act and are being used for accreditation purposes. 
Pharmacies are becoming a significant target for health plans that are being rated on quality through the star ratings program. 


At L&S, technology solutions that generate customized reports and patient nonadherence flags help identify patients and drive interventions. But they are also affecting the measurable performance of the pharmacy, according to Logan. 


L&S partners with a few different software vendors. One report they receive midweek, for instance, shows every single patient pushed to his or her pharmacy who has fallen below 80% proportion of days covered (the adherence metric) for cholesterol medications. The report is sorted by payer and adherence percentage.


“This allows us to target those most at risk and those in pay-for-performance programs, like CVS/Caremark SilverScript,” said Logan. 


Some prescription drug plans, like CVS/Caremark SilverScript, have even begun implementing pay-for-performance models that include bonus payments to top-performing pharmacies, according to Logan. 


“It has to be measurable and meaningful to someone else. That is why we are so focused on star ratings—it’s something we can implement change on,” he said. 


Translating research into tools


The statistics on poor medication adherence are well known at this point: an additional $2,000 per patient per year in medical costs and physician visits, according to the National Council on Patient Information and Education; an increase in medication-related hospital admissions; unneeded medication changes; unnecessary disease progression and complications; even death. 


Pringle, who helped lead the Penn­sylvania Project, sees pharmacists as the driving force behind improving medication adherence rates. She hopes her continued research can help pharmacists identify individuals as proactively as possible who can benefit from interventions. 


“What I’m seeing is a lot of insurance companies who are not really understanding that they have to begin to develop a workforce—which is the pharmacy workforce—to give them the tools to improve adherence at the rates that are going to be required by Medicare and other payers,” said Pringle. 




Technician Valerie Jolly helps a patient choose the right OTC.

Quick fixes, like automatic phone calling and special labeling, are not going to suffice, she said.


Outcomes of the Pennsylvania Project, which were published in the journal Health Affairs in August 2014, showed that pharmacists performing brief interventions of 2–5 minutes with patients taking chronic medications were able to increase adherence and decrease costs.


Pharmacists screened patients using two different tools: an adherence estimator for patients receiving new prescriptions, and an outcome rating scale for patients refilling prescriptions. Intervening pharmacists then counseled patients who were at risk of nonadherence in order to find out what barriers they were encountering, and they worked to address the issues either through education or calling the patient’s physician. 


Using the two adherence tools that were part of this study—which are also widely used in practices across the country—Pringle is now trying to find ways predictive analytics can supplement these tools. 


“We find that there’s a certain percentage of patients these tools miss, and we consider it a miss because these are people who go on to have adherence issues and who have not responded to some of the interventions,” said Pringle. 


Building consumer awareness


In communities across the United States, awareness has been growing around the importance of medication adherence. In 2011, the National Consumers League (NCL) launched the Script Your Future campaign with targeted efforts, such as health fairs and educational programs, in six pilot cities. Consumers are the central focus, but health care providers, including pharmacists, have been instrumental in communicating messages, along with tools, to help improve medication adherence for their patients. 


“Addressing the issue of adherence requires the entire health team, and as the medication expert, the pharmacist is a valuable and at times underutilized resource,” said Sally Greenberg, JD, Executive Director of NCL.


Greenberg said that from the beginning, pharmacists have been a champion of the campaign. 


Based on telephone survey data from adults living in the six pilot cities, NCL saw a significant increase—from the initial survey in 2011 and the midpoint survey in 2013—in pharmacist communication to patients, especially when compared with physicians. 
The data showed that more pharmacists were asking pa-tients about their medications every time they picked up a prescription, and there was a decrease in patients reporting that their pharmacist never asked about problems with medications during visits. 
One of the most successful tools that has carried over from the campaign is a wallet card handed out to patients, which includes their medications as well as a list of questions for patients to ask their pharmacist or doctor. 


“Having a conversation with your health care provider is an important part of the campaign, and the wallet card has proven to be more than just a piece of paper,” Rebecca Burkholder, JD, Vice President of Health Policy at NCL, told Today. 


Various stakeholders have been coming to NCL to ask for the wallet cards, which can also be custom branded and translated into different languages.


The campaign recently wrapped up after a 3-year run, but NCL will continue to be a resource for cities and communities that are interested in leading similar efforts. State pharmacy associations in Maryland and Ohio will take over the work that was begun in Baltimore and Cincinnati, two of the original pilot cities. 


Zeroing in on high-risk patients 


Many state pharmacy associations have also helped introduce bills pertaining to medication synchronization, which has been effective in improving adherence. To date, 18 states have passed or are working on passing bills that include medication synchronization language. 


According to Logan, medication synchronization, in which a patients’ prescriptions are synchronized to a single, convenient day each month for pick-up, works for some patients—but not everyone. He wants to try to find the best method of adherence intervention for each patient. Some might respond better to text reminders or certain labeling; others may require full-care coordination. 




Tripp Logan, PharmD, sees an array of barriers to adherence.

Since a more thorough approach takes time, pharmacy technicians at L&S are critical at every stage, according to Logan. 


L&S normally operates at a 5-to-1 technician-to-pharmacist ratio. Technicians are assigned specific roles—some are only dealing with third-party issues, but many are working as diabetes or transitions-of-care specialists. For instance, diabetes specialist technicians are managing diabetes support group recruitment or conducting blood glucose testing. Technicians in transitions-of-care specialist roles might be receiving the patient’s documentation from the discharge hospital or providing the medication list and discharge care plan to the pharmacist for review. 


These skills are valuable for the technicians, and having technicians in these specific roles can also be more cost effective for the pharmacy, according to Logan. 


However, he said that state rules on technician-to-pharmacist ratios can be a hindrance in this effort if ratios are low. He sees this firsthand in some states he consults with. 


Another key component for effective medication adherence, according to Logan, is focusing on those patients who are the sickest. This is also where technology and data can have the biggest impact. 


“You can’t help everybody at first,” Logan said. “You need to start with those who have the biggest impact, where you can make the most difference.”