Tackling the Adherence Problem:
Community Pharmacists Offer Solutions
The Adherence Problem
• For years, emphasis has been placed
on the problem of medication
non-adherence
 $290 billion a year in direct and
indirect costs = 13% of total health
care spend
 125,000 deaths that result from not
taking medication correctly
 69% of medication-related hospital
admissions due to poor adherence
 50% of new statin patients will
discontinue medication after 6 months
NEHI. Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. 2009
World Health Organization. Adherence to long-term therapies: Evidence for action. 2003
Benner JS, Glynn RJ, Mogun H. Long-term Persistence in Use of Statin Therapy in Elderly Patients. JAMA. 2002;288(4):455-461
Impact of Medication-Related Problems
Medication
Non-adherence
= $290 Billion
↑ costs to
health care
system
↑ costs to
employers and
payers
↑ premiums and copays to patients and
↓ health outcomes
It’s Time to Bring Solutions
• Transformation of health care delivery
with focus on quality
• 75% of total health care spending on
chronic disease, imperative to improve
adherence rates
• Medicare, one of the nation's largest
payers, has demonstrated its commitment to adherence:
 Adherence factored into of the Part D plan ratings program
 Pro-rated cost sharing to promote synchronization of refills
• Pharmacists have the capability and opportunity to
improve adherence that can achieve the ‘triple aim’ of:
 Better care
 Better health
 Lower costs
Why Community Pharmacists?
• Trusted medication expert
• Maximize medication use for
optimal outcomes
• Most accessible provider in
community
• Key touch point throughout
continuum of care
• Last health care professional
seen by patient before
medications are taken
Gastroenterologist
Cardiologist
Allergist
Dentist
PHARMACIST
ER
Gynecologist
Primary Care
Physician
Dermatologist
How Can Community Pharmacists Help?
• Addressing barriers to medication adherence:
 Health Literacy
• Translating medication information in a
patient-friendly manner
• Counseling on interactions, side effects
 Cost
• Identifying cost-effective alternatives that are clinically appropriate
• Generic medications dispensed by independent pharmacies: 72%
 Disease State Management
• Offering patient care services that help manage chronic diseases
through effective medication use
 Regimen Complexity
• Packaging, refill reminders, reduced dosing frequency
• Refill coordination
Effective Communication is Key
• Independent community
Patient
Improved:
•Communication
•Patient understanding
•Medication adherence
•Quality of care
•Health outcomes
Pharmacist
Physician
pharmacists are a vital link
between the patient and the
entire health care system
• Uniquely positioned to
complete the triad of care as
they communicate with
patients and collaborate with
physicians and other health
care professionals
Taking Care of Patients Takes Teamwork
• Pharmacists often contact prescribers to
make recommendations and improve
medication therapy for their patients
 Independent community pharmacists
consult with physicians or other health
care professionals about 7 times daily
regarding prescription drug therapy
 Approximately 93 percent of
independent community pharmacists
recommend brand to generic drug
changes when appropriate to other
health care professionals
Patients Are Our Priority
• 78% of independent community
pharmacies indicate they offer at
least one disease state
management service or
medication therapy management
• Top five services offered:
 Immunizations
 Blood pressure monitoring
 Diabetes training/education
 Smoking cessation
 Cholesterol monitoring
The Power of MTM
• Medication Therapy Management (MTM):
 Personalized, comprehensive reviews that can:
• Optimize the clinical benefits of patients’
medications (prescription and OTC)
• Reduce the risk of adverse drug events, drug
interactions, and the potential for side effects
• Increase patient adherence to prescribed
regimens through education and counseling
• Identify more cost-effective alternatives
• Study comparing MTM interventions found drug costs
decreased for those who received service from community
pharmacists, decreased somewhat for patients who received
service from a call center pharmacist, and were unchanged for
those who received MTM via educational mailings.
Winston S, Lin Y. Impact on drug cost and use of Medicare Part D of medication therapy management services delivered in 2007.
J Am Pharm Assoc. 2009;49(6):813–820.
Ounce of Prevention Worth a Pound of Cure
• The Asheville Project: Community-based,
pharmacist-directed, medication therapy
management (MTM) program provided for
several employers in Asheville, N.C.
• Assessment of the clinical and financial
outcomes of a long-term, pharmacist-driven
MTM program for patients with hypertension
and/or dyslipidemia found:
 Clinical improvements sustained as long as 6 yrs
 Approximate threefold increase in cardiovascular (CV) medication
use but CV-related medical expenses decreased by 46.5%
 Savings due to lower CV-related medical costs exceeded blood
pressure/lipid medication and program costs by 12.6%
Bunting BA, Smith BH, Sutherland SE. The Ashville Project: Clinical and economic outcomes of a community-based long-term medication
therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008; 48 (1):23–31
Don’t be Penny Wise and a Pound Foolish
• The Minnesota Experience: Objectives
 Provide medication therapy management
(MTM) services to patients
 Measure clinical effects associated with
provision of MTM services
 Measure percentage of patients achieving
clinical goals for high blood pressure and
high cholesterol compared to control group
not receiving MTM services
 Compare patients’ total health expenditures
for the year before and after receiving MTM
services
Isetts BJ, Schondelmeyer SW, Artz MB. Clinical and economic outcomes of medication therapy management services: The Minnesota
experience. J Am Pharm Assoc. 2008; 48 (2):203–211
Getting the Biggest Bang for Your Buck
• Results from the Minnesota Experience:
 Clinical Benefit: MTM intervention group
had a higher percentage of patients meeting
goals for hypertension and cholesterol
management vs. control group
• Hypertension (71% vs. 59%)
• Cholesterol (52% vs. 30%)
 Economic Benefit:
• Per person total health expenditures
decreased from $11,965 to $8,197
• Overall reduction in total annual health
expenditures exceeded cost of providing
MTM by more than 12 : 1
Isetts BJ, Schondelmeyer SW, Artz MB. Clinical and economic outcomes of medication therapy management services: The Minnesota
experience. J Am Pharm Assoc. 2008; 48 (2):203–211
Spend a Little—Save a Lot
Studies have found that increased pharmacy spending (due to increased
adherence) resulted in significantly fewer hospitalizations and significantly
lower health care costs – these savings are increased for patients over age 65.
$10,000.00
Benefit-to-Cost Ratios:
Congestive Heart Failure: 8.4:1
Diabetes: 6.7:1
High Blood Pressure: 10.1:1
High Cholesterol: 3.1:1
$8,881
$9,000.00
$8,000.00
$7,000.00
$6,000.00
$5,000.00
$4,413
$4,337
$4,000.00
$3,000.00
$1,860
$2,000.00
$1,058
$656
$1,000.00
$429
$601
$-
Congestive Heart
Failure
Diabetes
Increase in Rx Spend
High Blood Pressure
High Cholesterol
Reduction in Medical Spend
Roebuck MC, Liberman JN, Gemmill-Toyama M, Brennan TA. Medication adherence leads to lower health care use and costs despite
increased drug spending. Health Affairs 2011;30(1):91-99.
Spend a Little – Save a Lot
• Greater prescription medication More trips here can mean
access and proper utilization can
reduce health care costs, such as
hospitalizations
• Congressional Budget Office
estimates that a 1 percent
increase in the number of
prescriptions filled by
beneficiaries would cause
Medicare’s spending on medical
services to fall by roughly onefifth of 1 percent.
Fewer visits there
Offsetting Effects of Prescription Drug Use on Medicare’s Spending for Medical Services. Congressional Budget Office. November 2012
Not Rocket Science, Just Keep It Simple
• Complex regimens with multiple
prescriptions negatively impact
patient adherence
 Patients who make visits to a variety
of pharmacies (mix of chains,
mail order, independents) and those
who fill fewer medications per visit
(less refill consolidation) are substantially
less adherent to their prescribed therapy
 Medication use and prescription filling for patients with multiple
chronic conditions can be complex, and strategies to reduce this
complexity may help improve medication adherence
Choudhry NK, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, et al. The implications of therapeutic complexity on adherence to
cardiovascular medications. Arch Intern Med 2011;171(9):814-822
There’s No Place Like (a Pharmacy) Home
• Adherence improvement can
begin with increasing refill
consolidation at individual
pharmacies
• Having a “pharmacy home” to
serve as a central medication
information hub can simplify
access, improve safety and
ultimately adherence
Choudhry NK, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, et al. The implications of therapeutic complexity on adherence to
cardiovascular medications. Arch Intern Med 2011;171(9):814-822
Simplify My Meds
• Adherence can be improved when
patients coordinate refills (“refill
synchronization”) at a single pharmacy
• Nearly 600 community pharmacies
participating
• Facilitates improved adherence by:
 Reducing the potential for gaps
between refills
 Reducing medication-related hospital
readmits
 Providing mechanisms to identify nonadherence
Win-Win-Win
• Community pharmacists are best
positioned to positively influence
patient medication adherence that
will:
 Improve care with high-touch,
face-to-face counseling
 Keep patients healthier in their
communities
 Lower overall health care costs by
reviewing medications for the most
cost-effective therapies, and
reducing or preventing
hospitalizations in the long run