Welcome to ScriptDrop’s annual industry status report
Last year, our report “Bringing Healthcare Home: The Current State of Prescription Delivery” outlined the impact of the COVID-19 pandemic on the needs of patients. We considered which patient groups benefited most from prescription delivery, the different ways that delivery is conducted, and the delivery options available to patients and healthcare organizations.
At that point in the pandemic, we had seen only the beginning of how healthcare organizations would respond to this global health emergency.
Now there is no doubt: COVID-19 has changed American healthcare forever. Home delivery has become the default choice, telehealth is evolving quickly, and some organizations—including Amazon—are reviving the old tradition of house calls by doctors, albeit through a technologically-savvy lens.
As a result, many patients are experiencing expanded access to healthcare and prescription medication. Now our collective mission is to ensure that these solutions continue to put patients first. They should make healthcare simpler, not more frustrating.
In this year’s report we’ll inspect the growing prescription delivery industry, analyze its potential impact on patient adherence and medication abandonment, and consider its future as part of healthcare performed in the patient’s home. Throughout the report we’ll feature brief narratives about three fictional patients—Edie, Kevin, and Hayun—to better understand how delivery can meet the needs of many patient populations, now and well into the future.
Meet the Patients
These patients are representative of the many people who use prescription delivery.
Edie is an active 67 year old woman living alone in an apartment in a major metropolitan city. She is widowed, retired, and a Medicare member. Edie is in generally good health, aside from an issue with a heart valve. As a result, she is scheduled for a heart valve replacement surgery.
Kevin is 35 years old and living with their partner in a Midwestern suburb. They work several part-time jobs, including the night shift at a large retailer. Kevin is HIV positive and on antiretroviral therapy. Kevin has insurance through the Affordable Care Act.
Hayun is a 21 year old college student at a large university. Between school, family, friends, and an internship, Hayun is extremely busy. She has anxiety and depression, which she manages with medication and therapy. Hayun is on her family’s insurance plan through her father’s employer.
Medication abandonment is a sign that the patient’s health is likely going to get worse, not better. It goes without saying that patients who don’t have their medication in hand aren’t likely to start their therapy. Ultimately, that impacts not only the patient, but their family, friends, and community.
That’s why we’re viewing adherence as a key measurement of value. If delivery can improve adherence – and it can – every part of the healthcare ecosystem will benefit.
What is medication adherence?
A patient is said to be “adherent” when they follow a prescribed therapy as recommended by their healthcare provider. The therapy is usually mediation, but could also include recommendations regarding diet, exercise, sleep hygiene, counseling, and so on. If a patient has been prescribed a medication, they are considered adherent if they take the correct amount of medication in the correct way at the correct time for the full course of therapy.
However, few patients follow their doctor’s instructions perfectly 100% of the time, especially if they have a chronic illness and must follow a therapy for years. Many therapies remain effective even without perfect adherence, but some therapies require an extremely high level of adherence.
How nonadherence is harmful
In 2003, the World Health Organization determined that improving drug adherence was the single most important way to improve human health globally. In developed countries, adherence to long-term therapy for chronic illnesses averages only 50%. 7 That lack of adherence causes a vast amount of avoidable suffering and financial burden.
Risks of nonadherence 7
- More intense relapses of disease
- Increased risk of dependence on medication
- Increased risk of withdrawal from medication
- Increased risk of treatment-resistant disease
- Increased risk of accidents
Direct costs of medication nonadherence 8
- Avoidable hospitalization
- Increased use of doctor’s offices, emergency rooms, and urgent care centers
- Increased use of nursing homes, hospice, and dialysis centers
- Avoidable pharmacy costs related to therapy intensification
- Avoidable diagnostic testing
There are many factors that lead to nonadherence: socioeconomic status, health knowledge, the severity of illness and complexity of treatment, the doctor or pharmacist’s communication skills, and more. 9
A useful way to look at these factors is as perceptual versus practical barriers. 12 Perceptual barriers deal with the patient’s beliefs about medication and health, and are more difficult to change. But if we focus on the most common practical factors that delivery can affect, we might organize them within the following categories:
Barriers of place
- Pharmacy deserts (i.e. no convenient pharmacy nearby)
- Patient's insurance requires use of specific, in-network pharmacies
Barriers of situation
- Pharmacy access issues: lack of reliable transportation/parking, language barrier, need for physical assistance
- Patient is homebound
Barriers of time
- Inconvenient pharmacy hours
- Patient has other responsibilities (e.g. work, school, child care) that make it difficult to go to the pharmacy
Barriers of social environment
- Stigma associated with patient’s condition or treatment (e.g. psychotropics, antivirals, medications for opioid use disorder)
- Embarrassment with medication-taking
A patient may struggle with more than one of these barriers, and their challenges will shift over time. None of these are technically insurmountable—a patient who lacks a car might take a bus, for example—but they can introduce just enough complication to make medication less accessible.
This isn’t a far-fetched situation. As research conducted by Evidation and Lyft found, “transportation insecurity may magnify health disparities, and that healthcare inaccessibility for vulnerable populations remains a significant challenge across the United States.” 13 A study of greater Cincinnati, Ohio found that 1 in 8 prescriptions for children were never picked up, and that at least half of those children were in high poverty areas with low transportation access. 14
In addition, a national survey taken between March and July 2020 found:
- People who rated their health as poor were over 10% more likely to miss picking up a prescription than people who rated their health as excellent.
- People with mental health conditions were 15% more likely to miss picking up a prescription than people without.
- People insured through Medicaid were over 25% more likely to miss doses of prescription medication. 15
In short, the sicker, poorer, or more vulnerable a person is, the less likely they are to go to the pharmacy and the less likely they are to take their medication properly. The result? That person’s health worsens further. Their healthcare costs increase. Their community is negatively impacted.
But remember: 50% of all chronically-ill patients in developed countries do not adhere to therapy. That means even patients who are financially secure and have ample access to pharmacy services fail to take their medications appropriately. That’s why habit-based interventions like delivery can make such a difference. 16 By altering patients’ behavior, it is possible to override their unconscious and unintentional nonadherence.
Why adherence matters to hospitals and pharmacies
It’s clear that improving adherence benefits patients. But how does it affect hospitals and pharmacies?
The hospital-to-home care transition is a tricky one and, unfortunately, is a large factor in poor adherence (and subsequent rehospitalization). When a patient returns to the hospital less than 30 days after being discharged, the patient, the hospital, and American taxpayers have to pay the price.
This may sound like an unusual scenario, but unfortunately it is not. Back in 2009, the Centers for Medicare & Medicaid Services (CMS) reported, “On average, 1 in 5 Medicare beneficiaries who are discharged from a hospital today will re-enter the hospital within a month… Research has shown that hospital readmissions are reducing the quality of health care while increasing hospital costs.” 17 Over ten years later, hospital readmission rates are still a real concern.
To combat readmission, CMS began using the star rating system, which rates hospitals on a number of quality measures including their readmission rates. A hospital’s star rating is a summary of various measures across seven categories of quality, which are: 18
- Patient experience
- Effectiveness of care
- Timeliness of care
- Efficient use of medical imaging
Based on how well the hospital performs, it is given a star rating from one to five. This is meant to help patients decide which hospital is best for them. Star ratings affect more than a hospital’s reputation, however. In October 2012, CMS began reducing Medicare payments for subsection hospitals with excess readmissions, as measured within a three-year period. 19
By ensuring that patients have their medications in-hand during discharge, hospitals can not only ensure they meet expectations for the star ratings, but also help patients start therapy and remain adherent to their medications. This is essential for patients who have recently been hospitalized or have had surgery. After all, nearly half of hospitalized patients experience at least one medical error after leaving the hospital, and many of those errors involve discharge medications. 2021
This causes a sort of snowball effect: 19
- Patients misuse or never use their discharge medication,
- Patients are readmitted to the hospital,
- Hospital’s rehospitalization rate climbs,
- Hospital performs poorly in the the “Readmission” quality measure,
- Hospital receives a lower star rating,
- Hospital loses funding,
- Quality of care is negatively impacted.
Now that snowball is an avalanche, and whole communities can suffer as a result. To avoid that avalanche, it is key for hospitals to focus on ways they can help patients adhere to their discharge prescriptions.
Most pharmacies operate with razor-thin margins. They are highly motivated to save money and time, and improving adherence helps achieve those goals. As we’ve seen, when patients don’t pick up their medications, their health suffers. But the pharmacy is impacted too.
After a certain period of time—usually two weeks—an abandoned prescription is returned to stock (RTS). For an experienced pharmacy technician and pharmacist, this process is quick: 22
Less than one minute to retrieve the prescription, place the medication back in the stock bottles, and destroy any labels or packaging
10 seconds to QA the RTS process
But those numbers don’t reflect the real time and effort that is lost on RTS.
The prescription was initially filled, after all. While the time spent dispensing a medication ranges depending on customer and workflow, the average process takes longer than the RTS process: 22
For refills, the tech may take about two minutes to dispense the med, and the pharmacist will take a minute to review it
For new prescriptions, the tech may take about four minutes to dispense, and the pharmacist will take about two minutes to review it
That still might not sound like much. But note what these numbers don’t include:
- Calling the doctor with questions about prior authorization or DAW
- Counseling the patient
- Notifying the patient that their prescription is ready for pick up
- Additional services pharmacy staff may offer, like compounding, adherence packaging, etc.
Studies have estimated the cost per RTS prescription as between $5 and $10, which, multiplied by the 110 million prescriptions abandoned annually, makes for a staggering amount of waste that pharmacies simply can’t afford. 23
Pharmacies have used strategies like medication synchronization to improve adherence and, by extension, reduce waste. When a patient’s medications are all filled at the same time each month, the patient doesn’t have to make multiple trips to the pharmacy and the pharmacy can reduce their cost per prescription. 24
But delivery can ease the patient’s journey and reduce effort for the pharmacy staff even more than interventions like medication synchronization.
Solutions to improve adherence
Pharmacies have been offering delivery for generations, but it wasn’t considered a high-value service until the pandemic hit. As a result, there isn’t much data about the direct impact of prescription delivery on adherence rates, long-term health outcomes, pharmacy costs, or rehospitalization rates. To get a sense of how delivery affects patients’ adherence and health, we must turn to studies of mail-order pharmacies.
Mail-order pharmacies are generally run by pharmacy benefit managers. They have been shown to improve access and adherence. For example, one Kaiser Permanente study demonstrated that stroke patients who received their medications from a mail-order pharmacy were adherent about 74% of the time, whereas patients using a local pharmacy were only adherent about 47% of the time. 25 That’s a significant difference.
But here’s the problem: patients generally don’t like mail-order because it doesn’t meet their needs.
|Mail-order pharmacies||Prescription delivery|
|Control over therapy26||
Mail-order pharmaciesBy not offering patients the chance to express their treatment preferences or even choose when their prescription will be delivered, mail-order can cause patients to feel “less empowered in relation to treatment decisions” and have “negative attitudes towards… therapy and reported lower rates of adherence.” 7
Prescription deliveryPatients can usually choose when and where they’ll receive their prescriptions and have the choice to cancel orders, use prescription discount cards, and enjoy services like medication synchronization or adherence packaging.
|Access to a pharmacist||
Mail-order pharmaciesA recent survey found that 85% of respondents preferred getting prescription drugs from a local pharmacy instead of a mail-order service because they wanted the option to talk to the pharmacist they know and trust. 27
Prescription deliveryPatients still have access to their pharmacist.
Mail-order pharmaciesShipping via ground carriers is the only available service level for mail-order pharmacies. As we saw in late 2020, ground shipping can be dangerously slow. 28 This may be acceptable for refills of maintenance medications, but shipping is not ideal for new drug starts or urgent refills. Patients may end up using mail-order for some of their prescriptions but attempt to pick up others in person, negating the usefulness of mail-order.
Prescription deliveryService levels may include same-day, next-day, on-demand, and/or shipping, but typically can get a prescription to a patient’s home within 24 hours.
Major players in the medication access industry
Unsurprisingly, there are many prescription delivery options for patients, pharmacies, providers, and other healthcare organizations.
Patients can seek out delivery on their own or can ask their pharmacy whether they offer the service.
Pharmacies or health systems can develop their own solution – some small pharmacies simply hire a part-time driver – but partnering with a third party comes with useful benefits. Even businesses with an existing delivery solution may wish to explore their options in order to increase volume, save valuable time, and improve the delivery experience for patients and pharmacy staff.
Regardless, comparing the options is essential before choosing a solution.
- Patient Initiated
- PBM Mail Order
|NimbleRx||Phil Rx||Phox Health||ZipDrug||TaskRabbit||CourMed||Pills2Me|
|Web portal for pharmacy/provider||No||No||Yes||No||No||Yes||No||Yes||Yes|
|Web portal for patients||Yes||Yes||No||No||Yes||-||No||No||No|
Mobile app and/or text notifications for patients
Customer support team for patients/pharmacies
|Price of delivery|
|Free||Free||Free||Free. Only available to Medicare Advantage patients||Cost dependent on Tasker||Free||Free||$7 per delivery||Free|
|Service levels available|
|Generally same-day, but dependent on pharmacy. On-demand in specific cities.||Shipping||On-demand, same-day||Dependent on pharmacy||On-demand|
Same- and next-day
|Any partner pharmacy||Solution selects most efficient partner pharmacy||Solution selects most efficient partner pharmacy||Solution selects most efficient partner pharmacy||Any pharmacy||Any partner pharmacy||Any pharmacy in service area||Any pharmacy in service area||Any partner pharmacy (Independent pharmacies only)|
|California, Washington, Utah, Idaho, Texas. On-demand via Uber Eats in NYC; Chicago; Seattle; Atlanta; Miami; Dallas, Houston, & Austin, TX; and San Diego, Los Angeles, and Orange County, CA.||Nationwide||New Orleans, LA; Tacoma, WA||Less than 50% of states||Over 50% of states (metro areas)||Select cities in Florida, Texas, Arizona, California||Las Vegas, NV||California||Tampa Bay area|
|Security & Tracking|
Real-time tracking (other than shipping carrier tracking)
|Tamper-evident packaging provided||No||No||No||No||No||No||-||Yes||Yes|
|Means of delivery|
|Uber, other couriers||Shipping carriers||Courier companies for urgent deliveries. No solution for non-urgent; pharmacy provides delivery||No solution; pharmacy provides delivery||Independent contractors||Independent contractors||Independent contractors||Independent contractors||-|
|Schedule II medications||No||No||No||No||-||-||No||-||-|
|Patients can pay for prescriptions in the Nimble app.||Currently serving Ochsner health system in New Orleans and MultiCare in Tacoma.||Now owned by IngenioRx, Anthem's PBM.||Volunteer-based program started in response to the COVID-19 pandemic.||"DeliverMyRx" is the BaltoRx mobile app.||Patient needs a paper prescription to get started.|
What about DTC telehealth + digital pharmacy?
As stated previously, in the past twelve months we’ve seen an explosion of direct-to-consumer platforms that combine telehealth services with the convenience of digital pharmacies. These businesses position themselves as a one-stop shop: talk to a doctor online, get a prescription, get it filled, and get it delivered directly to your home.
However, these platforms have their limitations and are not for everyone.
- They are limited in the conditions they treat and medications they provide
- Typically only offer ground shipping, which can delay the patient’s initiation of therapy
- Rarely allow patients to use their insurance coverage, meaning all costs are out-of-pocket and do not contribute to a deductible
- Can only be accessed by the internet, which excludes many patients 30
Convenient for patients with one clearly diagnosable condition that doesn't require lab work
Inconvenient for patients with acute needs, complex therapies, or multiple health concerns
The future of bringing healthcare home
There has been one unexpected outcome of the pandemic: a renewed interest in the patient’s home as the site of care. While this might make us think of doctors making house calls with a black bag in hand, hospital care at home is much more than that.
In March 2020, CMS announced the “Hospitals Without Walls” program, which allowed hospitals to treat patients in other locations while still receiving CMS payments. 31 In November, CMS expanded the program to allow for care in the home. Becoming part of the program isn’t exactly easy, as hospitals need to have the resources to meet a range of qualifications. For example, adequate staffing is essential; each patient must have two in-person visits every day. But as of May 2021, 129 hospitals in 30 states have started offering hospital-level care at home. 32, 33
Generally, these programs are limited to patients with conditions like heart failure, pneumonia, COPD, asthma, and skin infections. Doctor Margaret Paulson, who leads the Mayo Clinic's home care program in rural Wisconsin, said that patients have embraced this new style of care: “to know that they can actually go home and sleep in their own bed and be with their family and have their pets by their side, it's just really reassuring.” 33
There’s no reason that home healthcare can’t expand beyond acute care, though. Mark Prather, MD and CEO of DispatchHealth, sees a lot of opportunities: 34
- Urgent care
- Screenings for many different conditions
- Support, counseling, and monitoring for patients with chronic illness
- Physical/occupational therapy
- Follow-up appointments after surgery or hospitalization
Like telehealth, we predict that home healthcare will be most successful when paired with delivery. But unlike the case of telehealth, delivery providers will need to adapt and expand their services beyond prescription drop-off.
What the future of delivery could look like
- Temperature-sensitive, compounded, or reconstituted medications delivered on-demand as ordered by providers
- Testing supplies dropped off and samples taken back by the courier to a hospital or laboratory
- Nutritionally-appropriate meals delivered to patients at specific times of day
- Paperwork dropped off to be signed and picked up for delivery to the hospital
But as with all healthcare innovations, there are significant challenges to healthcare at home.
We cannot expect widespread adoption until reimbursement for providers and pharmacists is ironed out. 35 For example, telehealth was not available to most Medicare members pre-pandemic because providers were not reimbursed for virtual services. Now, thanks to the CARES Act and changes to CMS policy, telehealth is broadly available to seniors nationwide. 36
We should not have to make patients wait until a global health crisis in order to receive care at home. Luckily, the federal government seems to understand that, and bipartisan support for healthcare at home is growing. During the Senate finance committee hearing, “COVID-19 Health Care Flexibilities: Perspectives, Experiences, and Lessons Learned,” Senator Mike Crapo (R - Idaho) stated, “Whether through telehealth, hospital at home, or other innovative care arrangements, it’s important to find ways to get patients care that best meets their needs and at the lowest cost possible.” 36
Poor data sharing and a lack of coordination between providers, pharmacists, and payers is already a problem in healthcare. Without interoperability, solutions like healthcare at home won’t scale.
In her editorial, “COVID-19 revealed how sick the US health care delivery system really is,” Elizabeth A. Regan, PhD, states that our current healthcare system is an “underperforming conglomerate” that offers a “disjointed set of services that don’t offer a coordinated plan of care.” 37 This is in part because patients’ electronic health records are not yet universally available at the point of care. The lines of communication between providers, pharmacists, and payers break down all too easily.
When we are sick, working is hard and learning is harder still. Illness blunts our creativity, cuts out opportunities. Unless the consequences of illness are prevented, or at least minimized, illness undermines people, and leads them into suffering, despair and poverty.
Kofi Annan, Secretary-General of the United Nations on the release of the Report of the Commission on Macroeconomics and Health, December 20, 2001 7
Last year, we ended our industry report with the words, “reliable prescription delivery must become the new normal.” We still believe that.
After all, COVID-19 isn’t the only obstacle to medication access. Patients will continue to struggle with adherence long after the pandemic. That’s why interventions like prescription delivery will continue to be essential.
Our patient narratives make it clear: regardless of background, age, health status, insurance coverage, or reasons for choosing delivery, all patients invariably benefit from greater medication access. Yet there is still work to be done to ensure our solutions are equitable and beneficial for all patients. As the industry currently stands, healthcare is actually becoming more complex as patients begin receiving care and medications from a variety of sources. 38
Back in 2003, the WHO report on adherence stated that in order for global health outcomes to improve, “changes to health policy and health systems are essential.” 9 That means healthcare – especially for for chronic illness – needs to pivot “away from a system that is focused on episodic care in response to acute illness towards a system that is proactive and emphasizes health throughout a lifetime.” 7 Eighteen years have passed, and we haven’t reached that goal.
All of us in the healthcare industry need to push for more continuous, proactive, value-based care. We need to pursue interoperable solutions and partnerships, not acrimonious competition. We need to ensure providers and pharmacists are reimbursed properly for their services and consultation.
Because when we ease the patient’s journey, give them a role in their own care, and improve collaboration between providers, pharmacists, payers, pharmaceutical companies, and patients, we all win.
We can get started by bringing healthcare home through prescription delivery.
- When a patient takes a medication exactly as prescribed (i.e. correct dose, correct administration, correct duration of therapy).
- Physical pharmacy stores. These may also use a website, patient portal, phone line, or app to conduct business, but largely depend on customers coming into the store.
- Chronic condition/illness
- A long-term disease or condition, variously defined as lasting at least 3-12 months, and requiring ongoing care or therapy.
- Pharmacies without physical locations that conduct business entirely online.
- Maintenance medications
- Prescriptions taken at regular intervals (usually daily) to treat chronic conditions.
- Over-the-counter, that is, not prescribed.
- Pharmacy benefit manager. Third-party companies that manage patients' prescription drug benefits on behalf of an insurer.
- Prior authorization
- Approval from the health plan or PBM that is required for payment of certain medications.
- Payments made to a pharmacy after a prescription is billed to the patient's PBM and the PBM accepts the claim.
- Return to stock (RTS)
- When prescriptions are dispensed but not picked up by the patient, the medication must be put back into stock containers. Some states have strict guidelines on returning to stock to ensure labels are appropriately destroyed and batches of medication are not mixed.
- Service levels
- In regards to delivery, the turnaround time from delivery request to completion. Service levels could include on-demand, same-day, next-day, shipping, expedited shipping, etc.
- Delivery completed by the USPS or other package carriers and transported by ground or air.
- Healthcare and health consultations delivered via telephone, online portal, or other telecommunications means.
Rear Admiral Pamela Schweitzer
Rear Admiral Pamela Schweitzer (retired) served as Assistant Surgeon General and Chief Professional Officer of Pharmacy for the United States Public Health Service. She remains active in all things healthcare and is particularly invested in expanding rural healthcare access.
Sloane Salzburg, MS
Sloane Salzburg serves as Vice President of Horizon Government Affairs, Executive Director of the Campaign for Transformative Therapies, and Vice President of the Council for Affordable Health Coverage.
Anup Salgia, DO
Dr. Anup Salgia is an emergency physician, informaticist, and healthcare strategist with 20+ years of healthcare experience. He is passionate about realizing success in early-stage companies, especially those in his home state of Ohio.