Meeting Patients Where They Are

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.

Hospitals

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

• Mortality
• Safety
• Readmission
• 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

1. Patients misuse or never use their discharge medication,
2. Patients are readmitted to the hospital,
3. Hospital’s rehospitalization rate climbs,
4. Hospital performs poorly in the the “Readmission” quality measure,
5. Hospital receives a lower star rating,
6. Hospital loses funding,
7. 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.

Pharmacies

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

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

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.

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.

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.

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