Ms. Heinze is a freelance writer based in Vancouver, British Columbia.
Major players in the pharmaceutical industry are also beginning to step up their efforts in this area, notes Daniel Garrett, RPh, MS, formerly senior director of medical adherence programs at the APhA Foundation and now executive director of the American Health Care Foundation. "Pharma's strategy is to improve awareness that adherence leads to lower overall health care costs," he said, citing GlaxoSmithKline's support for the Diabetes 10-City Challenge. Insurance carriers and pharmacy benefit managers, too, are starting to warm up to the idea that adherence is actually a cost-effective measure. "It wasn't too long ago that one of the reasons we had rising copays was because people were alarmed about how much money they were spending on medication," Garrett said. "Now we are starting to see some programs that promote adherence." He cites North Carolina Blue Cross/Blue Shield as an example of a carrier that has decreased its copays for medications targeting certain conditions, such as diabetes. Humana and others are also striving to promote awareness that adherence, in fact, does make a difference.
Pharmacists' proximity to the patient, however, puts the bulk of adherence promotion on their shoulders. Whereas certain programs like the Asheville Project offer reimbursement for counseling services, "right now, pharmacists do not get reimbursed for taking the time to sit down with people routinely," Garrett said. "When programs have been put in place and pharmacists have been paid for that time, we see dramatic improvements in adherence-not only in taking medications, but also in relation to lifestyle changes-and it contributes significantly to the bottom line."
Garrett argues that adherence promotion offers a significant opportunity for pharmacists to increase sales, and, thus, profitability. "If we know that 50% of people with chronic conditions aren't taking their medicine as prescribed, if they have efforts to improve adherence they have the opportunity to double sales," he said. "The business incentive is there, because they do make money when they fill prescriptions."
The sticking point is the issue of time: pharmacists are already fulfilling demanding workloads, and many wonder where they will find the hours to provide the patient counseling that adherence programs demand. To get around this, some are turning to technology as a way of expediting the prescription- filling process, freeing up time that would have otherwise been spent on filling orders manually.
"The key here is to free pharmacists' time up from one component of their work-it may be related to dispensing- and move that time over to the cognitive or counseling part of their work," said Michael Murray, PharmD, MPH, professor and chair of pharmaceutical outcomes and policy at the School of Pharmacy, University of North Carolina at Chapel Hill.
Pharmacists also can employ software to set up automated refill systems, suggests Stacey Swartz, PharmD, director of management and educational affairs at the National Community Pharmacists Association. "This can result in stable prescription volume and more manageable workflow," she noted. Additionally, some pharmacies have implemented antibiotic callback lists, which enable pharmacists or technicians to track those who have recently claimed a prescription for antibiotics. Swartz said that this serves as a marketing tool because, "patients know their pharmacist cares about them and can encourage good compliance with antibiotic regimens, which patients may be tempted to stop early."
Those active in the promotion of adherence emphasize that the most crucial element is the relationships that patients share with their caregivers. "What we have learned in Asheville and at the sites around the country with the patient selfmanagement program and the Diabetes 10-City Challenge is that it's really a personal relationship with a care provider that encourages patients to take their medicine," Garrett said. "You can put up billboards, you can have Internet Web sites, and you can send people mailings, but what really works is when there is a personal relationship."
Murray points out that each patient is different, requiring pharmacists to tailor their counseling accordingly. "There is the patient who is the busy person, for example, who wants to get in and get out without much counseling. How does a pharmacist handle that, when they really need to spend more than a few minutes with the patient, and neither one of you has the time?" It may require scheduling a follow-up call to go over adherence instructions or some other way of communicating this information, he adds.
Bruce Berger, PhD, professor and head of pharmacy care systems at Auburn University in Auburn, Alabama, argues that patient counseling leads to results only when the case is assessed thoroughly. "We are in an age where we think that just giving information is enough," he said. "We load patients up with things like: here's how to take this drug, here is what it is, it's for your diabetes, take it once a day, and then we think we've done our job. My retort to that is: if information were enough, nobody would smoke."
Berger applies a motivational approach, based on methodologies taught at Auburn's Motivational Interviewing Training Institute. The philosophy is simple: unless caregivers understand why a patient is not taking his or her medicine, there is little they can do to change this behavior. "If you've got a person in front of you who is not taking their medicine, and you start telling them why they need to, they're going to tell you why they won't," he said. "Even if they present a prescription, it doesn't mean that they are ready to do anything. We have patients who come into the pharmacy, and we never assess how ready they are to do any of this. What do they see as the benefits of doing it? What is going to get in their way of being able to do this?" Assuring a patient that their doctor would not prescribe an ineffective medication, Berger says, is not enough.
The following Web sites can provide more information on patient adherence programs:
Any health care provider who strives to improve adherence-especially for chronic, asymptomatic illnesses-must assess the patient's understanding of that condition, explain how the treatment works, and discern how confident the patient really is in the treatment itself, Berger underlines, adding that this requires regular follow-up. "Case management is doing this," he said. "If we don't do this, we are not going to be able to significantly change outcomes. Ultimately, if pharmacy cannot show that the use of medicine reduces total cost of care, we're not going to get paid for it."
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