The Business Case: Formal Adherence Service in the Community Pharmacy

Directions in Pharmacy, May 2015, Volume 2, Issue 2

A business model focused on medication synchronization can boost adherence and profits.

A business model focused on medication synchronization can boost adherence and profits.

The traditional, reactive approach to pharmacy, in which workload is dictated by patient calls and visits to the pharmacy, may be neither the optimal way to assist patients nor the best way to do business. It can create unnecessary risk for patients and stress for employees, and result in missed opportunities to grow sales volume and income. Consider a business model that turns the traditional model on its head and leads to immediate, measurable, and sustained benefits. Two examples of this model are presented here. This model liberates pharmacists from the knee-jerk process they have used for years and improves patient satisfaction and outcomes. In addition, it has led to the doubling of prescription volume without having to add any patients and makes the pharmacist accountable for outcomes.

This model also galvanizes the established, but still vastly underutilized, medication synchronization model by taking it one step further. Take a look at how small changes can significantly affect the bottom line.

Moving Away from Tradition

Consider the patient’s role in the traditional reactive pharmacy model. Some patients plan well, while others show up to fill prescriptions randomly or not at all. The result is an unorganized work process with busy periods verging on chaos alternated with periods of downtime. Routine requests that could be managed easily during slow periods—patients who need prescriptions immediately or report adverse effects or problems with dosage forms or schedules when they request or pick up refills—become emergencies when they present during busy spells. In addition, when left to their own devices, most patients who need refills every 28 to 30 days order refills every 37 to 45 days. That is approximately 8 prescription fills annually, leaving 4 months of time during which the patient has no medication.

A second business stressor is the other customer: physicians and other prescribers who write, fax, e-mail, or call in prescriptions. In most cases, the prescriber’s office staff makes the call, so if there are problems with the prescription, a callback is required and the patient must wait. On the other hand, if a patient reports a problem and the pharmacist calls the prescriber, the likelihood is that the prescriber is with a patient and will need to call back, resulting in additional wait time.

The third business stressor is insurance, specifically prescription drug riders. Pharmacy staff deal with an endless number of potential prescription coverage problems, all of which require communication with the insurer. This is rarely a simple process. Patients may not achieve expected or best outcomes when they are nonadherent and may become frustrated or angry. Prescribers, unaware that adherence could be a concern, may adjust the dosing, creating safety issues if patients suddenly become completely adherent. Insurers have little empathy for pharmacists who struggle with constantly changing formularies and patient-unique problems.

Finally, in the reactive model, the pharmacy’s work flow is unpredictable, stressful, and noisy. Undoubtedly, few pharmacists possess a skill set that allows them to organize so many stressors cheerfully, seamlessly, and successfully. The resultant chaos creates an increased risk of error.

Adherence-Focused Medication Synchronization

The root of the problem is that many patients with chronic diseases who take multiple medications are ill-equipped to manage their prescriptions and conditions. In retail, 10% of patients create roughly 75% of each store’s business. Organizing that 10% of patients can make an enormous difference in a pharmacy’s work flow.

Shipping 90-day supplies of medication has been offered by some stakeholders as a solution to nonadherence. In reality, the patients who receive 90 days of supplies are the least adherent group. For many patients, nonadherence is unrelated to access. These patients need frequent, individualized touchpoints to help them stay on track.

Tyson Drug Co in Holly Springs, Mississippi, identified medication synchronization with optional formal adherence interventions as an ideal organization method and currently manages 700 to 800 lives through their program. Pharmacy staff offers patients the choice of medication synchronization at 1 of 3 locations or a more intense program at a fourth pharmacy. Medication synchronization schedules prescription fills so the patient picks up all refills on the same day. When a patient adds a new prescription, the pharmacist provides a partial fill to synchronize the new medication’s later refills with other refills.

The next step, scheduling patients an appointment to talk to a pharmacist, is a beneficial change to the traditional model. Tyson Drug Co pharmacy staff schedule unhurried telephone calls to patients every 28 days so they have direct contact with patients 13 times annually. Other pharmacies often use a monthly, or 12-fill-per-year schedule.) Compared with the traditional model, these touch points are a considerable improvement: patients are guaranteed to talk to a pharmacist, and when they do, it is during a pressure-free period of time. The pharmacy also calls patients approximately 1 week before their scheduled visit and assesses patient needs. If they identify problems, the pharmacists have ample time to contact the prescriber and make appropriate adjustments or refer the patient back to the prescriber if a visit in needed. This is akin to level 1 medication therapy management.

A subset of any pharmacy’s population needs more focused help and could benefit from a formal adherence program. Tyson Drug Co augments and refines this model at its formal adherence pharmacy, a separate location that provides care specifically for enrolled patients. From 8:30 am to 5:30 pm Monday through Thursday, adherence pharmacy staff prepare patient prescriptions in strip packaging. Staff calls the process “adherence on steroids,” since all medications due at specific dosing times are packaged together. For example, all drugs for 8 am Monday are packaged in 1 large sealed pouch, as are doses for noon Monday, 4 pm Monday, 8 pm Monday, and so on. The premise is that medication synchronization alone does not fix adherence, and the extra step of strip packaging is designed to help patients boost adherence closer to 100%. The shorter work week has conspicuous business management benefits in terms of easier staffing, better employee satisfaction, and reduced pharmacy overhead.

Some strong data demonstrate that the “side effect” of medication synchronization is a better bottom line. A “prescription lift” of 61% over 4 years has been documented through data analysis by Health Mart in partnership with McKesson (see Table). A good portion of this prescription lift came from existing patients. The combination of increasing annual prescription fills from approximately 8 to nearly 13 has an obvious financial benefit for a pharmacy, as pharmacists have been able to identify other opportunities to improve their bottom line. They may identify patients with acute conditions that would respond to medication therapy, or identify untreated or undertreated conditions and refer patients back to prescribers for treatment that often includes medication. These patients, pleased to have the pharmacist’s ear, often ask for and follow advice concerning OTC medications and supplies.

This more sophisticated method improves adherence, although its effect on outcomes is harder to track. A small but very impressive study conducted by a pharmacist in Hawaii who uses the same model indicates that the potential savings to the health care system could be staggering. That colleague looked at medication adherence among 10 random patients enrolled in an adherence program. He compared proportion of days covered based on Ohana Health Plan claims for the 180 days before stating the program with the same calculation for the 180 days after the first adherence filling. Emergency department visits fell from 8 to 3, inpatient admissions fell from 6 to 2, and 30-day readmissions fell from 1 to 0. In addition, he captured institutional costs and found a remarkable decrease in them (see Figure).

Start Slow, Gather Speed

Although the most nonadherent and complex patients benefit most, every patient on maintenance medication could potentially benefit from an adherence program. Medicare Part D started a much-needed and aggressive discussion about adherence and the pharmacist’s role. The Medicare Star Ratings program ties reimbursement to medication adherence greater than 80%, and the incentive for plans to meet this goal is great: the federal government allows plans with the best ratings to market themselves and enroll people year-round. Although current quality measures monitor adherence in several therapeutic categories (eg, statins, renin angiotensin system antagonists, and diabetes medications), limiting oversight to just a few categories is shortsighted.

Clinical improvements aside, this model’s compelling argument for implementation is improved pharmacy efficiency. From a business perspective, pharmacists fill all prescriptions for the same patient simultaneously, which saves time. This streamlines work flow and decreases chaos, increasing safety and decreasing staff stress. Staff also have more time for patients, which creates an opportunity to offer and provide additional services, including immunizations, diabetes supplies, and OTC items. Scheduling patients who used to call or visit with problems makes those patients partners in their own care and allows them to feel heard, thereby improving patient satisfaction.

The Bottom Line

Medication synchronization with a formal adherence element represents the business theory of resource shift. Experience demonstrates that pharmacies that start by synchronizing one patient’s medications tend to add others quickly.

The first impetus is the array of benefits realized by patients and prescribers: improved understanding of medication and its role, earlier identification of problems, and a better overall picture when regulators apply quality measures. Second, at the pharmacy level, the clinical reward of seeing patients become eager partners in improving their health enhances employees’ job experience, decreasing turnover and improving satisfaction. Third, financial rewards accrue quickly as a program’s good reputation attracts additional patients. In Holly Springs, Mississippi, patients who heard about Tyson Drug Co’s more intense adherence program subsequently asked to be enrolled, even if it meant they would need to switch to a different pharmacy location.

Medication synchronization with emphasis on adherence is attracting attention, and most pharmacies would do well to move to this model within the next few years. Early adopters of this innovation— the trendsetters of pharmacy—are thriving, practicing pharmacy to its fullest while reaping financial benefits.

Bob Lomenick, RPh, is the owner of Tyson Drug Company in Holly Springs, Mississippi. He is a graduate of the University of Mississippi School of Pharmacy, where he currently serves on the board of visitors. He is a founding member of the Mississippi Independent Pharmacies Association, where he currently serves as district chair. Lomenick is considered a pioneer in improving adherence through the use of medication synchronization and medication therapy management. He was recognized for his innovative solutions in 2013, when he won the Next Generation Pharmacist Entrepreneur of the Year award.