The prescription pickup lag, an automatic prescription refill program, and community pharmacy operations

Impact of health system specialty pharmacies on total cost of care in cancer treatment, a multisite review

INTRODUCTION

Integrated delivery networks can use medically integrated dispensing of oral oncolytics on site through health system specialty pharmacies. There is little published research examining cost savings. Our objective was to demonstrate the financial value of health system specialty pharmacies among patients receiving oral oncolytics dispensed through fully, partially, and non-integrated dispensing strategies.

METHODS

This was a retrospective cohort study of adult patients from Symphony Health's Integrated Dataverse® repository who filled a prescription for an agent of interest from 7/1/16-6/30/20 that was written within 25 US health systems. Outcomes included costs, healthcare resource utilization, and duration of therapy.

RESULTS

In total, 36,816 patients were included; 986 patients (2.7%) integrated, 1,822 (4.9%) partially integrated, and 34,008 (92.4%) non-integrated. Mean 6-month medical charge and oncolytic prescription costs were lower for the integrated group ($36,831; $55,786) than the partially integrated ($46,304, p = 0.053; $63,295, p = 0.071) and non-integrated groups ($54,261, p < 0.001; $65,005, p = 0.004). In most healthcare resource utilization categories, the integrated group had the lowest patient percentage utilizing medical care. Duration of therapy was lower on average by ∼3 months in the integrated vs non-integrated group, which may represent closer monitoring of patient medical records and need for fills vs autoship practices.

CONCLUSIONS

Patients receiving oral oncolytics through medically integrated dispensing at health system specialty pharmacies may have lower medical and pharmacy costs and decreased healthcare resource utilization. This study adds to the growing body of literature supporting integrated delivery networks and integrated dispensing. Further research is needed to demonstrate the value of medically integrated dispensing through health system specialty pharmacies in the delivery of treatment to patients with cancer and other high-cost diseases.

Beyond the reminder: The next steps in pharmacist-driven, mHealth patient engagement

OBJECTIVE

To describe opportunities for pharmacists to use mobile messaging and real-time monitoring to engage with patients taking long-term medications.

SUMMARY

The proliferation of mobile phone use across the United States has been met with increased application of these devices by the medical community. However, beyond simple text messages and app-based functions, use of these devices by pharmacies and pharmacists has not been leveraged to improve patient outcomes, such as medication adherence. Resources now exist that can facilitate more advanced mobile communication between patients and pharmacists, which can be managed and informed by data available in most pharmacies. Such tailored messaging can be personalized further by being reactive to patient behavior using real-time medication use monitoring tools, facilitating low-cost, high-reach interventions for patients in need of ongoing guidance.

CONCLUSION

Mechanisms now exist for pharmacies to engage patients more proactively with their prescribed therapy using mobile communication and devices. By facilitating such engagement, pharmacists can remain connected with patients throughout their care, better interpret their needs, navigate adherence-related issues, and more holistically counsel patients based on observed behaviors. Community pharmacy leadership should pursue the use of these advanced mobile messaging techniques as another tool in their arsenal to improve patient outcomes.

Community health integration through pharmacy process and ergonomics redesign (CHIPPER)

As the expansion and utilisation of community pharmacy systems increases, so does the risk for an adverse drug event to occur. In attempts to mitigate this risk, many community pharmacies implement health information technology (IT); however, there are challenges in integrating the wider systems components necessary for a successful implementation with minimal unintended consequences. The purpose of this paper is to introduce a Community Health Integration through Pharmacy Process and Ergonomics Redesign (CHIPPER) framework, which explores the multiple angles of health IT integration to support medication delivery processes in community pharmacy systems. Specifically, CHIPPER identifies the information flows that occur between different parts of the system (initiation, upstream, midstream and downstream) with varying end-users and tasks related to medication delivery processes. In addition to the justification and presentation of the CHIPPER model, this paper reviews several broad applications for CHIPPER and presents two example studies that demonstrate the CHIPPER framework. Practitioner Summary: Most medication delivery in the US occurs through outpatient-based community pharmacy practice. Community pharmacies are challenged by inconsistent and incomplete information flow and technology integration between providers, pharmacy practitioners and patients. This paper presents a framework for improved healthcare systems engineering analysis of pharmacy practice, with case study examples.

Assessment of the rates and characteristics of the short-term supply of medication (Tider) from an integrated healthcare delivery system in the United States

Objectives:

The purpose of this study was to describe the rate of medication short-term supply dispensings (tider), patient and medication characteristics associated with a tider, and costs for tider dispensings in an integrated healthcare delivery system in Colorado, United States.

Methods:

This was a retrospective study conducted in an integrated healthcare delivery system’s outpatient clinics. All patients who had a prescription dispensed for a study medication at any of the system’s 28 outpatient pharmacies during the first quarter of 2016 were included. A tider was identified as a 3-day supply of a prescription medication that was dispensed at no charge to a patient. The quarterly tider rate and the per member per month (PMPM) cost of tiders were estimated. Patient and medication characteristics associated with a tider were assessed.

Results:

A total of 444,225 study medications were dispensed for 135,907 patients during the study period. There were 3,430 (0.77%, 95%CI 0.75%:0.80%) medications dispensed as a tider. The PMPM cost of tider medications and their dispensing fees was USD 0.03. There were 1,092 (0.8%) and 134,815 (99.2%) patients who did and did not, respectively, have at least one tider dispensed during the study period. Patient characteristics strongly associated with having had a tider dispensed included being older, male, and a Medicare beneficiary. Cardiovascular and neuromuscular medications had the highest rates of tider dispensing.

Conclusions:

The rate of tider dispensing was relatively low; however, approximately one out of 125 patients had at least one tider. Patients who had a tider were more likely to be older, female, a Medicare beneficiary, and having had a previous tider dispensing and a higher burden of chronic disease. The tider medication was more likely to be a cardiovascular or neuromuscular medication class and more likely to be dispensed on a weekend. The total cost of dispensing a tider appears reasonable since the benefits of providing patients with needed medications likely outweigh the cost. Future studies should be performed to assess the impact of tider dispensing on health outcomes.

Is the Currently Used Prescription Adjudication Date a Good Proxy for Calculating Medication Refill Adherence?

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) adopted the proportion of days covered (PDC) calculation for use in their Five-Star Quality Rating System for Medicare Advantage and Prescription Drug Plans. This calculation uses the prescription adjudication date (i.e., date the prescription is billed to the benefits manager by a pharmacy) as a proxy for medication adherence. Adherence programs, such as automatic refill programs, have become commonplace in community pharmacy and have been identified by industry leaders as interfering with the ability to accurately measure adherence using PDC.

OBJECTIVE

To evaluate the prescription pickup date instead of the currently used adjudication date to calculate PDC in the presence of a community pharmacy automatic refill program.

METHODS

This study used a post-only quasi-experimental design with patients aged 65 years or older enrolled in automatic and manual refill programs in a 29-store community pharmacy chain during 2014. PDC was calculated using the prescription adjudication date and pickup date (i.e., date the patient brought the medication home) using pharmacy dispensing data for CMS adherence metrics medications, including statins, renin angiotensin aldosterone system antagonists (RASA), and noninsulin diabetes medications. Mann-Whitney U and effect size calculations evaluated differences in PDC between automatic and manual refill prescriptions for the adjudication date and pickup date, as well as the difference in PDC between adjudication and pickup date.

RESULTS

10,936 prescriptions were included with 21.9% enrolled in the automatic refill program. Mean (SD) adherence was 88.6 (17.6) and 86.4 (17.1) for automatic refills and 85.8 (19.0) and 85.0 (18.9) for manual refills, using the adjudication date and pickup date PDC, respectively. Significant difference existed between automatic and manual refill prescriptions using the adjudication date (P < 0.001) but not for the pickup date. The difference between adjudication and pickup date PDC ranged from 0% to 32.0% for automatic refills and 0% to 38.7% for manual refills. The difference between adjudication and pickup date PDC was significant when comparing automatic and manual refill prescriptions (P < 0.001).

CONCLUSIONS

The artificial inflation seen with adjudication date PDC indicates that the prescription pickup date is a more accurate reflection of patient medication taking. Automatic refills resulted in a less reliable PDC compared with manual refill prescriptions. Discussion about the continued use of the adjudication date to calculate PDC is needed.

DISCLOSURES

The project described was supported by the Clinical and Translational Science Award (CTSA) program through the NIH National Center for Advancing Translational Sciences (NCATS), grant UL1TR000427. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Lester is employed as a pharmacist in the pharmacy chain that participated in this study. The authors report no other relevant conflict of interest. Study concept and design were contributed primarily by Lester, along with Look and Chui. Lester took the lead in data collection, along with Look, and data interpretation, along with Look and Chui. The manuscript was written and revised primarily by Lester, along with Look and Chui.