Tackling the Adherence Problem: Community Pharmacists Offer Solutions

1. Tackling the Adherence Problem: Community Pharmacists Offer Solutions

2. The Adherence Problem • For years, emphasis has been placed on the problem of medication non-adherence • $290 billion a year in direct and indirect costs = 13% of total health care spend • 125,000 deaths that result from not taking medication correctly • 69% of medication-related hospital admissions due to poor adherence • 50% of new statin patients will discontinue medication after 6 months NEHI. Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. 2009 World Health Organization. Adherence to long-term therapies: Evidence for action. 2003 Benner JS, Glynn RJ, Mogun H. Long-term Persistence in Use of Statin Therapy in Elderly Patients. JAMA. 2002;288(4):455-461

3. Impact of Medication-Related Problems

4. It’s Time to Bring Solutions • Transformation of health care delivery with focus on quality • 75% of total health care spending on chronic disease, imperative to improve adherence rates • Medicare, one of the nation's largest payers, has demonstrated its commitment to adherence: • Adherence factored into of the Part D plan ratings program • Pro-rated cost sharing to promote synchronization of refills • Pharmacists have the capability and opportunity to improve adherence that can achieve the ‘triple aim’ of: • Better care • Better health • Lower costs

5. Why Community Pharmacists? • Trusted medication expert • Maximize medication use for optimal outcomes • Most accessible provider in community • Key touch point throughout continuum of care • Last health care professional seen by patient before medications are taken Gastroenterologist Cardiologist Allergist Dentist PHARMACIST ER Primary Care Physician Gynecologist Dermatologist

6. How Can Community Pharmacists Help? • Addressing barriers to medication adherence: • Health Literacy • Translating medication information in a patient-friendly manner • Counseling on interactions, side effects • Cost • Identifying cost-effective alternatives that are clinically appropriate • Generic medications dispensed by independent pharmacies: 72% • Disease State Management • Offering patient care services that help manage chronic diseases through effective medication use • Regimen Complexity • Packaging, refill reminders, reduced dosing frequency • Refill coordination

7. Effective Communication is Key • Independent community pharmacists are a vital link between the patient and the entire health care system • Uniquely positioned to complete the triad of care as they communicate with patients and collaborate with physicians and other health care professionals Patient • Improved: • Communication • Patient understanding • Medication adherence • Quality of care • Health outcomes Pharmacist Physician

8. Taking Care of Patients Takes Teamwork • Pharmacists often contact prescribers to make recommendations and improve medication therapy for their patients • Independent community pharmacists consult with physicians or other health care professionals about 7 times daily regarding prescription drug therapy • Approximately 93 percent of independent community pharmacists recommend brand to generic drug changes when appropriate to other health care professionals

9. Patients Are Our Priority • 78% of independent community pharmacies indicate they offer at least one disease state management service or medication therapy management • Top five services offered: • Immunizations • Blood pressure monitoring • Diabetes training/education • Smoking cessation • Cholesterol monitoring

10. The Power of MTM • Medication Therapy Management (MTM): • Personalized, comprehensive reviews that can: • Optimize the clinical benefits of patients’ medications (prescription and OTC) • Reduce the risk of adverse drug events, drug interactions, and the potential for side effects • Increase patient adherence to prescribed regimens through education and counseling • Identify more cost-effective alternatives • Study comparing MTM interventions found drug costs decreased for those who received service from community pharmacists, decreased somewhat for patients who received service from a call center pharmacist, and were unchanged for those who received MTM via educational mailings. Winston S, Lin Y. Impact on drug cost and use of Medicare Part D of medication therapy management services delivered in 2007. J Am Pharm Assoc. 2009;49(6):813–820.

11. Ounce of Prevention Worth a Pound of Cure • The Asheville Project: Community-based, pharmacist-directed, medication therapy management (MTM) program provided for several employers in Asheville, N.C. • Assessment of the clinical and financial outcomes of a long-term, pharmacist-driven MTM program for patients with hypertension and/or dyslipidemia found: • Clinical improvements sustained as long as 6 yrs • Approximate threefold increase in cardiovascular (CV) medication use but CV-related medical expenses decreased by 46.5% • Savings due to lower CV-related medical costs exceeded blood pressure/lipid medication and program costs by 12.6% Bunting BA, Smith BH, Sutherland SE. The Ashville Project: Clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008; 48 (1):23–31

12. Don’t be Penny Wise and a Pound Foolish • The Minnesota Experience: Objectives • Provide medication therapy management (MTM) services to patients • Measure clinical effects associated with provision of MTM services • Measure percentage of patients achieving clinical goals for high blood pressure and high cholesterol compared to control group not receiving MTM services • Compare patients’ total health expenditures for the year before and after receiving MTM services Isetts BJ, Schondelmeyer SW, Artz MB. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. J Am Pharm Assoc. 2008; 48 (2):203–211

13. Getting the Biggest Bang for Your Buck • Results from the Minnesota Experience: • Clinical Benefit: MTM intervention group had a higher percentage of patients meeting goals for hypertension and cholesterol management vs. control group • Hypertension (71% vs. 59%) • Cholesterol (52% vs. 30%) • Economic Benefit: • Per person total health expenditures decreased from $11,965 to $8,197 • Overall reduction in total annual health expenditures exceeded cost of providing MTM by more than 12 : 1 Isetts BJ, Schondelmeyer SW, Artz MB. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. J Am Pharm Assoc. 2008; 48 (2):203–211

14. Spend a Little—Save a Lot Studies have found that increased pharmacy spending (due to increased adherence) resulted in significantly fewer hospitalizations and significantly lower health care costs – these savings are increased for patients over age 65. Benefit-to-Cost Ratios: Congestive Heart Failure: 8.4:1 Diabetes: 6.7:1 High Blood Pressure: 10.1:1 High Cholesterol: 3.1:1 Roebuck MC, Liberman JN, Gemmill-Toyama M, Brennan TA. Medication adherence leads to lower health care use and costs despite increased drug spending. Health Affairs 2011;30(1):91-99.

15. Spend a Little – Save a Lot More trips here can mean • Greater prescription medication access and proper utilization can reduce health care costs, such as hospitalizations • Congressional Budget Office estimates that a 1 percent increase in the number of prescriptions filled by beneficiaries would cause Medicare’s spending on medical services to fall by roughly one-fifth of 1 percent. Fewer visits there Offsetting Effects of Prescription Drug Use on Medicare’s Spending for Medical Services. Congressional Budget Office. November 2012

16. Not Rocket Science, Just Keep It Simple • Complex regimens with multiple prescriptions negatively impact patient adherence • Patients who make visits to a variety of pharmacies (mix of chains, mail order, independents) and those who fill fewer medications per visit (less refill consolidation) are substantially less adherent to their prescribed therapy • Medication use and prescription filling for patients with multiple chronic conditions can be complex, and strategies to reduce this complexity may help improve medication adherence Choudhry NK, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, et al. The implications of therapeutic complexity on adherence to cardiovascular medications. Arch Intern Med 2011;171(9):814-822

17. There’s No Place Like (a Pharmacy) Home • Adherence improvement can begin with increasing refill consolidation at individual pharmacies • Having a “pharmacy home” to serve as a central medication information hub can simplify access, improve safety and ultimately adherence Choudhry NK, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, et al. The implications of therapeutic complexity on adherence to cardiovascular medications. Arch Intern Med 2011;171(9):814-822

18. Simplify My Meds • Adherence can be improved when patients coordinate refills (“refill synchronization”) at a single pharmacy • Nearly 600 community pharmacies participating • Facilitates improved adherence by: • Reducing the potential for gaps between refills • Reducing medication-related hospital readmits • Providing mechanisms to identify non-adherence

19. Win-Win-Win • Community pharmacists are best positioned to positively influence patient medication adherence that will: • Improve care with high-touch, face-to-face counseling • Keep patients healthier in their communities • Lower overall health care costs by reviewing medications for the most cost-effective therapies, and reducing or preventing hospitalizations in the long run