- Email: [email protected]
Financial impact of patients enrolled in a medication adherence program at an independent community pharmacy
SCIENCE AND PRACTICE Journal of the American Pharmacists Association 58 (2018) S109eS113
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Financial impact of patients enrolled in a medication adherence program at an independent community pharmacy Cody L. Clifton, Ashley R. Branham, Harskin “HJ” Hayes Jr, Joseph S. Moose, Laura A. Rhodes, Macary Weck Marciniak* a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 September 2017 Accepted 10 April 2018
Objectives: To determine the financial impact of attributed patients enrolled in a medication adherence program at Community Pharmacy Enhanced Services Network (CPESN) pharmacies. Setting: Five independently owned Moose Pharmacy locations in rural North Carolina, which are CPESN pharmacies. Practice description: Moose Pharmacy has a longstanding history of innovative change. Each Moose Pharmacy location provides enhanced pharmacy services, including adherence packaging, medication synchronization programs, immunizations, home visits, home delivery, comprehensive medication review, disease state management programs, point-of-care testing, and compounding. Practice innovation: Certain CPESN pharmacies, including Moose Pharmacy, were attributed complex Medicare or Medicaid patients having at least 1 chronic medication and at least 80% of medications filled at a CPESN pharmacy. Patients were included if they were attributed to a study location and enrolled in the Moose Medication Adherence Program (MooseMAP) for more than 12 months. Patients were excluded if they were younger than 18 years of age or had less than 12 months of prescription fill data. Reviewed data included patient demographics, chronic and acute medications, immunizations, MooseMAP type, number of chronic medication prescribers, chronic medication class, payer, and patient health risk indicators. Yearly profit for prescriptions filled was determined per patient. Independent-samples t test was used to assess data. Evaluation: Yearly profit per prescription was $10.35 for combined chronic, acute, and immunization prescriptions, $10.57 for chronic prescriptions, $26.95 for acute prescriptions, and $27.69 for immunizations. Mean profit for strip packaging was $1561.82 per year compared with $1208.01 per year with bottles (P ¼ 0.021). There was a positive correlation between profit and number of prescriptions filled per 12 months (r ¼ 0.56; P < 0.001), number of medication classes (r ¼ 0.27; P < 0.001), and higher-risk indicator scores (r ¼ 0.21; P < 0.001). Conclusion: Enrolling complex patients in a medication adherence program can benefit community pharmacies, particularly CPESN pharmacies, through chronic medication fills and yearly profit. Greater profit is generated when prescriptions are dispensed in strip packaging instead of bottles. © 2018 Published by Elsevier Inc. on behalf of the American Pharmacists Association.
Disclosure: Macary Marciniak declares that her spouse is an employee of the American Pharmacists Association. Cody Clifton, Ashley Branham, and Joseph Moose are employed by CPESN USA. Funding: This work was supported by a $1000 grant from the American Pharmacists Association (APhA) Foundation. The sponsor had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The project described was supported by grant number 1C1CMS331338 from the Centers for Medicare and Medicaid Services, Department of Health and Human Services. The contents of this presentation are solely the responsibility of the author and do not necessarily represent the official views of the U.S. Department of Health
and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor. Previous presentations: American Pharmacists Association (APhA) Annual Meeting & Exposition, March 23e27, 2017, San Francisco, CA; Research in Education and Practice Symposium. May 22e23, 2017, Chapel Hill, NC. * Correspondence: Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, 115G Beard Hall, Campus Box 7574, Chapel Hill, NC 27599-7574. E-mail address: [email protected] (M.W. Marciniak).
https://doi.org/10.1016/j.japh.2018.04.022 1544-3191/© 2018 Published by Elsevier Inc. on behalf of the American Pharmacists Association.
SCIENCE AND PRACTICE C.L. Clifton et al. / Journal of the American Pharmacists Association 58 (2018) S109eS113
Key Points Background: Medication nonadherence is the United States’ number one avoidable health care cost, at an estimated $105 billion annually. Medication adherence programs can help pharmacies to combat low medication adherence, particularly in high-risk populations with multiple chronic medications or conditions, as well as providing an additional revenue stream. Findings: Community-based pharmacies that offer enhanced pharmacy services, such as medication adherence programs, may increase the number of chronic medication fills and profit by managing complex patients with the use of strip packaging compared with bottles. Patients enrolled in medication adherence programs who have a higher number of prescriptions and higher patient risk scores should be prioritized to significantly improve health outcomes and increase profit.
synchronization improved medication adherence and had a positive financial return on investment for patients taking chronic medications.9 As an added benefit, medication optimization through adherence improves health outcomes and decreases overall health care costs.10 A typical independent pharmacy generates more than 90% of its revenue from prescriptions.11 The National Community Pharmacists Association Digest reported that profit per prescription in 2015 remained stable at $11.99. However, over the past 2 years, gross margins for prescription medications have declined.11 For this reason, community-based pharmacies should consider implementing sustainable revenue streams by complementing drug dispensing with enhanced pharmacy services. Limited studies are available that discuss the financial impact of enhanced pharmacy services, such as immunizations. The financial impact of attributed patients to Community Pharmacy Enhanced Services Network (CPESN®) pharmacies enrolled in a medication adherence program is unknown. Objective The primary objective of this study was to determine the financial impact of attributed patients enrolled in a medication adherence program at CPESN® pharmacies. Setting Community Pharmacy Enhanced Services Network Pharmacies
The most significant cause of the increasing health care expenditure in the United States is the rising prevalence of chronic disease. An estimated $1.7 trillion annually, or more than 75 cents of each health care dollar spent, is used to treat chronic disease.1 In 2015, $310 billion was spent in the United States on medications.2 Medication nonadherence is the United States’ number 1 avoidable health care cost, at an estimated $105 billion annually.3 Medication adherence rates for many chronic conditions often range from 40% to 70%, which is well below the preferred 80% threshold preferred by many health plans, adding to health care expenditure.4,5 Studies provide examples of improved health outcomes and a reduction in health care costs for patients with high adherence to chronic medications.6,7 Medication optimization through improved adherence could save $290 billion.2 Medication adherence programs are one mechanism that pharmacies can implement to combat low medication adherence, particularly in high-risk populations with multiple chronic medications or conditions. Pharmacists are well positioned to facilitate this role because patients are estimated to visit their pharmacy several more times per year compared with visiting their medical doctor.2,4 Although some literature supports the claim that automatic prescription refill programs may be beneficial, medication adherence programs may assist in further improving adherence because they provide the patient longitudinal touch points with a pharmacist. Medication adherence programs traditionally include monthly medication reviews, medication synchronization, and packaging. Doucette et al. concluded that some enhanced pharmacy services, including adherence programs and influenza and herpes zoster immunization services, showed a net financial gain.8 In a systematic review by Nguyen et al., appointment-based model
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CPESN was an open network of more than 270 highperforming pharmacies in North Carolina that are dedicated to providing comprehensive community pharmacy care management and reducing total cost of care.2,12,13 CPESN was established by Community Care of North Carolina (CCNC) in September 2014, following receipt of a Centers for Medicare and Medicaid Innovation grant.14 Through the grant, more than 270 North Carolina high-performing pharmacies were dedicated to providing comprehensive community pharmacy care management and reducing total costs of care. Participating CCNC CPESN pharmacies were referred attributed patients, which are defined as “complex patients who are Medicare or Medicaid beneficiaries in the state of North Carolina.”2,12,13 Furthermore, attributed patients were eligible for enhanced services, such as medication adherence programs and immunizations, if they had at least 1 chronic medical condition and filled at least 80% of their chronic medications at a CPESN pharmacy.14 Each attributed patient had a risk score, presented as a value ranging from 1 to 100 (where higher numbers indicate higher risk). Developed with the use of pharmacy fill data, the risk score was used by CPESN pharmacies to triage the provision of enhanced pharmacy services to those most at risk for hospitalization or medication-related problems.15 Early findings indicate that CPESN pharmacies contribute to improved medication optimization because of increased touch points with patients.12 Moose Pharmacy Established in 1882, Moose Pharmacy consists of 5 locations in rural North Carolina, and the company has a
SCIENCE AND PRACTICE Financial impact of a medication adherence program
longstanding history of innovative change. Each Moose Pharmacy location provides enhanced pharmacy services, including adherence packaging, medication synchronization programs, home visits, home delivery, comprehensive medication review, disease state management programs, point-ofcare testing, immunizations, and compounding; there is minimal variation among the sites’ services. Each Moose Pharmacy location is a participating CPESN pharmacy and offers the Moose Medication Adherence Program (MooseMAP), which encompasses synchronization, medication packaging, home visits or in-store visits at enrollment, and monthly calls to ensure that patients are appropriately taking medications and to investigate possible medication-related problems. MooseMAP patients are enrolled in 1 of 2 adherence programs: A) patients with synchronized plus packaged medications in strip packaging; or B) patients with medications that are synchronized and filled in traditional prescription bottles.
Practice innovation Patients were included in this retrospective analysis if they were: 1) a patient attributed to 1 of the 5 Moose Pharmacy locations; 2) enrolled in the MooseMAP program; and 3) had been enrolled in MooseMAP for at least 12 months during the time period of September 2014 through December 2016. Patients were excluded from financial review if they transferred or discontinued the adherence program within the 12-month timeframe, died within the 12-month timeframe, or were younger than 18 years of age. The Institutional Review Board at the University of North Carolina, Chapel Hill, determined that this study was nonehuman subjects research and exempted it from review. Patients were identified by reviewing attribution lists, which were reports of attributed patients provided by CCNC, and patients were confirmed to be within the MooseMAP according to the pharmacy management system, PioneerRx. On their confirmation, a report that details the profit generated per patient was produced within PioneerRx. A nonadherence program control group was not used for the purposes of this study. Profit was determined for each patient; however, the reported value is solely the profit from the prescription on insurance submission, which does not include staffing costs, submission fees, or rebates. Additional data collected include the patient’s age, race, sex, number of acute and chronic medications filled, chronic condition based on chronic medication class, patient risk scores, type of adherence program (i.e., strip packaging or bottles), delivery, payer, and prescribers. Medications were considered to be acute if they were not in a chronic medication class and had less than 6 months of fills within a 12-month timeframe. Classification as an acute or chronic medication was determined at the discretion of the pharmacist. Immunizations were a specific area of interest for data collection, because Moose Pharmacy has focused on increasing immunizations during the past 2 years. The authors wanted to generally assess immunizations given to patients in the MooseMAP and the associated profit. A specific protocol was followed for collecting the data. Strip packaging involves the commingling of medications for 1 dose period (e.g., morning, noon, evening, bedtime) into a single cellophane pack, which is to be consumed by the patient according to the prescribed dosing instructions. Hypertension,
hypercholesterolemia, behavioral health (e.g., depression, anxiety, schizophrenia), diabetes, chronic obstructive pulmonary disease or asthma, and arthritis were selected as the 6 chronic conditions that could be quantified by medication class; this list was derived from a resource provided by the Centers for Medicare and Medicaid Services.16 Classification of chronic conditions based on medications was determined by pharmacists using clinical judgment, because diagnosis codes were not provided. Third-party coverage included Medicare, Medicaid, or both Medicare plus Medicaid; therefore, profit analysis did not include patients with private coverage. Descriptive statistics were used to summarize demographics. Statistical significance was determined at a P value of less than 0.05. Independent-samples t test assessed differences in profit and immunizations administered for patients enrolled in MooseMAP. Pearson correlation was used to determine correlation between profit and number of chronic medication classes and between profit and patient risk score. Data analysis was performed with the use of IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, NY). Evaluation The MooseMAP program had 738 patient enrollees. Of those, 501 (67.9%) were identified as attributed patients and 341 (46.2%) met the inclusion criteria required to be included in the final analysis. Patients had an average age of 62.4 years, received an average of 10 chronic medications monthly, and had an average patient risk score of 75.3. The top 3 health conditions based on chronic medication classes were hypertension, hypercholesterolemia, and behavioral health conditions. Medications were dispensed in bottles (53.1%; n ¼ 181) or strip packaging (46.9%; n ¼ 160). Prescription pick-up occurred on site (44.6%; n ¼ 152) or via delivery (55.4%; n ¼ 189). The most common documented third-party payers were Medicare (61.6%; n ¼ 210), Medicare plus Medicaid (dual eligible; 29.0%; n ¼ 99), and Medicaid (9.4%; n ¼ 32). Profit The mean prescription count (filled and picked up or delivered) per patient per 12 months was 128.34 ± 64.61. Profit per prescription per 12 months was $10.35 for combined chronic, acute, and immunization prescriptions, $10.57 for chronic prescriptions, $26.95 for acute prescriptions, and $27.69 for immunizations. Patients receiving prescriptions in strip packaging generated a mean profit of $1561.82 per year compared with $1208.01 per year with bottles (P ¼ 0.021). There was a positive correlation between profit and the following variables: number of prescriptions filled during the 12-month period (r ¼ 0.56; P < 0.001); number of medication classes (r ¼ 0.27; P < 0.001); and high-risk patients defined by patient risk scores of 75 or higher (r ¼ 0.21; P < 0.001; Figure 1). Immunization administration was significantly higher (P ¼ 0.004) in nondelivery patients (16.0%; n ¼ 55) than in delivery patients (3.0%; n ¼ 10). Practice implications This study suggests that profit was increased because the number of fills increased for patients in a medication S111
SCIENCE AND PRACTICE C.L. Clifton et al. / Journal of the American Pharmacists Association 58 (2018) S109eS113
Figure 1. Patient risk score and profit correlation. Each circle represents a patient. There is a positive correlation (r ¼ 0.21; P < 0.001) between higher-risk patients and profit.
adherence program, which should yield greater adherence because the medications were prepared and dispensed to the patient. This suggests the importance of pharmacies offering enhanced services, such as a medication adherence program. Patients in this study were complex chronically ill patients with a mean yearly profit per patient of $1561.82 for patients receiving strip packaging compared with $1208.01 for those receiving medication fills in bottles. Filling medications in adherence packaging, such as strip packaging, may increase yearly profit per patient by approximately $350. An internal analysis at Moose Pharmacy was performed to compare the cost to the pharmacy to dispense prescriptions in bottles versus strip packaging, which showed that packaging costs were similar for our average complex patient. For this reason, patients are not charged a fee for the service of strip packaging. It is important to note that the number reported for MooseMAP type was reported as the number of patients instead of number of prescriptions. The goal of reporting in this manner is to focus on the patient using a more comprehensive “whole-person” approach that includes enhanced pharmacy services rather than focusing solely on prescription counts. Additional services, such as immunizations, help to ensure that patients are receiving comprehensive care. The most profitable prescriptions filled were acute medications and immunizations. Ensuring that patients receive these medicines at the same pharmacy that fills their chronic medications can assist in closing gaps of care for patients as well as increasing yearly profit for the pharmacy. Furthermore, pharmacists are recognizing the need to provide community-based enhanced pharmacy services, as evidenced by over 1400 community-based pharmacies aggregating as part of CPESN USA's® clinically integrated network. To date, 41 CPESN networks have developed.12 CPESN USA® was formed from learnings from the Centers for Medicare and Medicaid Innovation grant, which expands to highperforming pharmacies in all states and not solely North Carolina. A paradigm shift is occurring in health care as the focus becomes value-based health care instead of volume-based health care. Dispensing prescriptions will remain relevant to community-based pharmacy practice. However, more emphasis will be placed on the quality that comes before and after the dispensing process. There may be implications for S112
community-based pharmacies that offer enhanced services on quality metrics because a comprehensive health care approach is being leveraged to resolve medication-related problems and close gaps in care.12 Behavioral health was the third most prevalent chronic condition in this study, and Medicaid was listed as either the primary or secondary payer in 38.4% of patients. On further research, it was found that 80% of the NC Medicaid recipients with any mental illness were enrolled in the NC Community Care Networks Medical Home.17 This finding supports the claim that pharmacies should ensure that there are structures in place to support behavioral health patients. Providing focused support to this cohort may ensure patient understanding of and adherence to behavioral health medications. Patients who remain adherent to behavioral health medications may increase adherence to medications for additional chronic conditions, such as hypertension or diabetes. This approach may provide mutual benefits for patients and pharmacies, because prescription adherence contributes to both positive health outcomes for patients and an increased yearly profit for pharmacies. Immunization rates were low for both delivery and nondelivery patients; a vaccine status assessment process should be routinely used to ensure that patients are fully immunized against vaccine-preventable disease, secondarily increasing profit per patient to the pharmacy.18 Pharmacy staff should focus on influenza, disease-related, and age-related vaccinations, such as pneumococcal, zoster, and hepatitis type B vaccinations. The present study shows a likely missed opportunity for delivery patients, providing a chance for pharmacy staff to follow up with delivery patients about immunizations during adherence check-ins. This study has several limitations. Determination of profit was limited to dispensing software reports, which do not account for discounts, rebates, direct and indirect remuneration (DIR) fees, or operating expenses. True profit amounts are likely to be different once these factors are considered, because rebates could produce a positive impact on profit and DIR fees could have a negative impact. Personnel expenses were not included; typical personnel costs for a medication adherence program could include a pharmacy technician who operates the strip packaging machine and a pharmacist’s time for verifying strip packaging. This study did not consider the additional profit that attributed patients provide to the pharmacy, such as a per-member per-month payment from the CCNC CPESN payment model, medication therapy management service profit, or profit generated from the provision of other enhanced services. It is possible that patients may have received bottles and strip packaging during the 12 months of data that were collected, because the dispensing software only showed the most recent MooseMAP type. Profit associated with increased risk scores may be due to the increased number of medications, but further analysis is needed. Finally, reimbursement from payers may change over time.
Conclusion Medication adherence programs may increase profit for complex, chronic patients as the number of prescription fills increases. Community-based pharmacies, particularly CPESN pharmacies that offer enhanced pharmacy services (in particular, a medication adherence program), may increase the
SCIENCE AND PRACTICE Financial impact of a medication adherence program
number of chronic medication fills and profit by managing complex patients with the use of strip packaging compared with bottles. Patients with a higher number of prescriptions, and thus higher patient risk scores, should be prioritized to significantly improve health outcomes and increase profit. This research adds to the limited body of literature emphasizing financial impact that attributed patients provide to community-based pharmacies. Acknowledgments The authors thank Community Care of North Carolina, CPESN USA®, American Pharmacists Association (APhA) Foundation, Troy Trygstad, Trista Pfeiffenberger, and Catherine Zimmer for their support. References 1. Kott A, Fruh D. Almanac of chronic disease. The impact of chronic disease on U.S. health and prosperity: a collection of statistics and commentary. Partnership to Fight Chronic Disease. Available at: http://www. fightchronicdisease.org/sites/default/files/docs/2009AlmanacofChronic Disease_updated81009.pdf. Accessed June 13, 2018. 2. Community Care of North Carolina. Community Pharmacy Enhanced Services Network USA (CPESN USA®): integrating pharmacists into the medical home team. Raleigh, NC: Community Care of North Carolina; 2017. Available at: https://www.communitycarenc.org/media/relateddownloads/cpesn-flyer.pdf. Accessed June 20, 2018. 3. QuintilesIMS. IMS Health study identifies $200þ billion annual opportunity from using medicines more responsibly. Danbury, CT: QuintilesIMS. Available at: http://www.imshealth.com/en/about-us/news/imshealth-study-identifies-$200-billion-annual-opportunity-from-using-me dicines-more-responsibly. Accessed August 22, 2016. 4. World Health Organization. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003. Available at: http:// www.who.int/chp/knowledge/publications/adherence_full_report.pdf. Accessed August 22, 2016. 5. Hansen R, Seifeldin R, Noe L. Medication adherence in chronic disease: issues in posttransplant immunosuppression. Transplant Proc. 2007;39(5):1287e3000. 6. Iuga AO, McGuire MJ. Adherence and health care costs. Risk Manag Healthc Policy. 2014;20(7):35e44. 7. Lester C, Mott D, Chui M. The influence of a community pharmacy automatic prescription refill program on Medicare Part D adherence metrics. Am J Manag Care. 2016;22(7):801e807. 8. Doucette WR, McDonough RP, Morman MM, et al. Three-year financial analysis of pharmacy services at an independent community pharmacy. J Am Pharm Assoc. 2012;52(2):181e187. 9. Nguyen E, Sobieraj DM. The impact of appointment-based medication synchronization on medication taking behaviour and health outcomes: a systematic review. J Clin Pharm Ther. 2017;42:404e413.
10. Braithwaite S, Shirkhorshidian I, Jones K, Johnsrud M. The role of medication adherence in the U.S. healthcare system. Avalere; June 2013. Available at: http://avalere.com/research/docs/20130612_NACDS_ Medication_Adherence.pdf. Accessed January 22, 2018. 11. Drug Channels. New data show prescription profits under pressure at independent pharmacies. Available at: http://www.drugchannels.net/2 016/12/new-data-show-prescription-profits.html. Accessed June 18, 2017. 12. Trygstad T. Community pharmacy networks deliver cost-effective care. Popul Health News. 2017;4(5):1e2. 13. Community Care of North Carolina. Community Pharmacy Enhanced Services Network: a primer for primary care providers working with CCNC. Available at: http://www.fightchronicdisease.org/sites/default/ files/docs/2009AlmanacofChronicDisease_updated81009.pdf. Accessed June 13, 2018. 14. UNC Eshelman School of Pharmacy. Achieving better quality and lower costs in Medicaid through enhanced pharmacy services. Available at: https://pharmacy.unc.edu/files/2015/03/Achieving-Quality-and-LoweringCost-in-Medicaid-through-Enhanced-Pharmacy-Services_CMOPP-whitepaper_April-2017.pdf. Accessed June 18, 2017. 15. CCNC Central Office Pharmacy Programs Staff. Care triage is now available within Pharmacehome. Raleigh, NC: CCNC; November 23, 2013. Available at: https://www.communitycarenc.org/media/files/care-triageannouncement.pdf. Accessed September 10, 2016. 16. Centers for Medicare and Medicaid Services. Chronic conditions among Medicare beneficiaries. Available at: https://www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trends-and-Reports/ChronicConditions/Downloads/2012Chartbook.pdf. Accessed August 22, 2016. 17. North Carolina Community Care Networks. Clinical program analysis. Available at: https://www.communitycarenc.org/media/files/roidocument-may-2015.pdf. Accessed June 18, 2017. 18. Rhodes LA, Branham AR, Dalton EE, Moose JS, Marciniak MW. Implementation of a vaccine screening program at an independent community pharmacy. J Am Pharm Assoc (2003). 2017;57(2):222e228. Cody L. Clifton, PharmD, Clinical Pharmacist, Moose Pharmacy, Concord, NC, and Coordinator of Quality Assurance and Best Practices, CPESN USA®; at time of study: PGY1 Community-based Pharmacy Resident, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, and Moose Pharmacy, Concord, NC Ashley R. Branham, PharmD, BCACP, Director of Clinical Services, Moose Pharmacy, Concord, NC, and Director of Network Development and Marketing, CPESN USA®, Raleigh, NC Harskin “HJ” Hayes Jr, PharmD, Assistant Professor, South University School of Pharmacy, Columbia, SC; at time of study: clinical pharmacist, Moose Pharmacy, Concord, NC Joseph S. Moose, PharmD, owner/pharmacist, Moose Pharmacy, Concord, NC, and Director of Strategy and Luminary Development, CPESN USA®, Raleigh, NC Laura A. Rhodes, PharmD, BCACP, Community Practice Engagement Fellow, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Assistant Dean of Experiential ProgramdCommunity, Clinical Associate Professor, and Director, PGY1 Community-based Pharmacy Residency Program, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Financial impact of patients enrolled in a medication adherence program at an independent community pharmacy Cody L. Clifton, Ashley R. Branham, Harskin “HJ” Hayes Jr, Joseph S. Moose, Laura A. Rhodes, Macary Weck Marciniak* a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 September 2017 Accepted 10 April 2018
Objectives: To determine the financial impact of attributed patients enrolled in a medication adherence program at Community Pharmacy Enhanced Services Network (CPESN) pharmacies. Setting: Five independently owned Moose Pharmacy locations in rural North Carolina, which are CPESN pharmacies. Practice description: Moose Pharmacy has a longstanding history of innovative change. Each Moose Pharmacy location provides enhanced pharmacy services, including adherence packaging, medication synchronization programs, immunizations, home visits, home delivery, comprehensive medication review, disease state management programs, point-of-care testing, and compounding. Practice innovation: Certain CPESN pharmacies, including Moose Pharmacy, were attributed complex Medicare or Medicaid patients having at least 1 chronic medication and at least 80% of medications filled at a CPESN pharmacy. Patients were included if they were attributed to a study location and enrolled in the Moose Medication Adherence Program (MooseMAP) for more than 12 months. Patients were excluded if they were younger than 18 years of age or had less than 12 months of prescription fill data. Reviewed data included patient demographics, chronic and acute medications, immunizations, MooseMAP type, number of chronic medication prescribers, chronic medication class, payer, and patient health risk indicators. Yearly profit for prescriptions filled was determined per patient. Independent-samples t test was used to assess data. Evaluation: Yearly profit per prescription was $10.35 for combined chronic, acute, and immunization prescriptions, $10.57 for chronic prescriptions, $26.95 for acute prescriptions, and $27.69 for immunizations. Mean profit for strip packaging was $1561.82 per year compared with $1208.01 per year with bottles (P ¼ 0.021). There was a positive correlation between profit and number of prescriptions filled per 12 months (r ¼ 0.56; P < 0.001), number of medication classes (r ¼ 0.27; P < 0.001), and higher-risk indicator scores (r ¼ 0.21; P < 0.001). Conclusion: Enrolling complex patients in a medication adherence program can benefit community pharmacies, particularly CPESN pharmacies, through chronic medication fills and yearly profit. Greater profit is generated when prescriptions are dispensed in strip packaging instead of bottles. © 2018 Published by Elsevier Inc. on behalf of the American Pharmacists Association.
Disclosure: Macary Marciniak declares that her spouse is an employee of the American Pharmacists Association. Cody Clifton, Ashley Branham, and Joseph Moose are employed by CPESN USA. Funding: This work was supported by a $1000 grant from the American Pharmacists Association (APhA) Foundation. The sponsor had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The project described was supported by grant number 1C1CMS331338 from the Centers for Medicare and Medicaid Services, Department of Health and Human Services. The contents of this presentation are solely the responsibility of the author and do not necessarily represent the official views of the U.S. Department of Health
and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor. Previous presentations: American Pharmacists Association (APhA) Annual Meeting & Exposition, March 23e27, 2017, San Francisco, CA; Research in Education and Practice Symposium. May 22e23, 2017, Chapel Hill, NC. * Correspondence: Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, 115G Beard Hall, Campus Box 7574, Chapel Hill, NC 27599-7574. E-mail address: [email protected] (M.W. Marciniak).
https://doi.org/10.1016/j.japh.2018.04.022 1544-3191/© 2018 Published by Elsevier Inc. on behalf of the American Pharmacists Association.
SCIENCE AND PRACTICE C.L. Clifton et al. / Journal of the American Pharmacists Association 58 (2018) S109eS113
Key Points Background: Medication nonadherence is the United States’ number one avoidable health care cost, at an estimated $105 billion annually. Medication adherence programs can help pharmacies to combat low medication adherence, particularly in high-risk populations with multiple chronic medications or conditions, as well as providing an additional revenue stream. Findings: Community-based pharmacies that offer enhanced pharmacy services, such as medication adherence programs, may increase the number of chronic medication fills and profit by managing complex patients with the use of strip packaging compared with bottles. Patients enrolled in medication adherence programs who have a higher number of prescriptions and higher patient risk scores should be prioritized to significantly improve health outcomes and increase profit.
synchronization improved medication adherence and had a positive financial return on investment for patients taking chronic medications.9 As an added benefit, medication optimization through adherence improves health outcomes and decreases overall health care costs.10 A typical independent pharmacy generates more than 90% of its revenue from prescriptions.11 The National Community Pharmacists Association Digest reported that profit per prescription in 2015 remained stable at $11.99. However, over the past 2 years, gross margins for prescription medications have declined.11 For this reason, community-based pharmacies should consider implementing sustainable revenue streams by complementing drug dispensing with enhanced pharmacy services. Limited studies are available that discuss the financial impact of enhanced pharmacy services, such as immunizations. The financial impact of attributed patients to Community Pharmacy Enhanced Services Network (CPESN®) pharmacies enrolled in a medication adherence program is unknown. Objective The primary objective of this study was to determine the financial impact of attributed patients enrolled in a medication adherence program at CPESN® pharmacies. Setting Community Pharmacy Enhanced Services Network Pharmacies
The most significant cause of the increasing health care expenditure in the United States is the rising prevalence of chronic disease. An estimated $1.7 trillion annually, or more than 75 cents of each health care dollar spent, is used to treat chronic disease.1 In 2015, $310 billion was spent in the United States on medications.2 Medication nonadherence is the United States’ number 1 avoidable health care cost, at an estimated $105 billion annually.3 Medication adherence rates for many chronic conditions often range from 40% to 70%, which is well below the preferred 80% threshold preferred by many health plans, adding to health care expenditure.4,5 Studies provide examples of improved health outcomes and a reduction in health care costs for patients with high adherence to chronic medications.6,7 Medication optimization through improved adherence could save $290 billion.2 Medication adherence programs are one mechanism that pharmacies can implement to combat low medication adherence, particularly in high-risk populations with multiple chronic medications or conditions. Pharmacists are well positioned to facilitate this role because patients are estimated to visit their pharmacy several more times per year compared with visiting their medical doctor.2,4 Although some literature supports the claim that automatic prescription refill programs may be beneficial, medication adherence programs may assist in further improving adherence because they provide the patient longitudinal touch points with a pharmacist. Medication adherence programs traditionally include monthly medication reviews, medication synchronization, and packaging. Doucette et al. concluded that some enhanced pharmacy services, including adherence programs and influenza and herpes zoster immunization services, showed a net financial gain.8 In a systematic review by Nguyen et al., appointment-based model
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CPESN was an open network of more than 270 highperforming pharmacies in North Carolina that are dedicated to providing comprehensive community pharmacy care management and reducing total cost of care.2,12,13 CPESN was established by Community Care of North Carolina (CCNC) in September 2014, following receipt of a Centers for Medicare and Medicaid Innovation grant.14 Through the grant, more than 270 North Carolina high-performing pharmacies were dedicated to providing comprehensive community pharmacy care management and reducing total costs of care. Participating CCNC CPESN pharmacies were referred attributed patients, which are defined as “complex patients who are Medicare or Medicaid beneficiaries in the state of North Carolina.”2,12,13 Furthermore, attributed patients were eligible for enhanced services, such as medication adherence programs and immunizations, if they had at least 1 chronic medical condition and filled at least 80% of their chronic medications at a CPESN pharmacy.14 Each attributed patient had a risk score, presented as a value ranging from 1 to 100 (where higher numbers indicate higher risk). Developed with the use of pharmacy fill data, the risk score was used by CPESN pharmacies to triage the provision of enhanced pharmacy services to those most at risk for hospitalization or medication-related problems.15 Early findings indicate that CPESN pharmacies contribute to improved medication optimization because of increased touch points with patients.12 Moose Pharmacy Established in 1882, Moose Pharmacy consists of 5 locations in rural North Carolina, and the company has a
SCIENCE AND PRACTICE Financial impact of a medication adherence program
longstanding history of innovative change. Each Moose Pharmacy location provides enhanced pharmacy services, including adherence packaging, medication synchronization programs, home visits, home delivery, comprehensive medication review, disease state management programs, point-ofcare testing, immunizations, and compounding; there is minimal variation among the sites’ services. Each Moose Pharmacy location is a participating CPESN pharmacy and offers the Moose Medication Adherence Program (MooseMAP), which encompasses synchronization, medication packaging, home visits or in-store visits at enrollment, and monthly calls to ensure that patients are appropriately taking medications and to investigate possible medication-related problems. MooseMAP patients are enrolled in 1 of 2 adherence programs: A) patients with synchronized plus packaged medications in strip packaging; or B) patients with medications that are synchronized and filled in traditional prescription bottles.
Practice innovation Patients were included in this retrospective analysis if they were: 1) a patient attributed to 1 of the 5 Moose Pharmacy locations; 2) enrolled in the MooseMAP program; and 3) had been enrolled in MooseMAP for at least 12 months during the time period of September 2014 through December 2016. Patients were excluded from financial review if they transferred or discontinued the adherence program within the 12-month timeframe, died within the 12-month timeframe, or were younger than 18 years of age. The Institutional Review Board at the University of North Carolina, Chapel Hill, determined that this study was nonehuman subjects research and exempted it from review. Patients were identified by reviewing attribution lists, which were reports of attributed patients provided by CCNC, and patients were confirmed to be within the MooseMAP according to the pharmacy management system, PioneerRx. On their confirmation, a report that details the profit generated per patient was produced within PioneerRx. A nonadherence program control group was not used for the purposes of this study. Profit was determined for each patient; however, the reported value is solely the profit from the prescription on insurance submission, which does not include staffing costs, submission fees, or rebates. Additional data collected include the patient’s age, race, sex, number of acute and chronic medications filled, chronic condition based on chronic medication class, patient risk scores, type of adherence program (i.e., strip packaging or bottles), delivery, payer, and prescribers. Medications were considered to be acute if they were not in a chronic medication class and had less than 6 months of fills within a 12-month timeframe. Classification as an acute or chronic medication was determined at the discretion of the pharmacist. Immunizations were a specific area of interest for data collection, because Moose Pharmacy has focused on increasing immunizations during the past 2 years. The authors wanted to generally assess immunizations given to patients in the MooseMAP and the associated profit. A specific protocol was followed for collecting the data. Strip packaging involves the commingling of medications for 1 dose period (e.g., morning, noon, evening, bedtime) into a single cellophane pack, which is to be consumed by the patient according to the prescribed dosing instructions. Hypertension,
hypercholesterolemia, behavioral health (e.g., depression, anxiety, schizophrenia), diabetes, chronic obstructive pulmonary disease or asthma, and arthritis were selected as the 6 chronic conditions that could be quantified by medication class; this list was derived from a resource provided by the Centers for Medicare and Medicaid Services.16 Classification of chronic conditions based on medications was determined by pharmacists using clinical judgment, because diagnosis codes were not provided. Third-party coverage included Medicare, Medicaid, or both Medicare plus Medicaid; therefore, profit analysis did not include patients with private coverage. Descriptive statistics were used to summarize demographics. Statistical significance was determined at a P value of less than 0.05. Independent-samples t test assessed differences in profit and immunizations administered for patients enrolled in MooseMAP. Pearson correlation was used to determine correlation between profit and number of chronic medication classes and between profit and patient risk score. Data analysis was performed with the use of IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, NY). Evaluation The MooseMAP program had 738 patient enrollees. Of those, 501 (67.9%) were identified as attributed patients and 341 (46.2%) met the inclusion criteria required to be included in the final analysis. Patients had an average age of 62.4 years, received an average of 10 chronic medications monthly, and had an average patient risk score of 75.3. The top 3 health conditions based on chronic medication classes were hypertension, hypercholesterolemia, and behavioral health conditions. Medications were dispensed in bottles (53.1%; n ¼ 181) or strip packaging (46.9%; n ¼ 160). Prescription pick-up occurred on site (44.6%; n ¼ 152) or via delivery (55.4%; n ¼ 189). The most common documented third-party payers were Medicare (61.6%; n ¼ 210), Medicare plus Medicaid (dual eligible; 29.0%; n ¼ 99), and Medicaid (9.4%; n ¼ 32). Profit The mean prescription count (filled and picked up or delivered) per patient per 12 months was 128.34 ± 64.61. Profit per prescription per 12 months was $10.35 for combined chronic, acute, and immunization prescriptions, $10.57 for chronic prescriptions, $26.95 for acute prescriptions, and $27.69 for immunizations. Patients receiving prescriptions in strip packaging generated a mean profit of $1561.82 per year compared with $1208.01 per year with bottles (P ¼ 0.021). There was a positive correlation between profit and the following variables: number of prescriptions filled during the 12-month period (r ¼ 0.56; P < 0.001); number of medication classes (r ¼ 0.27; P < 0.001); and high-risk patients defined by patient risk scores of 75 or higher (r ¼ 0.21; P < 0.001; Figure 1). Immunization administration was significantly higher (P ¼ 0.004) in nondelivery patients (16.0%; n ¼ 55) than in delivery patients (3.0%; n ¼ 10). Practice implications This study suggests that profit was increased because the number of fills increased for patients in a medication S111
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Figure 1. Patient risk score and profit correlation. Each circle represents a patient. There is a positive correlation (r ¼ 0.21; P < 0.001) between higher-risk patients and profit.
adherence program, which should yield greater adherence because the medications were prepared and dispensed to the patient. This suggests the importance of pharmacies offering enhanced services, such as a medication adherence program. Patients in this study were complex chronically ill patients with a mean yearly profit per patient of $1561.82 for patients receiving strip packaging compared with $1208.01 for those receiving medication fills in bottles. Filling medications in adherence packaging, such as strip packaging, may increase yearly profit per patient by approximately $350. An internal analysis at Moose Pharmacy was performed to compare the cost to the pharmacy to dispense prescriptions in bottles versus strip packaging, which showed that packaging costs were similar for our average complex patient. For this reason, patients are not charged a fee for the service of strip packaging. It is important to note that the number reported for MooseMAP type was reported as the number of patients instead of number of prescriptions. The goal of reporting in this manner is to focus on the patient using a more comprehensive “whole-person” approach that includes enhanced pharmacy services rather than focusing solely on prescription counts. Additional services, such as immunizations, help to ensure that patients are receiving comprehensive care. The most profitable prescriptions filled were acute medications and immunizations. Ensuring that patients receive these medicines at the same pharmacy that fills their chronic medications can assist in closing gaps of care for patients as well as increasing yearly profit for the pharmacy. Furthermore, pharmacists are recognizing the need to provide community-based enhanced pharmacy services, as evidenced by over 1400 community-based pharmacies aggregating as part of CPESN USA's® clinically integrated network. To date, 41 CPESN networks have developed.12 CPESN USA® was formed from learnings from the Centers for Medicare and Medicaid Innovation grant, which expands to highperforming pharmacies in all states and not solely North Carolina. A paradigm shift is occurring in health care as the focus becomes value-based health care instead of volume-based health care. Dispensing prescriptions will remain relevant to community-based pharmacy practice. However, more emphasis will be placed on the quality that comes before and after the dispensing process. There may be implications for S112
community-based pharmacies that offer enhanced services on quality metrics because a comprehensive health care approach is being leveraged to resolve medication-related problems and close gaps in care.12 Behavioral health was the third most prevalent chronic condition in this study, and Medicaid was listed as either the primary or secondary payer in 38.4% of patients. On further research, it was found that 80% of the NC Medicaid recipients with any mental illness were enrolled in the NC Community Care Networks Medical Home.17 This finding supports the claim that pharmacies should ensure that there are structures in place to support behavioral health patients. Providing focused support to this cohort may ensure patient understanding of and adherence to behavioral health medications. Patients who remain adherent to behavioral health medications may increase adherence to medications for additional chronic conditions, such as hypertension or diabetes. This approach may provide mutual benefits for patients and pharmacies, because prescription adherence contributes to both positive health outcomes for patients and an increased yearly profit for pharmacies. Immunization rates were low for both delivery and nondelivery patients; a vaccine status assessment process should be routinely used to ensure that patients are fully immunized against vaccine-preventable disease, secondarily increasing profit per patient to the pharmacy.18 Pharmacy staff should focus on influenza, disease-related, and age-related vaccinations, such as pneumococcal, zoster, and hepatitis type B vaccinations. The present study shows a likely missed opportunity for delivery patients, providing a chance for pharmacy staff to follow up with delivery patients about immunizations during adherence check-ins. This study has several limitations. Determination of profit was limited to dispensing software reports, which do not account for discounts, rebates, direct and indirect remuneration (DIR) fees, or operating expenses. True profit amounts are likely to be different once these factors are considered, because rebates could produce a positive impact on profit and DIR fees could have a negative impact. Personnel expenses were not included; typical personnel costs for a medication adherence program could include a pharmacy technician who operates the strip packaging machine and a pharmacist’s time for verifying strip packaging. This study did not consider the additional profit that attributed patients provide to the pharmacy, such as a per-member per-month payment from the CCNC CPESN payment model, medication therapy management service profit, or profit generated from the provision of other enhanced services. It is possible that patients may have received bottles and strip packaging during the 12 months of data that were collected, because the dispensing software only showed the most recent MooseMAP type. Profit associated with increased risk scores may be due to the increased number of medications, but further analysis is needed. Finally, reimbursement from payers may change over time.
Conclusion Medication adherence programs may increase profit for complex, chronic patients as the number of prescription fills increases. Community-based pharmacies, particularly CPESN pharmacies that offer enhanced pharmacy services (in particular, a medication adherence program), may increase the
SCIENCE AND PRACTICE Financial impact of a medication adherence program
number of chronic medication fills and profit by managing complex patients with the use of strip packaging compared with bottles. Patients with a higher number of prescriptions, and thus higher patient risk scores, should be prioritized to significantly improve health outcomes and increase profit. This research adds to the limited body of literature emphasizing financial impact that attributed patients provide to community-based pharmacies. Acknowledgments The authors thank Community Care of North Carolina, CPESN USA®, American Pharmacists Association (APhA) Foundation, Troy Trygstad, Trista Pfeiffenberger, and Catherine Zimmer for their support. References 1. Kott A, Fruh D. Almanac of chronic disease. The impact of chronic disease on U.S. health and prosperity: a collection of statistics and commentary. Partnership to Fight Chronic Disease. Available at: http://www. fightchronicdisease.org/sites/default/files/docs/2009AlmanacofChronic Disease_updated81009.pdf. Accessed June 13, 2018. 2. Community Care of North Carolina. Community Pharmacy Enhanced Services Network USA (CPESN USA®): integrating pharmacists into the medical home team. Raleigh, NC: Community Care of North Carolina; 2017. Available at: https://www.communitycarenc.org/media/relateddownloads/cpesn-flyer.pdf. Accessed June 20, 2018. 3. QuintilesIMS. IMS Health study identifies $200þ billion annual opportunity from using medicines more responsibly. Danbury, CT: QuintilesIMS. Available at: http://www.imshealth.com/en/about-us/news/imshealth-study-identifies-$200-billion-annual-opportunity-from-using-me dicines-more-responsibly. Accessed August 22, 2016. 4. World Health Organization. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003. Available at: http:// www.who.int/chp/knowledge/publications/adherence_full_report.pdf. Accessed August 22, 2016. 5. Hansen R, Seifeldin R, Noe L. Medication adherence in chronic disease: issues in posttransplant immunosuppression. Transplant Proc. 2007;39(5):1287e3000. 6. Iuga AO, McGuire MJ. Adherence and health care costs. Risk Manag Healthc Policy. 2014;20(7):35e44. 7. Lester C, Mott D, Chui M. The influence of a community pharmacy automatic prescription refill program on Medicare Part D adherence metrics. Am J Manag Care. 2016;22(7):801e807. 8. Doucette WR, McDonough RP, Morman MM, et al. Three-year financial analysis of pharmacy services at an independent community pharmacy. J Am Pharm Assoc. 2012;52(2):181e187. 9. Nguyen E, Sobieraj DM. The impact of appointment-based medication synchronization on medication taking behaviour and health outcomes: a systematic review. J Clin Pharm Ther. 2017;42:404e413.
10. Braithwaite S, Shirkhorshidian I, Jones K, Johnsrud M. The role of medication adherence in the U.S. healthcare system. Avalere; June 2013. Available at: http://avalere.com/research/docs/20130612_NACDS_ Medication_Adherence.pdf. Accessed January 22, 2018. 11. Drug Channels. New data show prescription profits under pressure at independent pharmacies. Available at: http://www.drugchannels.net/2 016/12/new-data-show-prescription-profits.html. Accessed June 18, 2017. 12. Trygstad T. Community pharmacy networks deliver cost-effective care. Popul Health News. 2017;4(5):1e2. 13. Community Care of North Carolina. Community Pharmacy Enhanced Services Network: a primer for primary care providers working with CCNC. Available at: http://www.fightchronicdisease.org/sites/default/ files/docs/2009AlmanacofChronicDisease_updated81009.pdf. Accessed June 13, 2018. 14. UNC Eshelman School of Pharmacy. Achieving better quality and lower costs in Medicaid through enhanced pharmacy services. Available at: https://pharmacy.unc.edu/files/2015/03/Achieving-Quality-and-LoweringCost-in-Medicaid-through-Enhanced-Pharmacy-Services_CMOPP-whitepaper_April-2017.pdf. Accessed June 18, 2017. 15. CCNC Central Office Pharmacy Programs Staff. Care triage is now available within Pharmacehome. Raleigh, NC: CCNC; November 23, 2013. Available at: https://www.communitycarenc.org/media/files/care-triageannouncement.pdf. Accessed September 10, 2016. 16. Centers for Medicare and Medicaid Services. Chronic conditions among Medicare beneficiaries. Available at: https://www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trends-and-Reports/ChronicConditions/Downloads/2012Chartbook.pdf. Accessed August 22, 2016. 17. North Carolina Community Care Networks. Clinical program analysis. Available at: https://www.communitycarenc.org/media/files/roidocument-may-2015.pdf. Accessed June 18, 2017. 18. Rhodes LA, Branham AR, Dalton EE, Moose JS, Marciniak MW. Implementation of a vaccine screening program at an independent community pharmacy. J Am Pharm Assoc (2003). 2017;57(2):222e228. Cody L. Clifton, PharmD, Clinical Pharmacist, Moose Pharmacy, Concord, NC, and Coordinator of Quality Assurance and Best Practices, CPESN USA®; at time of study: PGY1 Community-based Pharmacy Resident, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, and Moose Pharmacy, Concord, NC Ashley R. Branham, PharmD, BCACP, Director of Clinical Services, Moose Pharmacy, Concord, NC, and Director of Network Development and Marketing, CPESN USA®, Raleigh, NC Harskin “HJ” Hayes Jr, PharmD, Assistant Professor, South University School of Pharmacy, Columbia, SC; at time of study: clinical pharmacist, Moose Pharmacy, Concord, NC Joseph S. Moose, PharmD, owner/pharmacist, Moose Pharmacy, Concord, NC, and Director of Strategy and Luminary Development, CPESN USA®, Raleigh, NC Laura A. Rhodes, PharmD, BCACP, Community Practice Engagement Fellow, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Assistant Dean of Experiential ProgramdCommunity, Clinical Associate Professor, and Director, PGY1 Community-based Pharmacy Residency Program, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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