Compliance and Persistence in Continuous Medication Monitoring (CMM)

There has been a lot of interest lately in Medication Synchronization programs as a way to improve a pharmacy’s EQuIPP measures, especially as they related to measures of Proportion of Days Covered (PDC). While there are a number of possible ways to implement Med Sync, it is important to not lose site of the actual goals of therapy.

For years, mail order pharmacy has touted cost savings based on the supposition of improved patient compliance. As it turns out, these assumptions were often flawed due to the disconnect between the billing / shipping of the product and the patient actually taking the medicament. Indeed, automated refills of any nature, including mail order or Med Sync programs, will show improved compliance (based on claims data including the day supply and dates of refill), magically augmenting a pharmacy’s performance with respect to PDC.

While many pharmacies would be thrilled to improve their PDC related measures, making an investment in Med Sync appealing, the real story is both more interesting and harder to document.

The more important measure, and one that is not adequately measured by EQuIPP or other PDC style metrics, is the rate the patient takes their medication correctly. There is a subtle, yet important difference between these. The PDC is based only on claims data, which comes from the information written on the prescription. The latter is a combination of the instructions given to the patient by the prescriber directly (which are often at odds with those written) and the patient’s willingness or ability to follow thru with these directions.

Many Pharmacy Management Systems will flag early or late refills for the pharmacist or technician to follow-up with, but in reality these are difficult to leverage. For example, If a patient with 100% compliance to the prescription’s directions, picks up meds four our or five days early over the course of a few months (simply out of convenience), they could easily be 2 or more weeks late on the current refill without actually being out of medication. A calculation looking at 3 to 6 months of the dispensing record gives a more accurate picture of the patient’s compliance and persistence in taking their medication.

One of the tools we use daily in our pharmacy is Continuous Medication Monitoring (CMM). Each time we refill any medication for a patient, we carefully look at the entire patient profile. For each prescription in the patient’s profile, a persistence score is calculated over time using the total number of days dispensed (corrected for future days) versus the actual days passed. While this can be done manually, our software automatically flags any prescriptions showing any drop.

When we notice an unexplained drop in persistence for any medication, we can approach the patient to inquire if anything has changed. Quite often, any changes in persistence are explained not by the patient’s inability to follow the regimen prescribed, but by new instructions given to them by the prescriber that have not been communicated to the pharmacy.

Thru the use of CMM, these types of issues can be addressed with the patient at the counter. From there, the prescriber can be approached to provide a new prescription with updated instructions. In the end, compliance was not the problem, but communication between practitioners.

As you consider implementation of a Med Sync program, be sure to keep in mind that compliance and persistence are more than just claims data. Be alert for evidence of changes, and “Make Every Encounter Count” when you have the patient in front of you.

The Stripped Down Model of Pharmacy Practice

What does a pharmacist do? The answer to this question depends on who you ask, with patients, health care providers other pharmacists, PBMs and insurance companies offering a wide array of responses.

Maybe a better question to ask is this: “What is a pharmacist paid to do?” Based on reimbursement from Pharmacy Benefit Managers (PBMs), pharmacists are only paid for the product they dispense, and then, only the most inexpensive generic medications. Many times, pharmacies are not even receiving a dispensing fee for their work, let alone a professional fee for services rendered.

In other words, over the past 20 years, pharmacy has evolved into what we call the “Stripped Down Model” of pharmacy practice. This model has become the de facto prototype for pharmacies in the United States. Unfortunately, a low-cost model is not synonymous with patient care and lower overall healthcare costs.  Pharmacists concentrating only on dispensing the correct medication to the patient are doing little to improve patient outcomes and healthcare quality and, in fact, may easily be replaced by automation or less expensive providers.

This shift to a volume driven profession is not optimal  for patients or the health care system, and all of us are all to blame for this. Pharmacists have precious extra time to perform patient care services in many practices for a variety of circumstances including  pharmacy management emphasizing metrics of wait time and volume to their staff, patients wanting their medications to be cheap and fast, and PBMs and Insurance companies wanting to maximize profits and their bottom lines.

The Stripped Down Model doesn’t really use a pharmacist, and in truth as mentioned previously,  pharmacists can potentially be replaced by robotics or technician based dispensing models, creating additional savings for the “system” thru mitigation of expensive pharmacist salaries.

…the profession of pharmacy needs to work to create a network of truly high performing pharmacies and pharmacists.

While I believe that the above scenario is possible, I see another direction for pharmacy. Despite the oppression of this stripped down model, pharmacists across the country still work to apply their clinical skills and make interventions on behalf of the patient. Pharmacists can and are impacting healthcare by decreasing costs and more importantly improving patient outcomes.

Even Medicare is starting to understand, with the new emphasis on quality indicators. Pharmacists and pharmacy performance are about much more than prescription volume. It is the patient outcomes that matter.

As the paradigm of pharmacy changes, the emerging model should leverage the pharmacist for what they can do. In other words, a model that pays pharmacists to care for patients through appropriate mediation management. Pharmacists should be financially recognized for ensuring that patients are using safe and effective medications in the most cost-effective way so that they achieve optimal therapeutic outcomes.  In the coming days, weeks, months and years, the profession of pharmacy needs to work to create a network of truly high performing pharmacies and pharmacists. Pharmacists will need to work to become recognized for what they do and they will need to be paid to do it.

Pharmacists will need to “make every encounter count” with their patients!