The Noncompliance Epidemic

Can We Get Patients to Be More Compliant?

Neil Chesanow

Disclosures

January 16, 2014

In This Article

Pharmacists on Your Team

The care teams, disease coaches, and physician support that integrated health systems have developed will need to be adopted by Accountable Care Organizations (ACOs) and patient-centered medical homes (PCMHs) if they are to succeed with bundled care. Keeping patients on regimen requires monitoring. If patient outcomes are poor because compliance is poor, team profits plummet.

But what if you're not part of an integrated system, ACO, or PCMH? Who will monitor your patients for medication compliance on your behalf during the estimated 5000 hours a year[29] when they are living their lives out of your sight?

That monitoring -- and intervening, if necessary --will increasingly be done by your community pharmacist. Both the ACA and the Centers for Disease Control and Prevention (CDC) have called for pharmacists to play a more active role in medication compliance.[30,31] Major retail chain stores and small community pharmacies across the country are gearing up to do just that.[32,33,34,35]

"Patients who are on chronic medications typically see their pharmacist many more times than they do their primary care doctor and certainly their specialists," internist Harry Leider, MD, Chief Medical Officer at Walgreens, points out.

"Patients with diabetes come to the pharmacy counter 2.5 times per month, or 30 times per year," he observes, "where, in a best-case scenario, they might see their primary care doctor 4 times a year."

Many pharmacies now use automated voicemail systems to remind patients when a medication is due to be refilled. Walgreens can also notify patients by texting or email. Because forgetfulness is a major barrier to compliance, if a patient calls in a prescription refill and then forgets to pick up the medication, a member of the pharmacy staff makes a personal phone call several days later.

The ability to order a 90-day supply of medication, the option to order drugs by mail, and the ability to synchronize refills so that a patient only needs to make 1 trip to the pharmacy to pick up several drugs, even if their refill dates don't exactly match -- all recent initiatives -- are attempts to address several oft-cited logistical barriers to compliance.[36,37,38]

If a patient is new to therapy, or new to Walgreens, a system lock is put on the sale of the drug until a pharmacist can personally educate the patient about the medication and probe for compliance barriers such as " how do you fit this into your daily routine?" Kristi Rudkin says.

These conversations typically last 3-5 minutes and are held at the counter. In some pharmacies, a private office is available for patients who request it, but most patients are fine with having these discussions at the counter, Rudkin says.

Pharmacists are in an ideal position to offer such cognitive services to support primary doctors, Leider maintains. Pharmacists already offer medication therapy management as a benefit to Medicare patients, because many primary care physicians don't have time to conduct medication reviews during patient visits.

Pharmacists are also offering immunization services for flu, pneumonia, and shingles, as well as testing for cholesterol, blood glucose, blood pressure, hemoglobin A1c, and body composition.[39]

If the pharmacist finds that a patient is having a dosage-related adverse event, the pharmacist may adjust the dosage to keep the patient compliant and notify the physician, Leider says. Adverse events, though often temporary (which patients may not realize because they were never informed), are a major reason that patients stop taking their medication.

What if a pharmacist changes the regimen and the doctor, due to some glitch, isn't informed? This possibility has led to concerns about fragmented care. However, Leider sees pharmacists, backed up by compendious pharmacy data on a patient's prescribing habits, as an integral part of future ACOs and PCMHs.

In 2013, Walgreen's formed 3 ACOs with medical groups in New Jersey, Florida, and Texas to test how this collaboration would work.[40] Eventually pharmacists who are ACO team members will be able to download timely notes on patient status and regimen changes made at the pharmacy directly into a practice's electronic health record (EHR). The doctors, in turn, will be able to access a patient's fill and refill history directly from pharmacy computers.

"Many of the concerns that some doctors have will dissipate rapidly when we have that kind of transparency," Leider believes.

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