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Inundated.  That’s a really good word. It’s associated and friendly with other words like deluge, flood, and overwhelmed.  They’re all good words.  I could use any or all of those words to describe the correspondence pharmacies are getting from our PBM partners relating to switching patients to 90 day supply prescriptions.

It seems as if a 90 day supply of medication is the panacea healthcare is seeking to improve patient adherence, improve outcomes, and save money.  Everybody says so.  90 days supply is good.  It’s good for everybody on maintenance meds.  It’s good for you.  It’s good for me.  It’s good for us.  It’s good for them.  It’s good for the sick.  It’s good for the healthy.  It’s just plain good.

OK…..I live in  rural America.  One thing I have learned over the years is when you walk across a pasture, you are likely to step into something unpleasant and that something can stick to your boots.  The argument for 90 days supply (in most cases but not all) seems to be sticking to our boots.

The myth of the 90 day supply is if a person has plenty of medication on hand (remember PDC?) they will be adherent.  (Oops!  I’m going to have to scrape that one off my boots.)  In my experience, undocumented though it is, people who are not adherent on a 30 day supply are not sprinkled with fairy dust, given a 90 day supply and become magically adherent.  Granted, if a patient is motivated and adherent with a 30 day supply chances are the same will apply to a 90 day supply, and that can be more convenient.

In 2012 our friends at Express Scripts studied factors that contributed to patient nonadherence. One of the most telling findings……”69% of the problem (of nonadherence) is behavioral: Simple procrastination and forgetfulness.”  I’m thinking that whether you have 30 pills or 90 pills in a bottle you can still procrastinate or forget.  90 day supply isn’t an answer.  Adherence monitoring, patient engagement, and local healthcare professionals are the answers. 

The mandate of 90 day supply comes from Healthcare payers and PBMs who truly like 90 day supply scripts.  They like them so well they incentivize 90 day supply in patients whom they judge to be nonadherent.  That nonadherence judgement is based on claims data they see coming through their switches.  When we, as pharmacists, look at a patient we don’t see claims data or switches.  We see a patient in need of help becoming adherent.  Our first thought is not, “Woo, I need to give this nonadherent, out of control diabetic more Metformin tablets.”  Our first thoughts are, “What can I do to help this patient?  What is the reason for their nonadherence?”

If a person is nonadherent and 69% of the problem is behavioral, why more pills?  Sometimes more pills is just more pills.  If more pills is the solution, let’s give everybody a year’s supply and call it done.

That brings us to The Measure.  It’s a given.  People who are in need of chronic medication and don’t take their meds don’t respond well.  People who take their meds benefit from them and the healthcare system saves money in the long run.  With that in mind, payers have adopted a Proportion of Days Covered (PDC) as a standard metric to indicate adherence and quality performance.  PDC’s of 80% or higher are considered indicators of good adherence.  So enamored of the high PDC is CMS, that they reward their intermediary health plans based on aggregate PDC numbers across their pharmacies.  This reward ($) is great enough to entice these plans to mandate high performance via threat of withholding fees from individual pharmacies. 

While the PDC measure as a quality indicator can be a good one when done correctly, it can also be “gamed”.  Autofill programs can and have be used to artificially raise PDC without a corresponding benefit to the patient.  In order for PDC to be meaningful, it must be used in coordinated program that actually benefits the patient and addresses all of the reasons for their nonadherence.

Using a 90day supply as an easy end around to an elevated PDC is another example of a possible system “gamer”.  If you give a nonadherent patient 90 days worth of medication, to the plan they look adherent for 3 months whether they take the medication or not.  That games the system.  In my experience that can be a grave disservice to a patient.  My patients who struggle with adherence with a 30 day supply need more contact with the pharmacy and our adherence team not less.  Shouldn’t we focus on why the patient is nonadherent and not just give them more pills so their paid claims look like they are adherent?  We need to put those patients on a 15 day supply and assess them regularly at least until they become adherent.

In the last few years pharmacies have been deluged (or inundated) with requests and demands to switch patients to a 90 day supply of medication.  My question is this:  Is this for the patient’s benefit or is it to show a paid claim and game the system?  Hmmmmmmm.

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Adherence and Med-Sync

The patient was, at the time, about 96 years old.  She was extremely healthy, alert, lived alone and capably cared for herself.  She was a delight.  She also had hypertension.  It was her only treated condition.  For her hypertension she took one, small, pink pill every morning.  Or at least she was supposed to take one a day.  She was not very adherent.  Wishing to keep her around another 96 years, we enrolled her in our pharmacy’s adherence program.  We struggled.  She meant to take her medicine, but the days just got by her so quickly.  Enter my adherence technician (also my sister-in-law).  My technician engaged her in conversation (not hard since, according to her father, my technician had been vaccinated with a phonograph needle).  Through a continuing dialogue we learned much about that patient.  As she began to trust us and look forward to our calls, my technician developed a plan.  One day, on a “routine” call my tech said to this marvelous lady, “I know you are an early riser.  Do you get up and fix a big breakfast?” 

“No”, the lady replied, “I just get out of bed and make my coffee.  That’s enough for me.”

“Oh, coffee first thing in the morning?” my tech continued

“Yes, dear”, came the answer, “coffee every morning.”

“I love my morning coffee.” my tech replied, leading the lady into our trap.  “Do you drink yours black?”

“No, sweety,” came the reply as the jaws of the trap sprung, “I use one spoon of sugar in each cup.”

Wham!  We had her!  Clamping the jaws of the trap firmly shut, my tech said, “Put your pills in front of your sugar bowl to remind yourself to take them.”

Not realizing she had been thoroughly bamboozled, our patient put her pills in front of her sugar bowl and was adherent until the day her family came and moved her away.

If your pharmacy has a med-sync program that is focused on having pills filled on a set date each month, are you impacting a patient’s health or are you working on a convenient schedule for yourself and your pharmacy?  The best med-sync programs combine both.  The convenience of knowing when refills are due, if prescribed medications are appropriate, and the ability to have a conversation with patients are the hallmarks of quality patient care.  No matter how much we need to automate what we do for data collection, as a profession our greatest strengths, joys, and effectiveness come from simple conversations with patients.  Everything good starts at the pharmacy counter eye-to-eye.

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