The Future Of Medication Adherence: One Pharmacist’s Perspective
Written by: Cadmus Kyrala, MA, MBA, PharmD, Director, Clinical Intelligence, Product Development, Aspen RxHealth.
There’s no substitute for a pharmacist
My most formative experience as a PGY-1 managed care pharmacy resident occurred while on a ride-along with a case manager 5 years ago.
I advocated for visiting this particular patient as it appeared they were receiving multiple long-acting insulins from the same pharmacy, and given the potential complications associated with simultaneous dosing I was concerned that this was a life-threatening situation. I was also concerned that a lack of patient education on the matter may have created confusion regarding how to properly manage their multiple conditions. I’ve always found that these types of discussions around medication adherence, proper dosing, and appropriate medication administration were topics best addressed in person.
I can still remember the shock I felt when, upon sitting down with the patient in their home for a medication consultation, we discovered that the patient was indeed using both long-acting insulins simultaneously. It became clear why their blood sugar values dropped precipitously over the prior weeks, and I was more surprised to find medications stockpiled in the patient’s kitchen. Some had expired years ago, while some represented diagnoses we would have never seen by simply reviewing recent claims data. Piles of unused inhalers collected dust while other medications that should have never been used together were casually being interchanged at the patient’s discretion. Obviously, the lack of clarity on medication regimen as well as missing patient education increased the potential for adverse drug events.
By the time the case manager and I departed, the patient’s current medication regimen had been sorted out, expired medications disposed of, and the patient finally possessed a clearer understanding of how to properly utilize the remaining medications.
All these years later, I still recall that interaction – because it so clearly illustrates that there are undeniable blind spots that computers and data streams will not see. For this reason alone, the pharmacist-patient relationship will always have an important role to play in patient care.
Barriers to medication adherence
Kvarnström et al., in a 2021 issue of Pharmaceutics, did a comprehensive systematic review of medication adherence barriers drawn from qualitative research in the field. They created a taxonomy of barriers based on the aspects of patient care around which the barriers appeared centered. They found that medication adherence barriers could be sorted into a few categories:
- Patient-centered barriers
- Health system-related
The striking thing about the analysis is that recurring themes appear across multiple levels—lack of patient knowledge as it relates to disease state and therapies, lack of communication with health professionals, lack of coordination between health professionals, social or religious stigma, lack of time and money to negotiate the logistics of care, and fatigue from trying to manage it all.
The hard truth as healthcare professionals is knowing that we’ve only just begun to scratch the surface of remedying the core barriers to patient adherence to medication.
Simply put, our healthcare system must do a better job of connecting with patients, building pharmacist-patient relationships, and using patient education strategies to guide them from where they are to where we need them to be in their healthcare journey. The challenges to doing so are anything but easy to solve for:
- How do we support medication adherence when it may take months for a patient to see a primary care physician, much less schedule the appointments and tests that may be necessary to initiate treatment?
- How well can patients balance the time and transportation demands while struggling to maintain a normal work schedule to provide for themselves and or their families?
- How can a physician properly follow the care of a patient as we move progressively towards a model where a patient may be seen in a variety of community-based clinics that aren’t necessarily coordinating records with other physicians and none of the providers is necessarily following the patient long-term?
- How can pharmacists properly educate patients on their medications when the priority is getting as many prescriptions out the door as possible?
I say this as a clinical pharmacist myself. It is downright difficult to navigate healthcare as a patient in America. If we want to drive improved patient adherence to medication and bear witness to substantive and long-term improvement in patient health outcomes, the time to act is now.
Technology to properly augment the care team
We’re thankfully living in an age when technological innovations are abundant. In fact, a number of advancements stand the chance of revolutionizing how patients engage with their healthcare teams. Ranging from new digital health solutions and new ways of working, to automated dispensing and AI-powered analytics, these advancements pave the way for greater health outcomes than ever before.
The spread of telehealth has made it easier for people to check in with a healthcare professional. They can review their symptoms and on occasion be diagnosed without having to ever step foot in a doctor’s office. In fact, remote pharmacists present an opportunity to help leverage telehealth to improve patients’ medication adherence.
Smart health tracking devices are making it easier than ever for patients to track their vitals and specific lab values. Some have the unique capability to send real-time information to the health system or provider group monitoring the patient’s care.
Automated medication dispensing and delivery
Prescriptions can now be delivered by mail order, and depending upon where you live, can be dropped at your doorstep via drone. Fully automated remote pharmacies monitored by video feed are already a reality.
Artificial intelligence-powered predictive analytics is already used to improve our ability to identify diseases earlier thereby increasing our ability to treat and/or prevent progression. AI is also being used to provide broader access to drug information. Some organizations are already using it to provide live real-time QA and feedback for clinical consultations. However, none of these solutions solve the major lingering barriers to care.
A tried and true approach to adherence: clinical pharmacists
As patients continue to adopt digital care models, the ways they have traditionally received education on their diagnoses and treatments are changing. Those same patients are now finding themselves at increased risk for missing crucial patient education, while potentially being misinformed or misguided by non-clinical sources.
As more organizations, devices, and apps rise to the occasion with solutions to present, are we running the risk that communication will become even more fragmented between the custodians of patient care?
When real-time data is everywhere, how will we be sure we’re focusing on the most mission-critical data sets? How will we protect patient privacy?
Sometimes even the most modern technological advancements require a traditional approach. Once the care is perfectly coordinated, claims and medical history are available at the touch of a button, medications can be dispensed safely under AI supervision, yet the patient still will require human interaction to ensure optimal use of those medications.
The quality care only clinical pharmacists can provide
Patients will always need to be educated about their disease state. They’ll still need to be guided to trusted and reliable sources of information. They’ll need someone to help them negotiate their various treatment options. Once we get them the right drug at the right time, they’ll still need to know why it’s important to take. Ultimately, there is no substitute for the pharmacist-patient relationship.
There’s a large number of retail pharmacists who are highly trained in aspects of medication yet find themselves hindered by the pressures in retail. These pressures continue to intensify as aging populations create increased demand for medication therapy management. As payers and PBMs continue to consolidate, retail margins will grow slimmer, shifting the focus to value-based contracting models and patient outcomes, making clinical quality metrics more of an industry focus than they are today.
I foresee that automation will eventually replace most manual, repetitive tasks in retail pharmacies, and one pharmacist could potentially oversee multiple pharmacies at once, remotely.
Pharmacists who have intentionally kept their clinical skills sharp will fare best in our new frontier. Roles will exist for those who can help construct automation processes and train AI to increase efficiency without sacrificing safety. Yet, I predict that the vast majority of opportunities will be counseling those patients who require patient education on their medications and are at risk of being nonadherent due to barriers prevalent in their day-to-day lives.
A computer cannot replicate the human connection the same way a pharmacist can with tools such as motivational interviewing. A computer cannot understand what it’s like to balance family, work, and a sense of self. A clinical pharmacist can provide empathy, meet patients where they are, and use their clinical expertise to assess their therapy and offer practical suggestions to simplify and optimize their medication regimens. A clinical pharmacist can conduct a consultation and promptly coordinate with multiple prescribers, the patient’s health plan, and pharmacies to ensure that their care team is operating like a true team. They have the knowledge to answer prescriber questions about suggested therapeutic changes and the experience to push back where it is needed, guiding both patients and prescribers to beneficial behavior change.
Components of a successful medication adherence program
The health plan is on board with the value of pharmacists and wants to leverage them in a new medication adherence program. How do they design it to ensure success and improve medication adherence?
An effective medication adherence program needs several key components to be successful.
- It must be able to identify patients at the key touch points where they can most benefit from counseling. Are they new to therapy? Have they changed therapy? Was there a recent hospitalization? Are their lab values taking a turn for the worse? Are they late to fill a chronic medication? High-quality, complete, and timely data are essential for identifying these types of opportunities.
- Outreach needs to be timely. For most chronic conditions, gaps in medication treatment are a ticking time bomb. For the asthmatic child without a rescue inhaler, for the patient with uncontrolled blood sugar, for the heart failure patient without their maintenance medications, it is only a matter of time before they are in the ER or worse.
- Consultations need to be both thorough and empowering. Medication adherence counseling cannot be handled in a 30-second discussion at the retail drive-thru. Someone who understands the potential side effects and challenges of taking a medication needs to be able to take the time to build rapport with the patient. They need to dig deeper and find out why that patient who never fills their medications has plenty on hand. They need to find out why that patient, who regularly picks up their medication, has worsening lab values. They need to dig into the reality of that kitchen cabinet and look beyond the computer. It doesn’t matter if they have the medication on hand if they’re not taking it or not taking it correctly. This kind of rapport is not something that is easy to establish. It requires two things which have been notoriously scarce in health care —time and patience. These are things that we need to find a way to bring back.
- Sincerity should be non-negotiable. The patient on the other side of the counter or the other side of the phone needs to feel heard. They need to feel understood. They need to feel like the recommendations coming to them are from a sincere interest in their well-being and not a check-box formality. Ultimately, they must believe that this medication will do them some good even if it is inconvenient. They have to want to take it. A computer can call them to let them know they’re late to fill their medication, but it cannot adequately replace what a fully engaged clinical pharmacist can do.
- Finally, a successful medication adherence program requires repetition. It requires multiple contacts from someone who is familiar with their case history to check-in, reinforce, and to identify new barriers that may have arisen. Asking the patient to rebuild that rapport with a new face every month is unrealistic and exhausting for the patient. Eventually, they’re going to stop picking up the phone.
A prerequisite to all this is, of course, that healthcare organizations are willing to invest in this long-term commitment to lasting behavioral change for those whom they serve. I hope more organizations start breaking down the barriers between pharmacy spend and medical spend and really start to look at the year over year impact that medication adherence has on preventing hospitalizations and more costly and complex procedures. For this reason, many healthcare organizations are beginning to look toward outsourced pharmacy services, such as those provided by Aspen RxHealth.
Medication adherence programs raise pharmacy spend and are costly even when done right. Efficiencies can be found in automating the design and implementation of these programs, but the long-term payoff will be in the health and satisfaction of their members and the overall lifetime reduced medical costs associated with proper adherence to chronic medications, especially in specialty medication management programs. Once the industry solves this economic puzzle, clinical pharmacists can get back to the real work, the work that patients need and deserve.
About the author:
Cadmus Kyrala, MA, MBA, PharmD serves as Aspen RxHealth’s Director of Product Management, Clinical Intelligence. Cadmus leads all clinical program development for Aspen RxHealth’s nationwide health plan clients, blazing the trail toward better medication adherence and health outcomes for members. Follow Cadmus on LinkedIn here.