Written by: Cadmus Kyrala, MA, MBA, PharmD, Director, Clinical Intelligence, Product Development, Aspen RxHealth.
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.
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:
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:
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.
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.
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.
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.
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.
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.
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.