Community Medication Use: We Have to Do Better

For the vast majority of Americans with chronic diseases, the medication-use system in the community is broken in many ways.

It has been estimated that for every $1 spent on drugs for chronic diseases, nearly another is spent on the costs of poor outcomes from that drug therapy.¹ One could argue that the American public is getting a bad deal for what amounts to hundreds of billions of dollars spent. Although there are pockets of excellence in some communities that are making a difference, most patients remain subject to a medication-use system that is disconnected from the rest of the patient care team, expensive, inefficient, not held accountable for drug-related outcomes or quality measures, and not patient-centered. Many patients in both rural and urban communities, especially minorities and poor families, may reside in relative “pharmacy deserts,” creating additional medication-access challenges.^2,3 The majority of patients also receive limited education concerning their medications from their pharmacists and providers.^4,5 The end result is high primary and secondary nonadherence rates, poor medication literacy, and unsatisfactory overall medication-related outcomes. This is a very complex problem that lacks simple answers, but we must do better, and we can do better.

For health system pharmacies, why is this an ever-important concern? With the continued growth in value-based reimbursement models that emphasize the importance of population health management, commercial and governmental payers are increasingly shifting the accountability for outcomes of care and quality to providers, such as accountable care networks, health care systems, and provider networks, This shift in accountability incentivizes health care systems to maximize the outcomes and value of drug therapy, and the leadership of our organizations is turning to pharmacy for leadership to achieve these improvements. Continuing to do business as usual relative to the drug-use system in the community is not going to get the job done. Disruptive, innovative, patient-centered solutions are going to emerge, and if they are successful at enhancing value, they will be embraced by health care provider networks in their pursuit to best manage risk and improve overall outcomes. Health system pharmacies should take a lead in defining and evaluating these innovative system changes. We are going to have to own more of the medication-use system in the community to achieve the clinical and financial goals of our organizations.

An important question is whether health systems will pursue development of “in-house” pharmacy programs, partner with existing community-based pharmacy providers, or align with other currently undefined innovative approaches to best manage the needs of their at-risk patient population? Many large health care systems with affiliated accountable-care networks may conclude that they have the capacity and expertise to best implement and manage a patient-centered medication-use system that is actively engaged with their overall care management structures and will either incentivize or require patients to use their networked approach. This may have multiple advantages including full integration with the patient care team, use of a common medical record, use of data analytics to identify and target services, an ability to control drug costs, and full access to key data elements such as adherence measures, adverse events, and outcomes. The focus will have to shift away from a product-oriented dispensing process to a patient-oriented care process with accountability for improved outcomes. High-efficiency, high-technology drug distribution models will likely replace the prescription counter.

For systems that lack the capacity, desire, or size to internalize the drug-use process, they are likely to pursue partnership with existing pharmacy provider networks in the community. There will be an expectation of system changes and greater accountability for outcomes on the part of the health care system and an expectation of new business models on the part of pharmacy providers to provide resources to meet the defined needs. There will be downside and upside risks in these models to achieve the desired accountability on the part of the pharmacy providers. The Community Pharmacy Enhanced Services Network that started in North Carolina and has expanded to other areas of the country is an early example of the emergence of these types of partnerships that can take advantage of existing infrastructure, pharmacy expertise, and broad access in the community. We should fully anticipate that there will be other significant disruptive influences on the medication-use systems in the community that may dramatically redefine how patients and health care systems access medications and pharmacy professional services.

To quote Microsoft founder Bill Gates, “We always overestimate the change that will occur in the next 2 years and underestimate the change that will occur in the next 10.” If we do not innovate and take the lead on this issue, in the next 10 years, we may find ourselves in the position of the big-box retail store in the age of internet-based shopping. In future issues of this publication, it would be informative to share examples of how health systems are responding to this need by implementing novel approaches to changing or redefining the medication-use system in the community.

Curtis E. Haas, PharmD, FCCP, is the director of pharmacy for the University of Rochester health care system in New York.

References

• New England Healthcare Institute. Thinking outside the pillbox. nehi.net/writable/publication_files/file/pa_issue_brief_final.pdf. Published August 2009. Accessed August 10, 2018.
• Olumhense E, Husain N. ‘Pharmacy deserts’ a growing health concern in Chicago, experts, residents say. Chicago Tribune. chicagotribune.com/news/local/breaking/ct-met-pharmacy-deserts-chicago-20180108-story.html#. Published January 22, 2018. Accessed August 10, 2018.
• Pednekar P, Peterson A. Mapping pharmacy deserts and determining accessibility to community pharmacy services for elderly enrolled in a State Pharmaceutical Assistance Program. PLoS One. 2018;13(6):e0198173. doi: 10.1371/journal.pone.0198173.
• Kimberlin CL, Jamison AN, Linden S, Winterstein AG. Patient counseling practices in US pharmacies: effects of having pharmacists hand the medication to the patient and state regulations on pharmacist counseling. J Am Pharm Assoc. 2011;51(4):527-534. doi: 10.1331/JAPhA.2011.10012.
• Tarn DM, Paterniti DA, Kravitz RL, et al. How much time does it take to prescribe a new medication? Patient Educ Couns. 2008;72(2):311-319. doi: 10.1016/j.pec.2008.02.019.