“Payors are interested in finding ways that they can improve medication adherence for their members using community pharmacy resources,” says Dr. Janice Pringle, director of the program evaluation research unit at the University of Pittsburgh School of Pharmacy. This is just one of many lessons Dr. Pringle learned after being selected for the Centers for Medicare and Medicaid Services Innovation Advisors Program.
During an interview with HIN’s executive vice president and chief operating officer, Melanie Matthews, Dr. Pringle discussed why she applied for the Innovation Advisors Program, the medication adherence intervention she developed with Highmark and Rite Aid, other initiatives supporting medication adherence, and much more.
HIN: What prompted you to apply for the Innovation Advisors Program?
(Dr. Janice Pringle): I have always been interested in innovations and I teach a course on healthcare innovations at the University of Pittsburgh. I also have been involved in a program where we took some strategies that are used in behavioral health and applied them in community pharmacy services, and we looked to see if that had an impact. I considered that an interesting innovation. And I have to emphasize that I did this with my collaborators: Highmark, which is a commercial payor and is now Gateway, a Medicaid payor; and Rite Aid Corporation and CECity have all been part of this particular program. We’re funded through the Pharmacy Quality Alliance (PQA).
HIN: What have you learned thus far?
(Dr. Janice Pringle): We’ve learned a lot. First of all, we’ve learned that pharmacists want to have a greater impact on their patients, so when you’re giving them the opportunity to do so, they rise to the occasion. We’ve also found that community pharmacy organizations such as Rite Aid are interested in supporting this. We also know that the payors are interested in finding ways that they can improve medication adherence for their members using community pharmacy resources. We know that CECity, which provides some platforms to help us scale things, is a very important and necessary partner.
Finally, the PQA is important because they provide us with the national contacts. We’ve learned that the implementation barriers can be attenuated; we can get over them. Where there’s a will there’s a way. Even though pharmacists are very busy in community pharmacy settings, they can learn to have meaningful discussions with patients about their adherence and learn to fit it into their work. We’ve also learned that once they see this, they can continue to do it even more.
Our preliminary results have demonstrated to us, when we compare the medication adherence rate for the medication classes we’ve studied, that the pharmacy is better involved. 118 pharmacies improved medication adherence for the patients who received services there, compared to the pharmacies that we used as controls that were not using this intervention. What’s really key is that this effect seems to improve or increase over time, which shows us that the pharmacist gets better and better at it as they go forward. We’ve studied these data over a 12-month, or in some cases, a 13-month period. That’s everything that we’ve learned and we’re excited to see if we can continue to push this forward, and maybe change the conversation about the importance of community pharmacy in the healthcare arena and landscape.
HIN: What role do you believe medication adherence will play in the recommendations developed by the Innovation Advisor program?
(Dr. Janice Pringle): Medication adherence is definitely an important issue for many of my advisors. They’re programmed by looking at adherence, and it came up multiple times whether we were looking at transitions of care, palliative care issues, whether it was looking at issues of integrating and doing models using primary care, and so forth. Medication adherence has definitely come up. I would imagine, especially given we know that Dr. Will Shrank is a member of Brigham & Women’s Hospital Department of Medicine, Division of Pharmacoepidemiology & Pharmacoeconomics and his expertise is in medication adherence, it’s an important issue for them, and also for CMS in general and the innovation center.
HIN: Of the innovators selected to participate, what other types of initiatives support medication adherence? How do these programs complement or differ from yours?
(Dr. Janice Pringle): There was much interest in the issue of medication adherence, specifically some of what we were doing in our program and how they could apply it to their models. For most of the models that I heard about, the vast majority seem to have an interest in how they can improve medication adherence because they understood that this was an issue for them in improving health — or their “three-part aim” as they call it, which is improving health, improving care and reducing cost.
HIN: Can you briefly describe the intervention you’ve developed with Highmark and Rite Aid to improve medication adherence rates?
(Dr. Janice Pringle): The intervention involves screening, brief intervention (SBI) of patients for medication adherence issues. This way, you can place them in a risk profile. You use any screen that has validity in that purpose. You can sort your patients based on prior data and information. You can also do a universal screen where you ask them questions when they come in, but you want to bring up those patients that seem to be at greater risk than others. You can then apply a brief intervention, which is a two to five minute conversation that is based on motivational interviewing principles that address the issues of how we can help you improve your medication adherence. This is called a facilitative manner — you’re trying to have the patient and the pharmacist work together to address that issue.
HIN: When you spoke with us in May 2011, you were evaluating the preliminary results for the community pharmacist’s intervention. Can you share what results the program has achieved to date?
(Dr. Janice Pringle): With the pharmacies that were involved in the intervention, we looked at the patients that came to those pharmacies and looked at their formulary claims data. We found that their adherence significantly improved and continued to improve over time, so there was an acceleration of an effect over time. For the 13 months or so that we examined the data, compared to the control pharmacies that were fairly similar in many different ways, we examined the similarities to the intervention pharmacies on the same medication classes and the same adherence measures.
HIN: What did you learn in year one of the intervention and how have you modified the intervention based on these findings?
(Dr. Janice Pringle): One of the things that we’ve learned is that you have to keep in touch with the pharmacists consistently to make them aware, if they’re applying this innovation, that this is an innovation that has importance. Pharmacists have many competing requirements; immunizations, different tasks that come through in a community pharmacy chain. We keep in regular monthly contact with the pharmacists to determine what issues or concerns they may have or limitations. We want to get the issues addressed as quickly as possible. We also keep track of where they stand in the innovation process. That’s one thing that I think is important.
The second is, Rite Aid has reported this whole program and that’s key. Rite Aid put some very talented people in charge, such as Jesse McCullough, who is the clinical services manager for Rite Aid, and Rick Mohall, the director of clinical services at Rite Aid. They cleared the way for this to become an initiative for the pharmacies where we’re implementing so that it would continue to be priority. And they changed how they are evaluating the pharmacists.
There are raises also related to the pharmacy, but not just the pharmacist’s performance. The pharmacies are being evaluated as a unit. We found that one pharmacist could be on board, another may be less on board, and they could cancel each other out as they move forward. If you’re now evaluating the pharmacy as opposed to the pharmacists, that changes the conversation.
HIN: Do you have plans to expand the program to include other pharmacy chains?
(Dr. Janice Pringle): Yes. PQA and CECity have been working on the second phase of this, which is called Equipp. They are targeting the entire state of Pennsylvania, looking at some other pharmacy chains and other payors. They also have been talking to some other states. Dr. David Nau, PQA’s senior director of research and performance measurement, has been involved with CE City and is moving this forward to the other states, especially Pennsylvania.
HIN: Are the pharmacists receiving any higher payment for their services?
(Dr. Janice Pringle): Rite Aid has many programs that they’re using to provide incentives to their pharmacists, or to make up the way in which they’re reimbursed. Some of them relate to this study and some do not. What I’m about to say is one aspect of the many ways in which the pharmacists’ salaries were determined. I’m not privy to all of them.
I do know that Rite Aid has, as of January of this year, decided to look at ways that the entire pharmacy is performing, and adherence is one way to be able to look at that. There are other things that they’re looking at as well, but this was partially in response to our study and in response to other things, too, that indicated that it’s good to have the pharmacy be one unit in terms of how the pharmacy takes on innovation, or approaches ways in which we can be considered productive.
We will also be looking at, with Highmark, ways in which we can provide additional pay for performance, or value-based purchasing strategies for the pharmacist. We’ll be testing and developing some models for our colleagues. I wouldn’t expect those to be moved into the field until some time in 2013.
HIN: The community pharmacists can have a measurable impact on medication adherence, according to the results of your program. After the pharmacists, where should organizations concentrate their efforts to boost medication adherence? What should be done within the primary care practice?
(Dr. Janice Pringle): For our next step, we should bring physicians and pharmacists together. The same strategies we’ve used with the pharmacists can be used in the physician’s business. What could be interesting is having the physicians and pharmacists together with an understanding of common quality metrics, such as what CECity provides and what PQA has suggested regarding the measurement. This way, you can keep track of what’s going on with the patients between the physician’s practice and the pharmacy practice.
I think it would change the whole conversation of how we’re receiving medications in our community — if pharmacists are working in collaboration with physicians and physicians are learning the same skills. We could greatly enhance medication adherence and we could change the health of our communities. Again, it’s a matter of will to do that.
41.jpg)
