The 3.3 Percent Rx Dilemma

In recent years, a number of new studies have zeroed in on a common problem in pharmaceuticals management: Patients too often avoid filling the prescription they need. And there’s been a frequently cited link between the out-of-pocket cost of a drug and the likelihood that it will be shunned as sticker shock overrides the need for treatment.

For the makers of biologics — next-generation therapeutics that often wind up on the most expensive tier in the formulary — it’s a trend that can’t be ignored. But in a recent study, a group of researchers found that if pharmaceutical benefit managers apply a simple test, they have a good shot at identifying which plan members are likely to avoid specific therapies. And, they added, payers need to reflect carefully on how they design their drug formularies to make sure that members adhere to a prescribed treatment regimen.

Late last year, a team of investigators led by William Shrank, MD, at Harvard’s Brigham and Women’s Hospital, in Boston, drilled down into prescription drug data for a three-month stretch in 2008 and detailed just how many prescriptions actually got filled by pharmacists but were never picked up — and why.

Reporting their findings in the Annals of Internal Medicine (Shrank 2010), the investigators concluded that 110 million prescriptions — 3.3 percent of the total number of prescriptions filled by pharmacies —were abandoned. Those drugs were returned to pharmacy shelves. Slightly fewer than half of those prescriptions were filled later with a different drug. But the rest were simply left at the pharmacy without any follow-up.

William Shrank, MD, and his team found that 3.3 percent of filled prescriptions are abandoned at the pharmacy.

“The total number of abandoned prescriptions in the population is great,” noted the team, “and every essential prescription abandoned could represent an important clinical concern if the patient does not subsequently restart the medication or identify a substitute.”

There were two key factors that helped to determine which therapeutics were picked up and which ones were forgotten: Cost and need. Pain-killing opiates and antiplatelet medications were among the drugs least likely to be left behind. Antihypertensives, oral diabetic medications, and statins also had a low rate of abandonment. But proton-pump inhibitors, asthma medications, and insulin all registered among the drugs most likely to be ignored. Some therapies that weren’t critical to a patient’s health, such as certain dermatological agents, were also among the products most likely to be abandoned and returned to pharmacy shelves.

Out-of-pocket costs clearly played a big role. Shrank and his colleagues found that a drug with a copayment of $10 or less was left at the pharmacy only 1.4 percent of the time. But the abandonment rate shot up to 4.5 percent when the cost to a patient broke the $50 mark. Low-cost generics were commonly picked up whereas a large concentration of abandoned drugs turned out to be branded medications.

The e-prescribing conundrum

“Compared with prescriptions with no copayment,” Shrank said, “prescriptions with copayments of $40.01 to $50 had a 3.4 times greater probability of being abandoned, and prescriptions costing more than $50.01 had a 4.68 times greater probability of being abandoned.” By matching ZIP codes to average income for patients’ neighborhoods, the researchers also concluded that people from low-income areas were, not surprisingly, far more likely to abandon a drug.

The patients most likely to leave their drugs behind were most often younger — 18 to 34 — and had co-morbidities that required multiple drugs. They also were more likely to be starting on a drug rather than refilling an old prescription. “New users of medications had a more than 2.74 times greater probability of abandonment than prevalent users, and maintenance medications had a slightly less probability of being abandoned. Of note, prescriptions delivered electronically to the pharmacy had a 64 percent increase in the probability of being abandoned compared with those that were not electronically delivered,” noted the investigators.

The e-prescription finding wasn’t too surprising because patients don’t have to personally drop off or phone in the prescription. So it’s not hard to abandon a therapy when it turns out to be more expensive than bargained for. And some of these electronic prescriptions may inadvertently be going to the wrong pharmacies, creating a potential wrinkle in the electronic ordering system that needs to be ironed out.

Compared with the total number of prescriptions filled in the United States — 3.6 billion in 2008 — 110 million scripts may not seem like much, say the investigators. But when you consider that many of these drugs were needed to control serious medical conditions, clinical concerns emerge about the increased risk of deterioration of a patient’s health. On top of that, the prescriptions left undelivered cost pharmacies about $10 each in related costs. Even at half that $10-per-prescription rate, abandoned drugs are costing the nation’s pharmacies more than a half billion dollars a year. And, the researchers say, that with e-prescribing taking hold as one of the hottest trends in the healthcare industry, this is one cost that may well sap even more money out of the system in years to come.

Payers can help to reduce the incidence of abandoned prescriptions at the pharmacy by keeping copayments for essential drugs affordable.

What to do?

By compiling a profile of the people who abandoned drugs at the pharmacy, Shrank and his team came up with a simple algorithm that pharmacy benefit managers could use to help identify which patients were most at risk. The prediction rule, as they called it, uses four weighted variables to assess risk: Age, electronic prescription, new prescription, and copayment. In terms of weighting, age is the least likely risk factor driving the potential for prescription abandonment, and copayments of $50 or more are the greatest. Copayments of $30 to $50 carry about the same risk as whether a prescription was new and whether it was written electronically.

But they also know it won’t be easy to identify these patients and figure out some way to make sure they’re taking the right drugs for their condition.

In many cases, they add, physicians have no idea how much patients have to pay out of their own pocket when they go to pick up a therapy. Even if they did, it’s not uncommon for a physician to expect the pharmacist to play the lead role in intervening with a patient. But there are some strategies that could work at reducing the rate of abandonment.

First, say the authors, electronic medical records (EMR) will be able to flag some of these patients. As EMR systems are more commonly used, the technology can play a role in preventing setbacks triggered by noncompliance with a prescribed drug. When pharmacists see a drug returned to their inventory, they can notify the doctor involved, who often can find another medication to treat the condition at a lower cost. Payers can also help by making sure that the copayments for more expensive, and usually more effective, medications are kept low enough so that they aren’t left behind.

Communication helps

In an editorial accompanying the study, Michael D. Murray, PharmD, MPH, and Jeff Harrison, PhD (Murray 2010), noted that other studies have found high rates of nonadherence to a prescribed regimen among new drug users. The two also weren’t too surprised to find that branded drugs were more likely to be abandoned than generics. The whole purpose of a tiered formulary, they wrote, is to steer patients to less-expensive generics and preferred-brand medications obtained at a discount or with additional rebates to help reduce costs for payers. Even though abandoned drugs represent a significant loss for pharmacies as well as a potentially serious setback for the health of patients, the relatively low rate of return to the pharmacy shelves, Murray and Harrison opined, “provides some reassurance that the system is working reasonably well.” Other industries, they noted, don’t come even close when it comes to customer adherence.

The editorial also questioned just how big a role e-prescribing plays in nonadherence, noting that the researchers couldn’t factor in how many patients never bothered to drop off a hard copy of a prescription drug they never intended to take.

“Inflexible systems come with inherent risks, and good communication between providers and patients and among providers remains essential to promote adherence,” wrote Murray and Harrison. “Unfortunately, patients often receive insufficient education and instruction about new medications at either physicians’ offices or pharmacies, and electronic prescribing may be more time-consuming than paper prescribing. More sophisticated electronic prescribing and decision-support programs are required to tackle these issues.”