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Prevalence, Effectiveness, and Characteristics of Pharmacy-Based Medication Synchronization Programs
Alexis A. Krumme, MS; Danielle L. Isaman, BS; Samuel F. Stolpe, PharmD; J. Samantha Dougherty, PhD; and Niteesh K. Choudhry, MD, PhD
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Prevalence, Effectiveness, and Characteristics of Pharmacy-Based Medication Synchronization Programs

Alexis A. Krumme, MS; Danielle L. Isaman, BS; Samuel F. Stolpe, PharmD; J. Samantha Dougherty, PhD; and Niteesh K. Choudhry, MD, PhD
This study evaluates the prevalence, structure, and key features of pharmacy-based programs to synchronize prescription fill dates, about which, little is known.
1. Technology to track patients and identify opportunities. Synchronization on a smaller scale involves patient binders and a “pen-and-paper” approach to fill alignment. More recently, chain and retail pharmacies have implemented automated mechanisms that streamline targeting and management of their synchronized patient populations. One exemplar views the transition from live to automated reminder calls as a critical step in its plans to expand its program more than 20-fold. Technology has also facilitated patient engagement, with regular reminder messaging acting as a consistent link with healthcare providers.

2. Pharmacist consultation to reinforce adherence and link to other services. Exemplars cited the monthly pharmacist appointment as an important opportunity to direct patients to other healthcare services available in the pharmacy, including behavioral counseling and medication therapy management services. One exemplar plans to provide periodic glycated hemoglobin testing to program enrollees with diabetes, while another has embedded its pilot synchronization program into an existing compliance program in which pharmacists communicate adherence scores to patients. Several exemplars use pre-visit calls and monthly appointments to provide vaccination reminders and introductions to smoking cessation counseling.

3. Care integration. Exemplars from independent pharmacies noted the importance of integration with a patient’s primary care physician. One exemplar contacts hospitals for discharge orders to enable medication reconciliation with the physician, while another employs staff whose role is to relay acute health changes to a clinical staff member and follow up with the patient, caregiver, or physician, as needed. Both exemplars reported screening for therapeutic deficiencies and communicating these to the patient’s primary care provider at program start and throughout follow-up.

4. Flexible solutions for patients. Program flexibility and patient autonomy have been important in overcoming barriers to adoption and use. Across all programs, patients can select their synchronization start date and the timing of their refills, which allows them to manage co-payments around paycheck schedules or other budgetary constraints. Pharmacists across several programs can adjust fill dates to coincide with a paycheck or anchor the synchronization to the most expensive co-payment and supply remaining medications at either a reduced cost or free of charge.

Programs have also adjusted patient outreach approaches in response to some patients who dislike receiving automated calls, as seen in one exemplar program that calls all patients with caregivers who pick up their prescriptions. Other exemplars allow patients to opt out of text reminders and to easily be transferred to a live pharmacist during an automated call.

5. Pharmacist buy-in. Exemplars reported instances where pharmacist resistance to synchronization programs resulted in worse performance and slower program roll-outs, highlighting the need for sensitivity to pharmacist workforce culture. Several approaches to improving pharmacist buy-in have been implemented, including tailored training tools and educational materials emphasizing to pharmacists the benefits of practicing “at the top of their license” and having more sustained patient interactions over time, as well as the use of small pilots prior to full roll-out to identify pain points, solicit pharmacist feedback, and refine training materials.

DISCUSSION
Medication synchronization is a novel delivery redesign in pharmacy care that directly addresses complexity in the prescription filling and refilling process, a burden that disproportionately affects the growing number of patients who manage multiple chronic conditions. An estimated 8% of all pharmacies across the country offer a medication synchronization program—a rate that nearly doubled from 2013 to 2014. Today, medication synchronization programs are estimated to have over 1.5 million patients enrolled.

Although synchronization programs have proliferated in the last 2 years, evidence regarding improvements in patient-centered outcomes remains sparse. Results from a recent follow-up study by Holdford et al to their original study15 suggest that synchronization leads to meaningful improvements in adherence. However, none of the studies we identified through an extensive systematic review process robustly accounted for the fact that patients choosing to enroll in a synchronization program may be very measurably different from the general population, and that enrollment may lead to behavior changes that are independent of the program mechanism itself. Moreover, the short length of follow-up and small sample sizes in the studies evaluating cardiovascular biomarkers may have obscured our ability to see an impact on clinical outcomes. Robust research is needed to evaluate the impact of synchronization on clinically relevant outcomes and to compare effectiveness across programmatic features. Further, synchronization programs may confer additional benefits to patients that have not been measured by existing studies, such as improvements in patient safety and increased patient engagement through routine monthly appointments with pharmacists.

All existing synchronization programs are based on 2 standard program models; however, several additional features have contributed to the success and growth of these programs, including technology to track and recruit patients, links to other healthcare services, and flexible solutions for patients to manage medication costs and communication preferences. Interestingly, the exemplar programs we interviewed generally did not report relying on integration with care providers, seeing the monthly pharmacist appointment as sufficient to track changes in therapy regimens over time. It is not clear whether such a minimal level of care integration will serve the longer-term health of patients. Already, several studies have demonstrated the benefit of physician–pharmacist collaborations in chronic disease management and that alternative care models, such as embedded pharmacists in patient-centered medical homes, may provide better clinical outcomes at lower cost to payers.27,28

Meanwhile, recent studies of retail clinics found in many pharmacies suggest that the use of such clinics for the management of chronic conditions may disrupt continuity of care.29 Finally, more consideration will be needed regarding critically ill patients, particularly those with mental disabilities and those who rely on caregivers to pick up their medications.

Longer fills of chronic medications have become an important feature of pharmacy benefit design, with many plans requiring that such medications be filled by mail. To the extent that patients are restricted by mail order requirements, synchronization programs available at retail pharmacies may result in incomplete synchronization for such patients. Development of an analogous or complementary mail order program may be able to respond to these gaps in synchronization; however, they may also add complexity if patients are in 2 different synchronization programs simultaneously. A larger body of evidence—one that engages in comparative evaluations of medication synchronization program elements—will go a long way in demonstrating which interventions are most effective and transportable to other populations.

Exemplar programs did not report program cost as a major obstacle to growth, nor did they express concern over lost revenue due to reduced foot traffic in pharmacies. Program cost may not be an immediate concern if some program costs are recouped in the increased number of prescriptions that are filled by enrolled patients. Moreover, among chain pharmacies, medication synchronization is part of a larger rebranding strategy. By linking to the increasing number of healthcare services offered at many pharmacies, synchronization programs are expected to generate increased revenue.

A significant business strategy that several exemplar programs acknowledged is the use of synchronization programs to build relationships with healthcare payers. In so-called “narrow networks,” payers contract with pharmacies to generate preferred access to their patient populations in exchange for lower reimbursement rates.30 Synchronization programs have already attracted potential Medicare Part C and D sponsors by demonstrating improved adherence Star Ratings results, which for Part C sponsors are tied to increased reimbursement from CMS.31

Such agreements between payers and pharmacies may translate into less choice for patients regarding programs and whether to enroll at all. Conversely, if programs target specific groups of patients, such as those with higher costs, other patients who stand to benefit from synchronization may be excluded. Other shifts in program features aimed at reducing payer healthcare expenditures, such as automatic refilling or at mail refills only, may perversely result in reduced adherence if patients perceive these changes as restrictive or inconvenient.

A final area of change already underway is a legislative push to compel payers to allow partial co-payments for short fills of medications. A Medicare 2014 call letter requires sponsors to offer partial co-payments, with the specific mention of medication synchronization.32 Following CMS’ lead, legislative bills have been introduced in 13 states and approved in 3 that require payers to allow partial co-payments for partial fills. Detractors of legislation argue that allowing partial fills would result in a costly administrative burden for pharmacy benefits managers and would raise healthcare costs.

Limitations

As the landscape of these programs is rapidly evolving, our methodology may underreport the current number of programs and enrolled patients, as well as the wide array of program elements being implemented. Although we relied on impartial expert sources for this information, no formal nationwide estimation has taken place. Nonetheless, we believe that our approach accurately captures predominant trends while minimizing methodological bias. Additionally, because our results were based on experts speaking on behalf of exemplar programs, our findings may not be generalizable to all synchronization programs. We attempted to minimize such bias by forming a priori hypotheses about programmatic features and by not distributing questions to participants ahead of the interview.

CONCLUSIONS
As synchronization programs take on new directions and compete for patients and payer resources, it will be more important than ever to rigorously evaluate their ability to improve clinical outcomes while also providing the growing number of patients managing multiple chronic conditions with the highest level of patient engagement and consumer choice.

Author Affiliations: Division of Pharmacoepidemiology and Pharmacoeconomics (AAK, DLI, NKC), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; Pharmacy Quality Alliance (SFS), West Springfield, VA; Pharmaceutical Research Manufacturers of America (JSD), Washington, DC.

Source of Funding: This work was supported by an unrestricted grant from Pharmaceutical Research Manufacturers of America (PhRMA) to Brigham and Women’s Hospital.

Author Disclosures: Dr Stolpe received a grant for an unrelated research project on medication synchronization from Pfizer in 2013. Dr Choudhry received a grant from PhRMA to his hospital for this study. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AAK, DLI, JSD, SFS, NKC); acquisition of data (SFS, NKC); analysis and interpretation of data (AAK, DLI, SFS, NKC); drafting of the manuscript (AAK, DLI, JSD, SFS, NKC); critical revision of the manuscript for important intellectual content (AAK, JSD, SFS, NKC); obtaining funding (NKC); administrative, technical, or logistic support (AAK, DLI, SFS); and supervision (AAK, NKC).

Address correspondence to: Niteesh K. Choudhry, MD, PhD, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, Ste 3030, Boston, MA 02120. E-mail: nchoudhry@partners.org.
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