Currently Viewing:
The American Journal of Managed Care March 2016
Understanding Vaccination Rates and Attitudes Among Patients With Rheumatoid Arthritis
Diana S. Sandler, MD; Eric M. Ruderman, MD; Tiffany Brown, MPH; Ji Young Lee, MS; Amanda Mixon, PA; David T. Liss, PhD; and David W. Baker, MD, MPH
Remembering the Strength of Weak Ties
Brian W. Powers, AB; Ashish K. Jha, MD, MPH; and Sachin H. Jain, MD, MBA
Currently Reading
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
Trends in Hospital Ownership of Physician Practices and the Effect on Processes to Improve Quality
Tara F. Bishop, MD, MPH; Stephen M. Shortell, PhD, MPH, MBA; Patricia P. Ramsay, MPH; Kennon R. Copeland, PhD; and Lawrence P. Casalino, MD, PhD
Organizational Structure for Chronic Heart Failure and Chronic Obstructive Pulmonary Disease
Seppo T. Rinne, MD, PhD; Chuan-Fen Liu, PhD; Edwin S. Wong, PhD; Paul L. Hebert, PhD; Paul Heidenreich, MD; Lori A. Bastian, MD; and David H. Au, MD
Value of Primary Care Diabetes Management: Long-Term Cost Impacts
Daniel D. Maeng, PhD; Xiaowei Yan, PhD; Thomas R. Graf, MD; and Glenn D. Steele, Jr, MD, PhD
The Budget Impact of Cervical Cancer Screening Using HPV Primary Screening
Thomas Wright, MD; Joice Huang, PharmD, MBA; Edward Baker, MD; Susan Garfield, DrPH; Deanna Hertz, MHEcon; and J. Thomas Cox, MD
National Estimates of Price Variation by Site of Care
Aparna Higgins, MA; German Veselovskiy, MPP; and Jill Schinkel, MS
LDL Cholesterol Response and Statin Adherence Among High-Risk Patients Initiating Treatment
Suma Vupputuri, PhD, MPH; Peter J. Joski, MS; Ryan Kilpatrick, PhD; J. Michael Woolley, PhD; Brandi E. Robinson, MPH; Michael E. Farkouh, MD, MSc; Huifeng Yun, PhD; Monika M. Safford, MD; and Paul Muntner, PhD

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.

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.


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.

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:

1. Noncommunicable diseases: fact sheet, 2015. World Health Organization website. Updated January 2015. Accessed March 12, 2015.

2. Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933-944. doi: 10.1161/CIR.0b013e31820a55f5.

3. Heart disease facts. CDC website. Updated August 10, 2015. Accessed August 2015.

4. National diabetes statistics report, 2014: estimates of diabetes and its burden in the United States. CDC website. Published 2014. Accessed March 12, 2015.

5. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645.

6. Adherence to long-term therapies: evidence for action. World Health Organization website. Published 2003. Accessed December 4, 2014.

7. Corsonello A, Pedone C, Lattanzio F, et al. Regimen complexity and medication nonadherence in elderly patients. Ther Clin Risk Manag. 2009;5(1):209-216.

8. Choudhry NK, Fischer MA, Avorn J, et al. The implications of therapeutic complexity on adherence to cardiovascular medications. Arch Intern Med. 2011;171(9):814-22.

9. Ingersoll KS, Cohen J. The impact of medication regimen factors on adherence to chronic treatment: a review of literature. J Behav Med. 2008;31(3):213-24. doi:10.1007/s10865-007-9147-y.

10. Ross A, Jami H, Young HA, Katz R. Sync and swim: the impact of medication consolidation on adherence in medicaid patients. J Prim Care Community Health. 2013;4(4):240-244. doi:10.1177/2150131913486481.

11. Agarwal S, Tang SS, Rosenberg N, et al. Does synchronizing initiation of therapy affect adherence to concomitant use of antihypertensive and lipid-lowering therapy? Am J Ther. 2009;16(2):119-26. doi:10.1097/MJT.0b013e31816b69bc.

12. Delate T, Fairman KA, Carey SM, Motheral BR. Randomized controlled trial of a dose consolidation program. J Manag Care Pharm. 2004;10(5):396-403.

13. Pharmacy’s appointment based model: a prescription synchronization program that improves adherence. American Pharmacists Association Foundation website. Published August 30, 2013. Accessed December 1, 2014.

14. Holdford DA, Inocencio TJ. Adherence and persistence associated with an appointment-based medication synchronization program. J Am Pharm Assoc (2003). 2013;53(6):576-583. doi:10.1331/JAPhA.2013.13082.

15. Holdford DA, Saxena K. Impact of appointment-based medication synchronziation on existing users of chronic medications. J Manage Care Spec Pharm. 2015;21(8):662-669.

16. Datar M, Banahan BF, Hardwick S, Clark J. Analysis of the impact of prescription synchronization on adherence among Medicaid beneficiaries. Value Health. 2013;16:A1-A298.

17. Holdford D, Inocencio T. Patient Centric Model: Pilot data analysis report. Prepared for the Alliance for Patient Medication Safety. American Pharmacists Association website.  Published April 2011. Accessed December 1, 2014.

18. Banahan BF, Bynum LA, Holmes ER. Implementing a new prescription synchronization program that positively influences patient medication compliance. Presented at the: American Pharmacists Association Annual Meeting and Expo; March 25-28, 2011; Seattle, WA.

19. Datar M, Banahan BF, Hardwick S, Clark J. Analysis of the impact of prescription synchronization on adherence among medicaid beneficiaries. Presented at the: Annual International Meeting of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR); May 18-22, 2013; New Orleans, LA. Accessed April 12, 2013.

20. Schmidt T, Ramirez S, Davis J, Henson J, McLeod R. Evaluating prescription synchronization and medication management in a community pharmacy [unpublished]. Portland, OR; Fred Meyer-Oregon State University; 2010.

21. DiDonato KL, Vetter KR, Liu Y, May JR, Hartwig DM. Examining the effect of a medication synchronization or an education program on health outcomes of hypertensive patients in a community pharmacy setting. Inov Pharm. 2014;5(3): article 175.

22. Improving adherence in appointment-based model. American Pharmacists Association Foundation website. Published November 1, 2013. Accessed August 28, 2014.

23. Watson L. Pharmacy’s Appointment-Based Model: implementation guide for pharmacy practices. American Pharmacists Association Foundation website. Published 2013. Accessed August 28, 2014.

24. Simplify My Meds: pharmacy operations manual. National Community Pharmacists Association website. Published January 2013. Accessed August 28, 2014.

25. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497.

26. Ateb, Inc. Assessing the impact of a community pharmacy-based medication synchronization program on adherence rates. National Community Pharmacists Association website. Published December 10, 2013. Accessed December 11, 2014.

27. Howard-Thompson A, Farland MZ, Byrd DC, et al. Pharmacist-physician collaboration for diabetes care: cardiovascular outcomes. Ann Pharmacother. 2013;47(11):1471-1477. doi:10.1177/1060028013504738.

28. Hirsch JD, Steers N, Adler DS, et al. Primary care-based, pharmacist-physician collaborative medication-therapy management of hypertension: a randomized, pragmatic trial. Clin Ther. 2014;36(9):1244-1254. doi:10.1016/j.clinthera.2014.06.030.

29. Reid RO, Ashwood JS, Friedberg MW, Weber ES, Setodji CM, Mehrotra A. Retail clinic visits and receipt of primary care. J Gen Intern Med. 2013;28(4):504-512. doi:10.1007/s11606-012-2243-x.

30. The transformation of pharmacy: understanding and leveraging the rapidly changing retail environment. McKesson Corporation website. Published September 2014. Accessed December 15, 2014.

31. Trends in Part C & D star rating measure cut points. CMS website. Accessed May 8, 2014.

32. Advance notice of methodological changes for calendar year (CY) 2014 for Medicare advantage (MA) capitation rates, Part C and Part D payment policies and 2014 call letter. CMS website. Published February 15, 2013. Accessed August 29, 2014. 
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up