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The American Journal of Managed Care September 2016
Implications of Evolving Delivery System Reforms for Prostate Cancer Care
Brent K. Hollenbeck, MD, MS; Maggie J. Bierlein, MS; Samuel R. Kaufman, MS; Lindsey Herrel, MD; Ted A. Skolarus, MD, MPH; David C. Miller, MD, MPH; and Vahakn B. Shahinian, MD
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Amol S. Navathe, MD, PhD; Aditi P. Sen, MA; Meredith B. Rosenthal, PhD; Robert M. Pearl, MD; Peter A. Ubel, MD; Ezekiel J. Emanuel, MD, PhD; Kevin G. Volpp, MD, PhD
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Cost-Benefit of Appointment-Based Medication Synchronization in Community Pharmacies
Julie A. Patterson, BS; David A. Holdford, PhD, MS, BSPharm; and Kunal Saxena, PhD, MS
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Vivian Ho, PhD; Timothy K. Allen, PhD; Urie Kim, BBA; William P. Keenan, BA; Meei-Hsiang Ku-Goto, MA; and Mark Sanderson, PhD
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Robert S. Rudin, PhD; Eric C. Schneider, MD, MSc; Zachary Predmore, BA; and Courtney A. Gidengil, MD, MPH
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James D. Chambers, PhD; Matthew D. Chenoweth, MPH; and Peter J. Neumann, ScD
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Cost-Benefit of Appointment-Based Medication Synchronization in Community Pharmacies

Julie A. Patterson, BS; David A. Holdford, PhD, MS, BSPharm; and Kunal Saxena, PhD, MS
This study conducted a cost-benefit analysis of appointment-based medication synchronization for improving adherence in patients on chronic medications for hypertension, hyperlipidemia, and diabetes.

Objectives: To evaluate the cost-benefit of appointment-based medication synchronization (ABMS) offered in community pharmacies for patients taking chronic medications to prevent negative outcomes associated with hyperlipidemia, hypertension, and diabetes.

Study Design: Decision-tree analysis based on published literature and publicly available data.

Methods: Program benefits were based on linking published findings of improvements in medication adherence due to the implementation of an ABMS program to a claims-based study of disease-related medical costs associated with different levels of adherence. The direct cost of the program—increased medication utilization as a result of improved adherence—was calculated from publicly available prescription pricing data. Benefit-cost ratios were assessed from a payer perspective over a 1-year time frame.

Results: Additional medication expenditures due to improved adherence associated with ABMS enrollment were offset by lower disease-specific medical costs. Medical savings per additional dollar spent on medications ranged from approximately $1 to $37 depending on the medication and medication class considered. ABMS was most cost-beneficial for metformin and statins. Sensitivity analyses showed that cost-benefit was significantly impacted by medication costs and any service fees associated with ABMS.

Conclusions: ABMS programs have been shown to increase medication adherence in patients taking chronic medications. These programs were shown to have a significant cost-benefit for healthcare payers by reducing medical utilization and costs. Payers should consider supporting the provision of these programs in community pharmacies.

Am J Manag Care. 2016;22(9):587-593
Take-Away Points

Appointment-based medication synchronization (ABMS) programs in community pharmacies have been shown to increase medication adherence in patients taking chronic medications.  
  • Medication expenditures due to improved adherence associated with ABMS enrollment were offset by lower disease-specific medical costs. 
  • Economic analyses suggest that ABMS programs offer a significant cost-benefit to payers. 
  • Payers should consider supporting the provision of ABMS programs in community pharmacies.
Medication nonadherence is a major barrier to the provision of effective pharmacotherapy in patients with chronic conditions, and it is also associated with negative health outcomes and increased risks of hospitalization and mortality in patients with a variety of disease states, including cardiovascular conditions and diabetes.1-3 It is estimated that 33% to 69% of medicine-related hospitalizations are caused by poor adherence.4 Additionally, medication nonadherence accounts for projected annual US healthcare expenditures of $100 to $300 billion4; improving adherence, on the other hand, has been projected to result in annual per-person savings ranging from $1000 to over $7000 depending on the disease state.5,6 These savings reflect the association between poor adherence and increased nursing home admissions, physician visits, and hospitalizations and are robust even after controlling for healthy adherer behaviors.1,2,7-9

Although studies vary in their estimated rates of nonadherence for long-term medications, most studies report adherence at approximately 50%.10-12 Rates of adherence tend to decline over time and are lower in patients who are prescribed multiple chronic medications.13,14 Adherence appears to be similarly low among patients with hypertension, type 2 diabetes, or hyperlipidemia.10,15

Causes of medication nonadherence are multifactorial and often involve interconnecting patient, treatment plan, and healthcare system factors.4,16 Efforts to improve adherence often fail to achieve long-term desired results because they are too narrow in scope. Interventions, such as drug reminder packaging, mobile text messaging, and written and oral education, have inconsistent impact on both measures of adherence and clinical outcomes.17-19 Even when the scope of interventions is more ambitious, as with comprehensive medication therapy management, programs are not sustainable because they are often labor-intensive and costly.20

Pharmacists are well-positioned to impact patient adherence, particularly in community pharmacy settings.21 Regular pharmacist–patient communication and monitoring has consistently been linked to improved adherence.22,23 Still, current community pharmacy efforts at counseling, monitoring, and education show variable rates of success.24,25

Appointment-based medication synchronization (ABMS)—a system that offers individualized solutions to patients’ medication-related barriers—has been suggested as an effective and sustainable way of improving medication adherence in community pharmacies.26,27 In ABMS, pharmacists work with patients to synchronize their chronic medications to be filled on a single day each month. Prior to this date every month, pharmacists review patients’ medications, address patient concerns, and discuss any changes to the medication regimen. This system is designed to simplify the complexity of patients’ medication regimens and provide opportunities for consistent pharmacist–patient communications, which can help to clarify, modify, and enhance patient therapy. Communications with physicians are also enhanced through a formal process of physician contact regarding patient enrollment in the program and periodic calls to address medication therapy issues.

ABMS has demonstrated significant impact on patient adherence and persistence for chronic medications.27,28 A study in rural pharmacies in the midwestern United States showed that patients enrolled in an ABMS program who newly started a chronic medication had 3.4 to 6.1 times greater odds of adherence over a 1-year period than matched comparisons.27 Another study, of Ohio pharmacies with patients who had been taking chronic medicines for 6 months or more, indicated 2.3 to 3.6 times greater odds of adherence over a 1-year period with ABMS.28 These studies indicate that ABMS can be effective in improving medication adherence and, thereby, possibly improve health outcomes; however, there have been no analyses of the economic consequences of these programs.

The objective of this study was to model the economic impact of ABMS in community pharmacies for patients taking medications to prevent negative outcomes associated with diabetes, hypertension, and hyperlipidemia. The analysis was conducted from the perspective of a healthcare payer who wants to quantify the value to chronic disease populations of individuals enrolling in ABMS programs offered by community pharmacies.


The patients studied in the ABMS program consisted of adults who had been taking chronic medicines for 6 months or more and received at least 2 refills for at least 1 of 6 types of chronic disease medication categories. The medication classes studied were angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), beta-blockers (BBs), dihydropyridine calcium channel blockers (DCCBs), thiazide diuretics, metformin, and statins. Patients who opted into the ABMS program were matched with control patients who received standard pharmacy dispensing services. Matching was done according to patient history of prior adherence behavior, medication class, age, gender, and geographic region.

A decision-tree analysis (eAppendix, available at was constructed to model the cost-benefit of ABMS programs when compared with standard community pharmacy dispensing practices. The results of separate cost-benefit analyses for each medication class were presented with benefit-cost ratios calculated as follows:

Total Disease-Specific Direct Medical Costs Saved Due to Improved Medication Adherence Associated With ABMS (Diabetes, Hypertension, Hyperlipidemia) /

Total Medication Costs Added Due to Improved Medication Adherence Associated With ABMS

The model estimated, in US dollars, the benefit of the program on reduced disease-specific health expenditures over a 1-year period, relative to additional medication costs. Program benefits came from projecting how improvements in medication adherence due to the program would reduce medical costs for the treatment of the disease state associated with each medication class. This was done by matching adherence levels to chronic medications reported in an ABMS study,28 with research linking the same adherence with disease-related medical costs (Table 1).5 Program costs were estimated based on the average cost per prescription refill and the number of additional fills due to improved adherence.

Adherence data for the base-case model came from the Ohio ABMS study of individuals on the chronic medications for at least 6 months.28 The proportion of days covered (PDC)—a ratio of the number of days covered by prescription fills divided by the total number of days in a study period—was used to measure adherence. PDC scores range from 0 to 1, with larger proportions indicating greater adherence. The PDC scores for patients from the study28 were stratified into 5 categories (PDC scores of 1%-20%, 21%-40%, 41%-60%, 61%-80%, and 81%-100%) to match utilization data in the study linking medication adherence with disease-related medical costs.5 

To model the relationship between medication adherence and disease-specific medical costs, indications needed to be assigned to the medication classes. The indication for ACE inhibitors/ARBs, BBs, DCCBs, and thiazide diuretics was assumed to be hypertension.29 Metformin and statins were assumed to be treating diabetes and hyperlipidemia, respectively. This allowed each of the 5 levels of adherence (1%-20%, 21%-40%, 41%-60%, 61%-80%, 81%-100%) to be matched with data from research linking these medication adherence levels with disease-related healthcare costs.5

Additional costs associated with ABMS in the base case came from the increased medication costs that resulted from a higher number of annual medication refills. In the calculation of medication cost per fill, the price of the medication from each class with the highest total prescriptions in 2012 was assumed to be representative of the entire class.30 These representative drugs were lisinopril (ACE inhibitors/ARBs), simvastatin (statins), metoprolol (BBs), amlodipine (DCCBs), hydrochlorothiazide (thiazide diuretics), and metformin (diabetic medications). Cost per fill was calculated at an assumed cost of average wholesale price (AWP) minus 70% to reflect generic drug pricing.31-34

Sensitivity analyses were conducted on key variables in the model. These variables included the relative effectiveness of ABMS compared with usual care on medication adherence, cost of chronic medications, medical costs, patient cost sharing, and addition of a service fee for the program.


Adherence data for comparing ABMS with controls are presented in Table 2. Significantly more patients in the ABMS program had PDC scores of 81% to 100%, whereas patients in the comparison group had more patients in categories with lower PDC scores.

Table 3 shows disease-related medical costs for levels of medication adherence adjusted to 2015 costs, according to the medical inflation index.35 With the exception of drug costs, which increased with greater adherence, direct medical costs were much lower, on average, for patients with higher PDC scores.

Benefit-cost ratios for 6 medication classes were reported (Table 4). In base-case analyses of the cost-benefit, ABMS enrollment was associated with slight increases in medication expenditures due to improved adherence, but lower disease-specific medical costs. Medical savings per additional dollar spent on medications ranged from $1.25 to almost $37 depending on the medication class. ABMS yielded the greatest benefit relative to costs for metformin and statins and lower benefits relative to costs for thiazide diuretics and ACE inhibitors/ARBs.

One-way sensitivity analyses varied the medication costs from as low as Veterans’ Health Administration (VA) costs, obtained from the National Acquisition Center website, to as high as the AWP. Additional medication costs included in the sensitivity analyses included AWP minus 50% (AWP – 50%) and AWP minus 30% (AWP – 30%) (Table 4).36 In additional 1-way sensitivity analyses, disease-specific medical costs and the PDC distribution of ABMS patients were each increased and decreased by 20%. (Table 5).

The impact of adding a service fee to ABMS programs was also examined in sensitivity analyses. ABMS is currently offered free of charge by most pharmacies, so the effect of annual per-patient fees of $100, $150, and $200 for program enrollment was explored in sensitivity analyses. In addition, co-payments of $5 and $10 per fill were included in sensitivity analyses to reflect average cost-sharing arrangements with patients.37 Discounting was not performed because both costs and outcomes occurred within a 1-year period.

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