Experts Say DTC Models Offer Flexibility, but Higher Costs May Limit Medication Adherence

The American Journal of Managed Care^® explored the potential of direct-to-consumer (DTC) models to improve medication adherence and outcomes compared with traditional pharmacy channels through interviews with Jennifer Graff, PharmD, of Innov8 Health Policy; Joey Mattingly, PharmD, MBA, PhD, of the University of Utah College of Pharmacy; and Brian Reid, MS, of Reid Strategic.

The experts note that determining adherence under these models is challenging, as the measurement often relies on insurance claims. They also explain that while the flexibility and incentives of DTC models could encourage more consistent medication use, higher costs may reduce adherence.

Learn more about the potential benefits of DTC models for patients here.

This transcript has been lightly edited for clarity; captions were auto-generated.

Transcript

How do DTC models influence medication adherence and clinical outcomes compared with traditional pharmacy channels?

Graff: There's no one-size-fits-all for a DTC model, so some have partnered with a specialty pharmacy to deliver all of that care. In that system, specialty pharmacy providers, such as Alto Pharmacy, etc, can provide all the same medication therapy management and potentially even improved medication adherence and support services because they're in touch with that individual.

Beyond that, for those programs where the DTC model provides a prescription and offers the price for you to go and fill at your local pharmacy, you'll have similar medication adherence and support services, just as you would if it were getting paid for by your health plan and was prescribed by your local physician.

I think the third piece, and there are some models, for instance, LillyDirect, that allow you to use your own provider if they're part of that network. In that case, it's a payment mechanism, not necessarily how you receive the medication, that's different. We've seen that this really matters, not only to individual consumers, but we're seeing some employers beginning to sign up for these direct-to-consumer models, anywhere from Amazon and the state of Indiana to QuickTrip gas stations and some smaller groups. Employers are seeing this as an important piece, especially when they look at their health care spending, and they see that certain medication classes or drugs are their number 1, 2, and 3 health care spend each year.

Mattingly: When we talk about adherence, the challenge that we have is that when we measure adherence, we need to see that a patient is getting the medication and taking the medication. Measuring adherence is one of the most difficult things when you're looking at a population of 350 million people.

One way that we typically do it is through the health insurance plan. If I go to 3 different pharmacies, 1 each month, because maybe there are a couple in my area, and 1 was closer to my house, 1 was closer to my work, and I just picked up the same medication at 2 different places, it's difficult to see, if I'm not using my health insurance, it's difficult to see, from a data perspective, that I've been taking my medication appropriately. But the health insurance plan sees the claims from, say, Walgreens, Walmart, and Kroger, or whatever, so the insurance company will know that you've gotten the medication.

We've actually used health insurance claims, administrative claims, as a way of measuring adherence. Is it a perfect measure of adherence? No, because I could get a medication and throw it away or not take it appropriately. So, there are different ways of measuring adherence. If we get into the component of cost, if the cost is lower, so maybe if the drug was more expensive through the patient's insurance and they could get it cheaper direct-to-consumer, then there's absolutely a potential benefit in adherence gains. But the challenge is going to be measuring the adherence, so making sure they actually get the medication, that they're taking the medication appropriately, and that there are no gaps in care.

Reid: I don't think we have good answers to the question of: how do [DTC models influence adherence] or do they? Is this a binary question, that yes, direct-to-consumer is better or worse? You can certainly think of theories that work both ways. Obviously, anytime something is more expensive, if you have the choice between getting a fully insured product through your benefit, that's oftentimes going to be cheaper than getting something direct to consumer. There's probably a trade-off there; more expensive products tend to have lower adherence.

On the other hand, the flexibility of the direct-to-consumer offerings really allows you to do different things. You've seen some of the companies involved here say, "Look, we will offer you this medicine at a lower price if it gets filled on a regular basis and if you can kind of act in a way that is consistent with you being adherent."

There are ways of kind of nudging, using the apparatus of direct-to-consumer, nudging patients towards better adherence. I've talked to some executives who are thinking about how you build additional structures on top of the plumbing of direct-to-consumer that would allow you to kind of fine-tune benefit decisions in ways that may reward better adherence.

On the one hand, saying anything that's going to be more expensive is probably going to lead to worse adherence. On the other hand, the tools in the toolbox that direct-to-consumer offers may present some other opportunities.