The Longitudinal Impact Of A Multistate Commercial Accountable Care Program On Cost, Use, And Quality.

The prevalence of accountable care organizations (ACOs) has grown significantly across Medicare and commercial payers in the past decade, but there are limited insights regarding the effect of ACOs on costs in the commercial population. We used longitudinal administrative claims data over the course of nineteen calendar quarters from 2016 to 2021 to assess the ongoing incremental impact of Elevance Health's commercial ACO program on cost and use across fifteen US states. We also analyzed the program's impact on spending subcategories (inpatient, outpatient, professional, and pharmacy) and measured differences in quality performance. The program was associated with incremental savings during this period. Incremental savings were greater in the fully insured population relative to the administrative services only population and were due to outpatient and pharmacy savings. ACO providers had superior quality performance measures relative to contracted providers not participating in ACOs. Payers should be aware of the potential for diminishing marginal returns of ACO contracting on containing health care costs.

The impact of a retail prescription synchronization program on medication adherence.

OBJECTIVES: To understand the impact of prescription synchronization, offered through the ScriptSync® program at CVS pharmacies nationwide, on adherence and reducing visits to the pharmacy. DESIGN: Cohort study, conducted between March 26, 2015, and December 18, 2015. Program enrollment occurred in August 2015, with a 120-day baseline period preceding enrollment and a 120-day follow-up period. SETTING AND PARTICIPANTS: CVS retail community pharmacies across the United States. CVS Pharmacy patients voluntarily enrolling in the prescription synchronization program at CVS retail community pharmacies across the United States who filled 3 or more eligible prescriptions before program enrollment. The study included 126,597 patients who enrolled in the program and 81,355 patients who enrolled after the study enrollment period. OUTCOME MEASURES: Adherence was defined as the medication possession ratio. The average number of pharmacy visits per month was a second outcome measure. RESULTS: Exposed patients had a 7.5 percentage point adherence improvement (from 79.6% to 87.1%), compared with a 2.8 percentage point improvement among the unexposed (from 78.1% to 80.9%) for a benefit of 4.7 percentage points (P < 0.0001). Among patients with adherence opportunities, the net impact on adherence was 10.6% (P < 0.0001). The program resulted in 0.17 fewer visits per month (P < 0.0001). CONCLUSION: Offering prescription refill synchronization at a large national retail pharmacy chain resulted in improved adherence and fewer visits to the pharmacy in the 4 months following ScriptSync enrollment. Prescription refill synchronization programs should be considered in the care of patients with multiple comorbidities.

Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial.

Importance: Forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices. Objective: To compare the effect of 3 low-cost reminder devices on medication adherence. Design, Setting, and Participants: This 4-arm, block-randomized clinical trial involved 53 480 enrollees of CVS Caremark, a pharmacy benefit manager, across the United States. Eligible participants were aged 18 to 64 years and taking 1 to 3 oral medications for long-term use. Participants had to be suboptimally adherent to all of their prescribed therapies (with a medication possession ratio of 30% to 80%) in the 12 months before randomization. Participants were stratified on the basis of the medications they were using at randomization: medications for cardiovascular or other nondepression chronic conditions (the chronic disease stratum) and antidepressants (the antidepressant stratum). In each stratum, randomization occurred within blocks defined by whether all of the patient's targeted medications were dosed once daily. Patients were randomized to receive in the mail a pill bottle strip with toggles, digital timer cap, or standard pillbox. The control group received neither notification nor a device. Data were collected from February 12, 2013, through March 21, 2015, and data analyses were on the intention-to-treat population. Main Outcomes and Measures: The primary outcome was optimal adherence (medication possession ratio ≥80%) to all eligible medications among patients in the chronic disease stratum during 12 months of follow-up, ascertained using pharmacy claims data. Secondary outcomes included optimal adherence to cardiovascular medications among patients in the chronic disease stratum as well as optimal adherence to antidepressants. Results: Of the 53 480 participants, mean (SD) age was 45 (12) years and 56% were female. In the primary analysis, 15.5% of patients in the chronic disease stratum assigned to the standard pillbox, 15.1% assigned to the digital timer cap, 16.3% assigned to the pill bottle strip with toggles, and 15.1% assigned to the control arm were optimally adherent to their prescribed treatments during follow-up. There was no statistically significant difference in the odds of optimal adherence between the control and any of the devices (standard pillbox: odds ratio [OR], 1.03 [95% CI, 0.95-1.13]; digital timer cap: OR, 1.00 [95% CI, 0.92-1.09]; and pill bottle strip with toggles: OR, 0.94 [95% CI, 0.85-1.04]). In direct comparisons, the odds of optimal adherence were higher with a standard pillbox than with the pill bottle strip (OR, 1.10 [95% CI, 1.00-1.21]). Secondary analyses yielded similar results. Conclusions and Relevance: Low-cost reminder devices did not improve adherence among nonadherent patients who were taking up to 3 medications to treat common chronic conditions. The devices may have been more effective if coupled with interventions to ensure consistent use or if targeted to individuals with an even higher risk of nonadherence. Trial Registration: clinicaltrials.gov Identifier: NCT02015806.

Association among change in medical costs, level of comorbidity, and change in adherence behavior.

OBJECTIVES: Interventions to improve medication adherence are effective, but resource intensive. Interventions must be targeted to those who will potentially benefit most. We examined what heterogeneity exists in the value of adherence based on levels of comorbidity, and the changes in spending on medical services that followed changes in adherence behavior. STUDY DESIGN: Retrospective cohort study examining medical spending for 2 years (April 1, 2011, to March 31, 2013) in commercial insurance beneficiaries. METHODS: Multivariable linear modeling was used to adjust for differences in patient characteristics. Analyses were performed at the patient/condition level in 2 cohorts: adherent at baseline and nonadherent at baseline. RESULTS: We evaluated 857,041 patients, representing 1,264,797 patient therapies consisting of 40% high cholesterol, 48% hypertension, and 12% diabetes. Among those with 3 or more conditions, annual savings associated with becoming adherent were $5341, $4423, and $2081 for patients with at least diabetes, hypertension, and high cholesterol, respectively. The increased costs for patients in this group who became nonadherent were $4653, $7946, and $4008, respectively. Depending on the condition and the direction of behavior change, savings were 2 to 7 times greater than the value for individuals with fewer than 3 conditions. In most cases, the value of preventing nonadherence (ie, persistence) was greater than the value of moving people who are nonadherent to an adherent state. CONCLUSIONS: There is important heterogeneity in the impact of medication adherence on medical spending. Clinicians and policy makers should consider this when promoting the change of adherence behavior.

Rationale and design of the Randomized Evaluation to Measure Improvements in Non-adherence from Low-Cost Devices (REMIND) trial.

BACKGROUND: Long-term adherence to prescription medications for the treatment of chronic disease remains low. While there are many contributors to suboptimal medication use, simple forgetfulness is widely believed to be central. Relatively simple devices may be a particularly cost-efficient and scalable way to promote adherence, however limited data exists about their ability to improve adherence in real-world settings. METHODS/DESIGN: The REMIND trial is a prospective, intent-to-treat randomized control trial to evaluate the impact on medication adherence of three simple, low-cost devices (Take-N-Slide(™), the RxTimerCap(™), and a standard pillbox). In March 2014, we enrolled 53,480 individuals 18 to 64 years old taking one to three medications to treat chronic disease whose prescription drug benefits were administered by CVS Caremark. The study's primary outcome is optimal adherence over the 12-month period after randomization. Using a randomization ratio of 1:2 between control and each intervention arm, the study has more than 80% power with an alpha of 5% to detect a 1% difference in the rate of optimal adherence between intervention and control groups and across intervention arms. DISCUSSION: The REMIND trial is the first randomized study to rigorously evaluate the impact of simple, low-cost reminder devices on medication adherence. The results will inform comparative cost effectiveness studies of reminder systems in improving medication adherence and clinical outcomes.

Five features of value-based insurance design plans were associated with higher rates of medication adherence.

Value-based insurance design (VBID) plans selectively lower cost sharing to increase medication adherence. Existing plans have been structured in a variety of ways, and these variations could influence the effectiveness of VBID plans. We evaluated seventy-six plans introduced by a large pharmacy benefit manager during 2007-10. We found that after we adjusted for the other features and baseline trends, VBID plans that were more generous, targeted high-risk patients, offered wellness programs, did not offer disease management programs, and made the benefit available only for medication ordered by mail had a significantly greater impact on adherence than plans without these features. The effects were as large as 4-5 percentage points. These findings can provide guidance for the structure of future VBID plans.

Injectable tumor necrosis factor α inhibitors and outpatient antimicrobial use in children with rheumatic diseases: analyses of prescription claims from a pharmacy benefit manager database.

OBJECTIVE: To estimate the incidence and rate of outpatient antibiotic and antiviral medication use among children receiving methotrexate and/or an injectable tumor necrosis factor α (iTNFα) inhibitor (etanercept and/or adalimumab)and to compare these rates with those of a control population. METHODS: Data were obtained from a pharmacy benefit manager (PBM) database. Children were included if they had >1 prescription claim for an iTNFα inhibitor or methotrexate prescribed by a pediatric or adult rheumatologist between 2008 and 2010 and if they were age <18 years at the time of the claim. A control cohort of randomly selected children was generated from the PBM database. Poisson regression was used to compare antimicrobial rate ratios (RRs). Incidence rates and RRs were adjusted for age, sex, and prednisone exposure. RESULTS: In total, 4,312 children were included. The adjusted RRs for antibiotic prescriptions among children receiving methotrexate monotherapy or iTNFα inhibitor and methotrexate combination therapy compared with the control cohort were 2.18 (95% confidence interval [95% CI] 1.92­2.47) and 2.12 (95% CI 1.79­2.50), respectively. The adjusted RRs for antiviral prescriptions among children receiving methotrexate monotherapy or iTNFα inhibitor and methotrexate combination therapy compared with the control cohort were 3.67 (95% CI 1.98­6.78) and 4.34 (95% CI 1.86­10.14), respectively. The RRs for the iTNFα inhibitor group were similar in magnitude. There was no significant difference in RRs between the medication exposure categories for either antibiotic or antiviral prescriptions. CONCLUSION: Children receiving methotrexate and/or an iTNFα inhibitor had higher rates of antibiotic and antiviral use compared with the control cohort. Data sets with additional patient-level and disease-specific data are required to assess this association in more detail.

Methotrexate and injectable tumor necrosis factor-α inhibitor adherence and persistence in children with rheumatic diseases.

OBJECTIVE: To measure adherence and persistence with methotrexate (MTX) and injectable tumor necrosis factor-α (iTNF-α) inhibitors (etanercept, adalimumab) among children prescribed these medications by a rheumatologist. METHODS: Data were obtained from a US pharmacy benefits management firm. Children were included if they were < 18 years of age, had ≥ 1 prescription claim between January 2009 and December 2010 for MTX or an iTNF-α inhibitor that was prescribed by an adult or pediatric rheumatologist. The medication possession ratio (MPR) was calculated for each medication, with MPR ≥ 80% indicating good adherence. MPR were compared by route of administration, age, and by new users versus continuing users. Persistence was measured for new users of each medication from initiation until discontinuation, or for a maximum of 1 year. RESULTS: A total of 1964 children were included. The majority of children had MPR < 80%. Children taking subcutaneous MTX had the lowest mean MPR [46.9%; median 44.9%; interquartile range (IQR) 23%-69.6%] and the lowest persistence, with 26% of children continuing the medication at 1 year. Mean MPR was highest for iTNF-α (65.7%; median 70.1%; IQR 46%-89.3%), as was persistence, with 52% of children continuing the medication at 1 year. Children age < 13 years tended to have higher MPR, but this was statistically significant only for oral MTX (61.1% vs 54.9% in children age ≥ 13 yrs; p = 0.02). CONCLUSION: Adherence and persistence in this cohort varied by medication and route of administration. Both outcomes are important considerations for physicians prescribing these medications in routine clinical care and for the assessment of treatment effectiveness in the research setting.

Are caregivers adherent to their own medications?

OBJECTIVE: To explore caregiver adherence to chronic medications and predictors of appropriate medication use. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: United States in May 2009. PARTICIPANTS: 2,000 adults randomly selected from a large national consumer panel. INTERVENTION: Web-based survey of community pharmacy patients. MAIN OUTCOME MEASURE: Self-reported medication adherence. RESULTS: 21% of those invited (3,775) responded to the survey invitation. Of the 2,000 individuals who were eligible to participate, 38% described themselves as caregivers. Among caregivers, 45% agreed that they were more likely to forget their own medications than medications for their caregivees. Caregivers were 10% more likely to forget to take their medications, 11% more likely to stop taking medications if they felt well, and 13% more likely to forget to refill their medications than noncare-givers (P < 0.001 for all). In fully adjusted models, caregivers had 36% greater odds (95% CI 0.52-0.79) of reporting that they were nonadherent compared with noncare-givers and increased medication use among caregivees was associated with worse adherence among caregivers (P < 0.05). CONCLUSION: Medication nonadherence was common in this population, and caregivers were more likely to report poor medication adherence than noncaregivers. Considering that caregivers often engage health professionals, physicians and pharmacists may choose to screen for caregiving status. Pharmacists are uniquely positioned to intervene to enhance appropriate medication adherence.

Physician perceptions about generic drugs.

BACKGROUND: With constrained health-care resources, there is a need to understand barriers to cost-effective medication use. OBJECTIVE: To study physician perceptions about generic medications. METHODS: Physicians used 5-point Likert scales to report perceptions about cost-related medication nonadherence, the efficacy and quality of generic medications, preferences for generic use, and the implications of dispensing medication samples. Descriptive statistics were used to assess physician perceptions and logistic regression models were used to evaluate predictors of physician perceptions. RESULTS: Among the invited sample, 839 (30.4%) responded and 506 (18.3%) were eligible and included in the final study population. Over 23% of physicians surveyed expressed negative perceptions about efficacy of generic drugs, almost 50% reported negative perceptions about quality of generic medications, and more than one quarter do not prefer to use generics as first-line medications for themselves or for their family. Physicians over the age of 55 years were 3.3 times more likely to report negative perceptions about generic quality, 5.8 times more likely to report that they would not use generics themselves, and 7.5 times more likely to state that they would not recommend generics for family members (p < 0.05 for all). Physicians reported that pharmaceutical company representatives are the most common (75%) source of information about market entry of a generic medication. Almost half of the respondents expressed concern that free samples may adversely affect subsequent affordability, yet two thirds of respondents provide free samples. CONCLUSIONS: A meaningful proportion of physicians expressed negative perceptions about generic medications, representing a potential barrier to generic use. Payors and policymakers trying to encourage generic use may consider educational campaigns targeting older physicians.

Recent trends in the dispensing of 90-day-supply prescriptions at retail pharmacies: implications for improved convenience and access.

BACKGROUND: Mail-service pharmacies offer consumers the convenience of prescriptions filled with a 90-day supply of medication. Unlike mail-service pharmacies, retail pharmacies traditionally dispensed maintenance medication prescriptions with a 30-day supply. However, the retail landscape changed in May 2008 with Walmart's announcement of an extension of its $4 Prescription Program to include 90-day-supply prescriptions. OBJECTIVE: To evaluate recent changes in access to and use of 90-day-supply maintenance medications dispensed via retail pharmacy. SUMMARY: As of the first quarter of 2007, the proportion of retail-dispensed maintenance medications with a 90-day supply (compared with all maintenance prescriptions dispensed) among Medicare Part D plans, self-insured employers, and private health plans was 5.1%, 5.1%, and 5.0%, respectively. As of December 2009, this ratio had risen to 8.0% for Medicare plans and 8.1% for commercial health plans; the ratio among employers had risen more modestly to 6.1%. Of particular interest and importance, the proportion increased similarly for brand and for generic medications. CONCLUSION: There has been substantial growth in 90-day prescriptions dispensed via retail pharmacy, a trend that is likely to continue as more insurance providers adopt compatible benefit designs. It is important to continue monitoring these trends and to identify opportunities to rigorously evaluate their impact on medication adherence and healthcare costs.