Senior couple reading prescription labels
HealthJune 01, 2019

When pharmacies close: Unexpected patient nonadherence

It’s well documented that the cost of medications impacts adherence. But it’s not just cost or affordability that hinders adherence. When a pharmacy closes its doors for good, many patients can be literally cut off from filling their prescriptions.

It’s a trend that is sweeping America. Retail pharmacies are closing their doors at an unprecedented rate. Stefano Pessina, the CEO of Walgreens, commented recently that industry conditions are the toughest he’s seen in his tenure. In a move designed to close locations that were “underperforming”, CVS Health recently announced it is shutting 46 stores. The pharmacy giant is not alone. Over the last 12-18 months, Walgreens closed 750 of the Rite Aid stores it purchased (and it plans to close 200 Boots drugstores in the UK).

Shopko, a chain of retail stores in Wisconsin, auctioned its 146 pharmacies at the beginning of the year. Fred’s, which operates in 15 states in the southeastern United States, closed 159 stores this past May and an additional 49 stores in June. Kmart stores continue to close. And regional chains in Missouri and Ohio were sold to CVS, which then closed most of those locations. On a smaller scale, many family-owned pharmacies are bowing to competition and shuttering after decades of serving local communities.

And here’s why this trend matters: pharmacy closures could lead to medication nonadherence. The connection? If patients don’t have a place nearby to pick-up their medicines, they are less likely to take them.

In a recent study by the Journal of the American Medical Association (JAMA), the authors conclude that pharmacy closures and the resulting challenges in accessing medications led to a significant drop in adherence to essential cardiovascular medications among older adults in the US, and it persisted for a full year of follow-up. Researchers ruled out the cost of the drugs leading to nonadherence because the majority of copay amounts– some 75% – were under $10.

The authors noted that declines in adherence were most pronounced among older adults using independent pharmacies, purchasing from a single store to fill all their prescriptions, or living in so-called “low-access” neighborhoods that had fewer pharmacies. The drop-offs in adherence were also consistent across several classes of cardiovascular medications.

According to the study, before a pharmacy closure, heart medication adherence was similar among patients using pharmacies that stayed open and those using pharmacies that closed. However, after pharmacies shut their doors, adherence to statin, beta-blockers, and oral anticoagulants in the closure group immediately plummeted within the first 3 months. These differences persisted even 1 year after a closure.

Marsha K. Millonig, president and CEO of Catalyst Enterprises, joins us for this Health Clarity Q&A to discuss the findings of the JAMA study — and its implications.

Pharmacy Benefit Managers (PBM) are known as “middlemen” who negotiate drug prices between insurers and employers. Many in the retail pharmacy industry say difficult PBM policies are a reason for financial strain, which contributes to pharmacy closures. How are states addressing the PBM issue?

(Marsha K. Millonig) NCPA and NACDS have both worked to educate the current administration on issues affecting pharmacies and pharmacists and believe they are seeing results. Recently, the state of Ohio fired its PBM and West Virginia carved out and managed its own drug benefit with millions in savings. In addition, Pennsylvania, Arkansas, Connecticut and Kentucky are currently investigating PBM practices.

From 2011 to 2016, we’ve seen 3,622 retail pharmacies close. Why is this happening — and how is it affecting adherence issues?

(Marsha K. Millonig) First, let’s put the closures in perspective: Many assume those closures were limited to independent pharmacies, and 42 percent of them were, however, big-box and grocery store drug stores were also affected.

Due to the popularity of value-based insurance plans, patients are encouraged by their plan to switch to retail and mail-order pharmacies owned by their PBM. This diversion of patients can impact local retail pharmacies and lead to closures. And, as we’ve seen from the Journal of the American Medical Association (JAMA), if patients don’t have a place to pick-up their medicine, they are less likely to take it.

Besides adherence issues, pharmacies are struggling financially. Some pharmacies have seen their retroactive DIR fees climb through the roof. Correcting this issue is a significant part of the National Association of Chain Drug Stores (NACDS) Campaign for Change. Luckily, the preferential practices that many believe are contributing to these closures are being addressed around the country by state legislators. For example, Prescription Drug Benefit manager reform is spreading across states and is also being addressed as part of the Trump administration’s 2018 blueprint for lowering drug pricing.

How are states trying to reign in drug costs?

(Marsha K. Millonig) According to the National Center for Biotechnology Information, 33 to 69 percent of medication-related hospital admissions are due to poor medication adherence. The related costs range from $100 to $300 billion every year. The National Conference of State Legislatures shares a few examples of states that are trying to reign in the costs.

  • Idaho: At Group Health Cooperative, case managers educate patients about their conditions, create action plans with patients and refer patients to programs that help them find more affordable medications.
  • New York: All patients served by HIV-specialty pharmacies must have a medication adherence program.
  • Pennsylvania: The state employee program contracts with Geisinger Health System and collects patients’ medication preferences through an electronic survey. Nurses follow-up with patients to answer any questions or concerns about their medication.
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