Community pharmacy and mail order cost and utilization for 90-day maintenance medication prescriptions.

Although community pharmacies have been the mainstay for drug distribution in the USA, plan members are encouraged to use mail-order pharmacies as a cost-containment strategy. Both channels differ with respect to reimbursement rates, utilization, and costs. We evaluated the differences in reimbursement rates and in ingredient costs between the two dispensing channels. We used pharmacy claims from a large Midwestern retirement system for the period 2000-2005. A representative sample of drug products was selected. We estimated the aggregated gross reimbursement, the ingredient cost, dispensing fee, pharmacy incentives for drug substitution, professional fee for other services, sales tax, and reimbursement per payer. The sample contained 1964 observations-four million claims. There were 58.5% observations for single source brands and 39.0% for generics. Observations with lower unit gross reimbursement rate in community pharmacy increased from 10.3% to 16.5%. Unit ingredient cost and dispensing fees were higher in community pharmacy than in mail-order pharmacy. Community pharmacy had a lower reimbursement rate per unit of medication (33.5-44.6% observations) compared with mail-order pharmacy. There were 87.3-98.1% observations with a higher patient co-financing per unit of medication in community pharmacy. Gross pharmaceutical reimbursement rates and unit ingredient costs were higher in community pharmacy than in mail-order pharmacy; but in more than 10% of the observations, the costs were higher in mail-order pharmacy than in community pharmacy.

Background: Community pharmacies, also known as retail pharmacies, is the last point of contact for patients to get access to their medications. Retail pharmacies are an integral component of India’s health care ecosystem and are thriving now. The Community pharmacies are considered a “Chain community pharmacies” if the organization consists of four or more stores in which an individual consumer may have a prescription order filled. Online pharmacies are an internet-based vendor and includes both legitimate and illegitimate pharmacies. It is a business model that deals with the preparation and sale of prescription and non- prescription medicines as in the traditional pharmacies. Methodology: This was a prospective questionnaire-based study in which 250 Community pharmacy owners were enrolled. The survey instrument was a structured, self-administered questionnaire. Result: Out of 250 surveyed Community pharmacy owners, 96% reported serving less than 100 customers daily. Most pharmacies offer discounts and home delivery. 99% were aware of both chain and online pharmacies, with high familiarity with Apollo (98.4%), MedPlus (98.4%), and Aster (87.2%). 87.2% reported 25-50% sales reduction due to the rise of chain pharmacies. 68% are willing to provide online pharmacy services and 98% believe chain and online pharmacies will disrupt working of independent pharmacies. 83.6% reported that delivery impacting potency of medicines were the drawbacks of online pharmacies to the public. Conclusion: Our study highlights the need for standardized approach to improve quality of services in independent pharmacies as well as to enforce stricter regulatory framework for online and chain pharmacies to improve customers confidence and to alleviate from the concerns raised about online and chain pharmacies. Independent pharmacies can provide value added services such as patient counselling, screening of blood pressure/diabetes etc to attract the customers. Aim: To understand the perception of owners of independent pharmacies regarding online and chain pharmacy services.

inhibitor (PPI) esomeprazole in the third copayment tier on the TRICARE formulary on July 17, 2005. The change to nonpreferred formulary status for esomeprazole included a $13 copayment increase (from $9.00 to $22.00) for either a 30-day supply purchased from a community pharmacy or a 90-day supply purchased from the mail-order pharmacy and a $0 copayment if obtained from a military pharmacy but with a prior authorization (PA) requirement. The change to nonpreferred formulary status was designed to encourage the use of PPIs other than esomeprazole and to increase the use of the mail-order pharmacy for esomeprazole purchases. To quantify changes in (a) the TRICARE beneficiary utilization of esomeprazole relative to other PPIs and (b) the pharmacy settings used for filling esomeprazole prescriptions following implementation of a copayment increase and nonpreferred formulary status for esomeprazole. A census of outpatient pharmacy fill records for prescription acid-reducing medications (PPIs, histamine-2 blockers, misoprostol, and sucralfate) obtained by beneficiaries aged 18 years or older from January 1, 2005, through December 31, 2006, was examined. Interrupted time series regression analyses without a control group were used to compare the utilization of esomeprazole relative to other PPIs, as well as the pharmacy setting used to obtain esomeprazole, in the months before and after the formulary change. The rates of continued esomeprazole use, switching to other prescription PPIs (lansoprazole, omeprazole, pantoprazole, and rabeprazole), switching to non-PPI prescription acid-reducing drugs, and discontinued prescription acid-reducing medication use among existing esomeprazole users (i.e., beneficiaries who obtained esomeprazole as the last PPI fill before the formulary change) were calculated overall and for each pharmacy setting used prior to the formulary change. Over the 24-month study period from January 1, 2005, through December 31, 2006, the total numbers of PPI fills and PPI users increased by 8.5% and 9.0%, respectively, and the number of esomeprazole users decreased by 4.6%. Of esomeprazole users, the percentages of individuals obtaining esomeprazole from military pharmacies and community pharmacies, respectively, decreased from 1.7% to 1.1% and from 89.7% to 81.7%, while the percentage of individuals obtaining esomeprazole from the mail-order pharmacy increased from 8.8% to 17.6%. Time series analysis yielded a positive, statistically significant growth in esomeprazole fills (beta1=0.114; P=0.012) during the 6-month pre-intervention period (January through June 2005) and a significant reduction in August 2005 (beta2=-5.0%; P<0.001), the month immediately following the formulary change. During the 17-month post-intervention period (August 2005 through December 2006), no statistically significant change in trend for esomeprazole fills (beta3=-0.0265; P=0.534) was observed, although a small increase in the raw number of esomeprazole fills was noted. Among the 117,801 existing esomeprazole users, 86,386 (73.3%) continued using esomeprazole, 17,676 (15.0%) switched to other prescription PPIs, 679 (0.6%) used only non- PPI prescription therapy, and 13,060 (11.1%) discontinued all prescription acid-reducing pharmacotherapy after the formulary change. Significantly higher PPI switching and acid-reducing therapy discontinuation rates were observed among men aged 18-44 years and in TRICARE enrollees relative to women, those over 45 years of age, and those who used other health insurance (P<0.001). Individuals who used military pharmacies, where a PA requirement was implemented, were more likely to change pharmacy settings to obtain esomeprazole (43.8%) than were users of community pharmacies (11.9%) or the mail-order pharmacy (22.8%). Mail-order pharmacy users were less likely to discontinue acid-reducing pharmacotherapy (4.9%) than were community (11.9%) or military (12.9%) pharmacy users (P<0.05). After adjustment for serial correlation, the formulary change was associated with a migration of approximately 5% of all PPI fills and 25% of esomeprazole fills to the preferred PPIs in the first post-intervention month. Over the 17-month post-intervention period, the trend toward increased esomeprazole use was slowed and use of the mail-order pharmacy for esomeprazole fills nearly doubled. Our observed PPI switch rate of 15.0% resembled the rate observed for another insured population that experienced a similar formulary restructuring, but was substantially lower than the rates reported for more sizeable formulary changes. Thus, the present study's copayment differentials for third-tier medications ($19 compared with tier 1 and $13 compared with tier 2 copayments) may be less than the threshold amount required to optimize switching to preferred PPIs.

Mail order pharmacies are commonly used to deliver CVD risk factor medications. Previous studies have shown that mail order pharmacy use is associated with greater medication adherence; however, no studies have examined whether mail order pharmacy use is related to improved CVD risk factor outcomes. To examine the comparative effectiveness of mail order pharmacy vs. local pharmacy use on LDL-C control in new statin users. Observational cohort study. 100,298 adult Kaiser Permanente Northern California (KPNC) members who were new users of statins between January 1, 2005 and December 31, 2007. The main outcome measure was LDL-C control in the 3-15 month period after statin therapy was initiated. After adjustment for patient, clinical, and census-block characteristics, and for potential unmeasured differences between mail order and local KPNC pharmacy users with instrumental variables analysis, 85.0% of patients who used the mail order pharmacy to deliver their statin at any time achieved target LDL-C levels compared with 74.2% of patients who only used the local KPNC pharmacy to dispense the statin (p < 0.001). Greater adjusted rates of LDL-C control in mail order pharmacy users were seen across all gender and race/ethnicity subgroups. Mail order pharmacy use was positively associated with LDL-C control in new statin users. Future research should continue to explore the relationship between mail order pharmacy use and outcomes, and address how to appropriately target mail order services to patients most likely to benefit without compromising patient choice, care, and safety.

As Amazon rolls out pharmacy venture, pharmacists must be at top of their game

Objective:To examine medication adherence among Medicare Part D beneficiaries initiating oral anti-diabetic medications and explore whether there is any association of using mail-order pharmacy (vs. retail pharmacy) with better adherence in this patient population.Research design and methods:Using administrative pharmacy claims data, we conducted a retrospective cohort study on Medicare Part D beneficiaries who newly initiated oral anti-diabetic treatment between July 1, 2008 and December 31, 2008. Mail-order pharmacy users were matched to retail pharmacy users via propensity scoring, controlling for patient demographic and clinical characteristics. Adherence with oral anti-diabetic medications during the benefit year of 2009 was assessed using the proportion of days covered (PDC). Comparison of medication adherence between the mail-order pharmacy group and retail pharmacy group was conducted in the propensity matched sample using the paired t-tests and McNemar’s tests.Results:A total of 22,546 patients who initiated oral anti-diabetic medications were identified. The average PDC was 0.60 and only 41.6% of the study population attained good adherence (defined as PDC ≥ 0.8) with oral anti-diabetic medications during calendar year 2009. The matched sample included 1361 patients in each of the mail-order and retail pharmacy cohorts. Compared with the retail pharmacy group, mail-order pharmacy users demonstrated a significantly higher PDC (0.68 vs. 0.61; P < 0.001) throughout the benefit year. More patients in the mail-order pharmacy group (49.7%) attained good adherence with their oral anti-diabetic medications compared to 42.8% in the retail pharmacy group (P < 0.001).Limitations:The study was subject to limitations inherent in retrospective claims database analysis.Conclusions:Adherence with oral anti-diabetic medications among Medicare Part D beneficiaries is suboptimal. Patients using mail-order pharmacy had better adherence to oral anti-diabetic medications than those who used retail pharmacies. However, the causal relationship between mail-order pharmacy use and adherence should be further examined in a randomized study setting.

Improving the evidence base for performance-based pharmacy payment models

Over 50% of breast cancer patients prescribed a 5-year course of daily oral adjuvant endocrine therapy (ET) are nonadherent. We investigated the role of costs and cancer medication delivery mode and other medication delivery factors on adherence. We conducted a retrospective cohort study of commercially insured and Medicare advantage patients with newly diagnosed breast cancer in 2007-2015 who initiated ET. We examined the association between 12-month ET adherence (proportion of days covered by fills ≥ 0.80) and ET copayments, 90-day prescription refill use, mail order pharmacy use, number of pharmacies, and synchronization of medications. We used regression models to estimate nonadherence risk ratios adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments, and generic AI availability. Sensitivity analyses were conducted using alternative specifications for independent variables. Mail order users had higher adherence in both commercial and Medicare-insured cohorts. Commercially insured patients who used mail order were more likely to be adherent if they had low copayments (< $5) and 90-day prescription refills. For commercially insured patients who used local pharmacies, use of one pharmacy and better synchronized refills were also associated with adherence. Among Medicare patients who used mail order pharmacies, only low copayments were associated with adherence, while among Medicare patients using local pharmacies both low copayments and 90-day prescriptions were associated with ET adherence. Out-of-pocket costs, medication delivery mode, and other pharmacy-related medication delivery factors are associated with adherence to breast cancer ET. Future work should investigate whether interventions aimed at streamlining medication delivery could improve adherence for breast cancer patients.

Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between mail order pharmacy (MOP) and better medication adherence, but little is known about the barriers and facilitators to MOP use in diabetes patients. This qualitative study examined factors related to use of MOP vs. traditional pharmacies to obtain prescription medications. We conducted four 90-minute focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred pharmacy use and perceptions of barriers and facilitators of MOP use. One researcher independently coded each focus group transcript, with two transcripts double-coded by an additional researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software. The average age of participants was 64.1; 57% were female; 21% were Asian; 21% were black/African-American; 7% were Hispanic/Latino, and 14% were Native Hawaiian/Pacific Islander. Analysis uncovered 26 themes related to the decision to use MOP for dispensing medications. Most themes (18 out of 26) fell into the COM-B category of ’Opportunity.’ Barriers to MOP use included unpredictability of medication delivery date, concerns about mail security, and difficulty of coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Receiving a MOP incentive of free one-month supply of prescriptions was a motivational facilitator to using MOP for delivering medications. These findings can be used to design interventions and quality improvement initiatives to increase MOP usage and improve medication adherence in diabetes patients across health care systems. Disclosure J. Schmittdiel: None. C. Marshall: None. D. Wiley: None. C.V. Chau: None. C.M. Trinacty: None. J.F. Wharam: None. O. Duru: None. A.J. Karter: None. K. Estacio: None. S. Brown: None.

To explore the types of drug information used by pharmacists in daily practice, their needs and wishes concerning drug information and their opinions about future changes of pharmacy practice. Postal survey to a random sample of 223 (26% out of 859) community pharmacies from the German-speaking part of Switzerland. The 48-item questionnaires were processed automatically with the Cardiff TELEform-Software. In addition, a telephone-survey to a random sample of 20 non-responders was performed in order to test for non-response bias. A total of 108 pharmacists (response rate 48%) reported that the official Swiss drug reference book is still the most popular source of drug information used to solve all kinds of drug related problems. The Internet as a source of drug information is of minor importance, even though 88% of the pharmacies have Internet access. Deficits in drug information were reported for paediatrics, phytotherapy, drugs during pregnancy/lactation and for therapy guidelines. According to 35% of the pharmacists, the importance of offering drug information to customers will increase in the future. Most of the pharmacists are not afraid that Internet pharmacies would replace them. The results show that the majority of the community pharmacists are only partially satisfied with the sources of drug information currently available. The Internet still plays a minor role for solving drug-related problems in daily practice, even though the available infrastructure makes the community pharmacies able to use the Internet more frequently. The pharmacists need more websites tailored to their needs. The pharmacists have clear visions about possible future developments. They do, however, have to adopt quickly to the changes ahead in order to remain competitive.

ObjectiveA core feature of e-prescribing is the electronic exchange of prescription data between physician practices and pharmacies, which can potentially improve the efficiency of the prescribing process and reduce medication errors. Barriers to implementing this feature exist, but they are not well understood. This study's objectives were to explore recent physician practice and pharmacy experiences with electronic transmission of new prescriptions and renewals, and identify facilitators of and barriers to effective electronic transmission and pharmacy e-prescription processing.DesignQualitative analysis of 114 telephone interviews conducted with representatives from 97 organizations between February and September 2010, including 24 physician practices, 48 community pharmacies, and three mail-order pharmacies actively transmitting or receiving e-prescriptions via Surescripts.ResultsPractices and pharmacies generally were satisfied with electronic transmission of new prescriptions but reported that the electronic renewal process was used inconsistently, resulting in inefficient workarounds for both parties. Practice communications with mail-order pharmacies were less likely to be electronic than with community pharmacies because of underlying transmission network and computer system limitations. While e-prescribing reduced manual prescription entry, pharmacy staff frequently had to complete or edit certain fields, particularly drug name and patient instructions.ConclusionsElectronic transmission of new prescriptions has matured. Changes in technical standards and system design and more targeted physician and pharmacy training may be needed to address barriers to e-renewals, mail-order pharmacy connectivity, and pharmacy processing of e-prescriptions.

The Mainstreaming Addiction Treatment Act removed the separate registration requirement to prescribe scheduled medications for maintenance or detoxification treatment, creating an opportunity to utilize community pharmacists' expertise and accessibility to expand access to medications for opioid use disorder (MOUD). This study aimed to develop pharmacist prescribing models of care within community pharmacies. Data were collected via interviews with community pharmacists and pharmacy technicians, treatment providers, and people with lived experience in Washington State from January to May 2024. Interviews were analyzed using a rapid content analysis approach guided by the Practice, Robust Implementation and Sustainability Model and existing evidence-based models of care for MOUD in primary care settings. The research team utilized the themes to develop models of care with input from an interdisciplinary advisory panel. Thirty-one interviews were conducted with 9 community pharmacy staff, 11 treatment providers, and 11 people with lived experience. In total, 21 themes were identified, including 8 themes regarding intervention characteristics, 5 regarding recipients, 5 regarding implementation and sustainability infrastructure, and 3 regarding external environment. Within intervention characteristics, 3 themes were identified regarding medication therapy, 3 regarding education, 1 regarding coordination of care, and 1 regarding psychosocial services. Two models of care were developed: one for MOUD initiation and another for maintenance or ongoing treatment. This study resulted in the development of models of care for MOUD initiation and maintenance at community pharmacies. Future research is needed to evaluate the effectiveness of these models of care.

Community pharmacies vary widely in terms of ownership structures, location, and dispensing policies. It is unknown if an association exists between the type of community pharmacy and the degree of medication adherence exhibited by patrons-patients.To describe adherence to statin therapy among subjects patronizing different types of community pharmacy categories (department- mass merchandise, chain-franchise, and independent-banner) in Saskatchewan, Canada, between 2000 and 2005.Study data were obtained from the Saskatchewan Drug Plan and Extended Benefits database, which is maintained by the government of Saskatchewan, Canada. The study included all subjects who (a) filled a statin prescription within selected community pharmacies between January 1, 2000, and December 31, 2005; (b) had no record of statin prescriptions during the year prior to the first statin prescription, according to the records of the Saskatchewan Drug Plan and Extended Benefits; and (c) demonstrated active utilization in the drug plan database for at least 1 year after the first statin prescription. The proxy criterion for activity was any dispensing record for statin or nonstatin medications at least 1 year following the index claim. Statin adherence level was estimated as tablets per day, defined as the total number of tablets dispensed divided by the total number of days of observation. Each subject's observation period began on the index date and ended on the earlier of (a) 30 days after the last recorded fill for any type of prescription medication (statin or nonstatin), or (b) December 31, 2005. The primary end point was the proportion of subjects within each pharmacy category who maintained an adherence level of 80% or greater during their individual observation period. Additional adherence calculations were performed for each of 3 time periods, beginning on the index date and ending on days 365, 729, and 1094 (i.e., 1, 2, and 3 years). Patients were included in the analysis for each time period if they met a proxy criterion for availability for observation, defined as the dispensing of any drug at least 1 day after the end date of each period. Pearson chi square tests were used to assess the significance of differences in baseline characteristics and adherence proportions, comparing pharmacy categories. Logistic regression analysis estimated the odds of an adherence level of at least 80% during the individual observation period, adjusting for pharmacy category, sex, age 65 years or older, known low-income drug coverage, number of distinct drug classes filled concurrently during the first year of observation, loyalty to index pharmacy, and length of observation. Using similar methods, we also estimated "pharmacy loyalty" by calculating the proportion of subjects who refilled 75% or more of their statin prescriptions at the pharmacy that dispensed their first statin prescription.From an initial sample of 12,818 subjects who had at least 1 pharmacy claim for a statin in the period from January 1, 2000, through December 31, 2005, 8699 subjects met the inclusion criteria. Subjects were observed for a mean (SD, range) of 3.7 (1.7, 1.0-7.0) years after the index statin prescription. During the first year following the index claim, statin adherence rates were at least 80% for 1799 of 3761 (47.8%) patrons of department-mass merchandise, 1778 of 3235 (55.0%) patrons of chain-franchise, and 921 of 1703 (54.1%) patrons of independent-banner stores (P < 0.001). Measured from the index date through day 1094, 869 of 2292 (37.9%), 874 of 1887 (46.3%), and 457 of 975 (46.9%) subjects in the department-mass merchandise, chain-franchise, and independent banner categories, respectively, had a statin adherence level of at least 80% (P < 0.001). In logistic regression analysis, pharmacy category type was significantly associated with statin adherence; subjects in the chain franchise and independent-banner categories were more likely to be adherent to their statin medications during their observation periods than were those in the department-mass merchandise category (adjusted odds ratio [OR] = 1.36, 95% CI = 1.23-1.50, P < 0.001 and OR = 1.39, 95% CI = 1.24-1.57, P < 0.001, respectively). From the index date through day 1094, 1752 of 2292 (76.4%), 1475 of 1887 (78.2%), and 795 of 975 (81.5%) subjects remained pharmacy-loyal in the department-mass merchandise, chain franchise, and independent-banner categories, respectively (P = 0.006). Controlling for several potential confounders using logistic regression, independent-banner pharmacy patrons were more likely to remain pharmacy- loyal during their observation periods than were those patronizing department-mass merchandise (adjusted OR = 1.34, 95% CI = 1.16-1.54, P < 0.001) or chain-franchise stores (adjusted OR = 1.22, 95% CI = 1.06-1.42, P = 0.009).One year after their first statin fill, subjects demonstrated low rates of adherence, ranging from 48% to 55%, regardless of the type of pharmacy they patronized. Although the differences by type of pharmacy reached statistical significance, their clinical importance is not evident, reinforcing the fact that the problem of nonadherence appears to exist among all types of community pharmacies, regardless of their categorization.

This study evaluated adherence to medications used to treat chronic conditions for patients with 90-day prescriptions, comparing patients with access to workplace pharmacy services versus patients using mail order services. De-identified pharmacy claims data were used to compute medication possession ratio and gaps in therapy. Results were compared for patients who filled 90-day prescriptions at workplace pharmacies versus patients who filled 90-day prescriptions using mail order pharmacy services in a 1-year period. Statistical tests to assess between group differences were performed controlling for differences because of age, sex, number of select chronic conditions, number of unique medication therapeutic classes, and patient out-of-pocket cost per therapy day. Statistically significant differences were found between patients who filled their maintenance medications at the worksite compared to those who used mail-order pharmacy services. Patients filling prescriptions at a workplace pharmacy were 22% less likely to have a gap in therapy of over 30 days compared to similar patients using mail order services. Workplace pharmacy utilizers also had overall adherence rates 3.68% higher than patients who utilized mail order pharmacy services. Our analysis suggests that it may not be just the quantity of medication dispensed that impacts patients' adherence to their prescription medication, but a variety of other factors including pharmacist-patient interaction. Having a pharmacist on-site and available to patients with chronic considerations could provide added value. These results can aid employers and other stakeholders to decide which prescription benefits to offer their employees and members.

Background The COVID‐19 pandemic accelerated online shopping, especially for pharmacies, as consumers favored convenience, contactless delivery, and sanitization. This shift prompted rapid expansion of online pharmacy services. Objectives This study aims to descriptively explore customer behavior toward online pharmacy services in Saudi Arabia before and after the COVID‐19 pandemic and to examine how community pharmacists handle online medication requests and comply with relevant regulations. Methods A descriptive, exploratory, cross‐sectional study was conducted in Saudi Arabia. Two questionnaires were developed to fulfill the objectives of the study: one targeted the Saudi community, while the other targeted community pharmacists. This study is descriptive in nature and does not test inferential hypotheses. Key Findings A total of 467 individuals participated from community and 13 pharmacists were from community pharmacies. There were 131 (28.1%) respondents who bought medicinal products from OPs, 101 of them (77.1%) purchased medicines online during the COVID‐19 pandemic, whereas 68 (51.9%) started purchasing medicines online before the COVID‐19 pandemic. The OP customers who reported that they were not asked to provide a prescription, fill a survey about health status, or make conversation with a pharmacist upon submission of an order comprised 70.5%. Easy online access to pharmacists and reduced visits to healthcare providers were the most reported motivational factors for online medication purchasing. Pharmacists indicated that the number of OPs and the use of OP services have changed since the COVID‐19 pandemic, with new regulations being implemented. Conclusion OP purchases are not yet popular in Saudi Arabia, despite the COVID‐19 pandemic. Many customers use international pharmacies to buy pharmaceuticals. This study highlights the need for government bodies to implement regulations to ensure safe online purchases.