Auto-Refill (Part II)

A few weeks ago, I posted my thoughts on the auto-refill solution that various pharmacies are implementing. After talking with a reporter about the topic, I posted it in a discussion group to get some additional thoughts. As a proponent of the solution, I was surprised by a few of the comments and questions which were more skeptical.

With that in mind, I thought I would post some clarifications to the issues raised in the discussion group.

1. Is the auto-refill solution the same for retail, mail, and specialty?
   Generally, it is retail pharmacies and mail order pharmacies that are implementing this type of program for maintenance drugs. You wouldn’t want to implement this on controlled substances (even if it was legal). You wouldn’t want to implement it for drugs where patients frequently change strengths (i.e., titrate). You wouldn’t want to implement it when a patient was new to therapy in case of side effects or other issues. Once they are stabilized on a maintenance medication, this makes a lot of sense.
2. Is auto-refill a solution for adherence? Aren’t there many other issues?
   People are non-adherent for numerous reasons. The most common reason in many studies is “I forgot”, but there are significant issues around health literacy. There are also cost barriers, side effects, and belief or cultural issues.
   Obviously, auto-refill won’t address all of those issues, but it can help with the people who say they forget to refill. It can also help minimize the gaps in care which exist (i.e., I run out of pills a few days before I pick up or receive my new prescription).
3. Does auto-refill lead to accumulation of drug supply?
   Anything can lead to accumulation if the patient is not using their medication but refilling their drug on a regular basis. [How many patients do that…the drugs cost money.]
   This concern can be addressed in two ways: (a) setting the auto-refill trigger to be after 85-90% of the days supply last dispensed should have been used AND (b) reaching out to the consumer to see if they are ready for their next fill.
4. Isn’t the best strategy for adherence to use “live” agents?
   Of course, we’d all love the luxury of talking to every patient at length around their therapy (imagine a world where commercial MTM was economically sustainable). This would be ideal, but in general, this “live” interaction is best for the initial diagnosis and new start of a script.
   Plenty of studies have shown that automated calling technology compares very favorably to nurses, agents, and other professionals in driving consumer behavior (at a much lower cost). Speech recognition technology creates a conversational tone with the consumer and can employ best practices such as personalization, motivational interviewing, behavioral sciences, and linguistics in a systemic way.
   At Silverlink, our studies have shown significant lift in improving refill rates and closing gaps-in-care around adherence through the use of automated calls.
5. What about “auto-refill reminders”?
   This is exactly what I advocate. It’s much like the “choice architecture” that Express Scripts talks about in their Consumerology positioning around mail order. You’re more likely to get someone to refill a medication (typically appropriately) when asking them to opt-out of the refill than asking them to opt-in to the refill. And, neither I (or anyone I know) would advocate having a patient enroll in an auto-refill program and simply keep getting their medication shipped to them to simply drive up revenues and false adherence metrics.
6. What about health literacy and education?
   This came up several times. An understanding of their disease, why the medication is important, what the medication will do, and other issues are critical for a patient to be engaged and “own” their condition. This is a systemic issue that begins with the lack of time for discourse at the physician’s office and runs throughout the entire process. We have to address these things. The more you can personalize adherence communications to reflect personal barriers and proactively address them during the interaction with the patient the better. Some of that can automated, but yes, some it has to be “escalated” to a “live” interaction.
7. At the retail pharmacy, doesn’t this increase returns to stock?
   Again, I think this is in how you implement the program. Since I recommend that clients implement it with a reminder to the patient to tell us if you don’t need it refilled yet, I think you can avoid some of this. You might also be able to embed some system logic into your system (i.e., you could look for other therapeutically equivalent new starts within the same therapy class in the past 30-days to identify patients that may no longer be on the original drug).An example of the process might be:

• Patient X fills their 4^th fill of a maintenance drug on 3/17.
  
• Patient X receives an offer to enroll in the auto-refill program.
  
• Patient X receives an automated call on 4/10 stating “This is your pharmacy calling. Is this Patient X? As requested, we are calling to let you know that we are ready to refill your medication. If you are no longer taking the medication or you have more than 7 days supply left, please call us at 800# to let us know. Otherwise, your medication will be ready for you to pick it up in 2 days.” [Note that this would have to follow certain HIPAA guidelines.]
  

You can see more dialog on this at The Pharmacy Chick blog or in this article from last year.

“Steven Friedman, VP of pharma services at PDX-Rx, notes that the company’s dispensing and adjudication software, when engaged for auto-refill, has been shown to add as much as two additional months on therapy (i.e., two more months of adherence) in a six-month period—a substantial improvement both in adherence and in pharmaceutical sales.”

What’s the net of all this (IMHO)…

• Adherence is a huge issue.
• We need to try lots of things to address it.
• People forget more than they are likely to admit.
• Auto-refill (renewal) isn’t for everyone but is a nice service when implemented right.
• It will drive up more Rxs but no one’s going to pay for (and/or pick up) scripts they don’t need.
• I support it.