February 5, 2012 
I think we can all agree now that 90-day prescriptions are correlated with better adherence (and the percentage of retail 90-day scripts is going up). The latest study here is from Walgreens.
A new Walgreens study analyzing relative medication adherence of patients filling 90-day supplies of maintenance medications using retail and mail order channels over a one-year period concluded that patients who fill prescriptions via retail have as high or slightly higher adherence levels than those utilizing mail (77 percent vs. 76 percent). The study, “Medication Adherence for 90-Day Quantities of Medication Dispensed Through Retail and Mail Order Pharmacies,” was recently released in the November issue of The American Journal of Managed Care.
This reflects other studies from CVS Caremark, Express Scripts, Kaiser, and BCBSNC. (Although sometimes it shows mail order as better and sometimes retail.)
Of course, the data is slightly different in either case, but the general consensus is the same. So, the question is what’s next. How should you compare the two channels?
- Generic fill rate
- Overall health literacy and health outcomes
- Patient experience / satisfaction
- Payer cost
- Cost to fill
This issue won’t go away so it’s going to be important to continue to find ways to compare the channels and find populations that are similar for comparison or remove the bias.
Enabling Healthy Decisions 
Per the linked Press Release, “Adherence was measured by medication possessions ratio (MPR)…”
Adam goes to the retail pharmacy, receives a 90 day supply. Adam never refills the script.
Bob goes to the retail pharmacy, receives a 30 day supply. Bob never refills the script.
Adam has a higher MPR than Bob.
Is Adam more adherent than Bob?
I agree. Adherence measures aren’t perfect. But, short of using the technology that monitors if we swallow each pill, is there a better way?
When there was a PBM mail order study out there (June 2011) stating that mail order was superior to retail regarding clinical significant adherence;
Adam Fein Stated: “I like this study a lot because it looked at clinical outcomes rather than just counting how many pills were in the medicine cabinet”
I responded that I appreciate that, Adam; you are now including health outcomes in your thought process regarding ROI on the decision of which drug distribution channel to be used. The more you look at health outcomes as part of the cost of distribution the more you and others will see that health care supplied at the community level is by far the most cost effective.
Secondly, however let me “again” point out this study that you liked regarding health outcomes is not a comparison of retail adherence vs. mail order adherence but rather a comparison of 30 day fill adherence vs. 90 day fill adherence.
When you compare a 90 fill at retail vs. a 90 fill at mail order you will see that compliance at retail exceeds mail order; due to convenience, elimination of psycho-social problems, and lack of complexity with local/community 90 day fills. Dayton Adherence Project 2008. We go out and to the studies not Meta-analysis of others work.
In a second rebuttal to an Adam Fein blog where he stated that mail order had better adherence than retail, on 08/11/2011 I stated:
In regards to mail order vs. retail compliance/adherence rates that are circulating on the blogs today 08/11/2011, and I am sure soon to be in the main stream media, I agree with their facts , 90 days’ supply does increase adherence, but disagree with their conclusion.
This study was not a comparison of retail adherence vs. mail order adherence but rather a comparison of 30 day fill adherence vs. 90 day fill adherence.
Now this new study (WHI/Walgreens) on the blogs today backing up the Dayton Adherence projects show that PBMs are not only non-fiduciary towards their clients (See Van Antwerp) but also harmful to their client’s health when PBMs contractually prohibit or dis-incentivize 90 day fills at the local community pharmacies.
Take-Away Points on mandatory mail order
By restricting pharmacy choice and access, mandatory mail appears to cause some
members to discontinue therapy prematurely.
When members choose to discontinue rather than switch pharmacy channels, the unintended
consequence is a reduction in medication adherence and the potential for increased medical expenses.
Individuals without previous use of mail-service pharmacy are particularly sensitive to
Mandatory plan designs and are an important population to target for interventions to support adherence.
Now that is shown that there is no evidence that clinical adherence is improved with mail order, and given the take away points there solid inference that clinical and financial harm is caused by the use of mandatory PBM prescription mail order.
Jim Fields RPh CFO ApproRx