The other day, I wrote about a case involving a medication for which the plan required to be filled at a specialty pharmacy. This was an example of fragmentation of care. In Pharmacy, fragmentation is often either financial, or the result of contractual requirements imposed by benefit managers or plans. Examples include:
- maintenance medications that are required be filled by a mail order pharmacy
- requiring specific, specialty pharmacies to fill certain medications
- doctors sending patients to multiple pharmacies to help the patient save money on select medications
- pharmacies offering incentives to transfer mediations, creating transient patients using numerous pharmacies.
- drug companies directing patients to specific pharmacies for special pricing of their products.
The list could go on, but each example has the same consequence: the complete patient record resides across multiple pharmacies. The record is fragmented. This makes it much more difficult for any one pharmacist or practitioner to have a complete understanding of the patient’s medication therapy, making assessing and monitoring the patient’s therapy much more difficult.
The implications of care fragmentation are significant. If the pharmacist cannot accurately determine if the prescription they are filling is appropriate, inappropriate or even dangerous, problems will arise. Problems, in the context of prescription medications are, at a minimum, undesired. They can be a lot more significant, too; the worst case scenario might death. While the PBMs do pass pharmacies some information about medications filled by other pharmacies, the data is mostly designed to prevent duplicate fills of a given medication. It is paramount, therefore, that pharmacists work combat both fragmentation and its consequences.
Combatting Fragmentation
There is no way to completely eliminate fragmentation as long as our system puts its emphasis on reducing cost, and not on patient outcomes. While an outcomes based system may be something that will eventually become prominent in our country, we cannot afford to wait. We need to combat this problem, and the weapon of choice is communication.
The first problem for the pharmacist is identifying fragmentation. Patients don’t just walk in and announce that they use four different pharmacies. Using tools like electronic claim notifications and rejects can alert you to the existence of some forms of fragmentation. Communicating with the patient, however, is the best way. Regularly ask the patient what other medications they are taking that your pharmacy doesn’t provide. Any time you discover the potential for multiple pharmacy use, it is important to document your findings in the patient’s pharmacy record. More to the point, communications need to be initiated to ensure that all pharmacies involved have a good understanding of the patient’s therapies and outcomes. Once the problem is identified and information exchanged, the immediate crisis is over. It is now time to address the root cause of the fragmentation.
I always start the discussion with the patient. It is important to understand exactly why they are using more than one pharmacy provider. I always emphasize the importance of having a single pharmacy home, but I am always watchful for circumstances that will prevent this from occurring. Once I understand the reasoning, I look for solutions.
- Whenever possible, I try to consolidate the pharmacies a patient uses. Ultimately, I would prefer to get them to use one pharmacy, their pharmacy home. Obviously, I would prefer that they use my pharmacy, but that is a decision for the patient. Even if I lose a them, they will be better off in the long run with a single pharmacy home.
- In cases where the patient must use more than one pharmacy, I try to have the patient minimize the total number of pharmacies involved.
- Finally, I educate the patient. If they must use, or they insist on using, multiple pharmacies, I emphasize that they as the patient, are responsible for making sure that all parties involved are kept up to date on all medications. They must be their own advocate. While some inter-pharmacy communication does occur, it may not be enough to prevent real problems from occurring.
Mis-information is also a problem, and education is a part of the this solution, as well. I have personally observed prescribers sending patients to multiple pharmacies for a variety of reasons. Mostly, though, they are simply trying to help the patient get the best value for their healthcare dollar. Prescribers understand that the medication doesn’t do any good for their patent if they cannot afford it or fail to take it regularly. This is a great place to educate the physician on the value of the pharmacist in the equation. Spend some time visiting with prescribers. Let them know what a good pharmacist does to ensure good compliance. Talk about medication synchronization and compliance packaging. Make sure they understand that a single pharmacy home may have a larger impact on outcomes than price alone. If they have an open mind, you may change their habit. What is more, you might actually receive additional referrals for your efforts.
Ultimately, fragmentation comes down to choices. Our job is to be sure that people making choices do so with the best information possible. If we do our job well, everyone benefits. Make your encounters count.
