Opinions of a small sample of pharmacists about pharmacy setting and patient adherence to antiretroviral therapy.

Many private and public health insurance plans increasingly encourage their beneficiaries—either through mandates or incentives—to fill prescriptions for longterm chronic conditions through a mail order pharmacy or at a community-based or mail order specialty pharmacy designated by the pharmacy benefit manager. Approximately 90% of employers as of May 2011 and 25 state acquired immune deficiency syndrome (AIDS) Drugs Assistance Programs (ADAPs) for uninsured and underinsured persons living with human immunodeficiency virus (HIV) as of June 2010 offered a mail order service option; 18% of employers and 17 of the 25 ADAPs mandated the use of mail order pharmacy for chronic medications. Although the shift to mail order pharmacy may have been motivated by perceived economic benefits of mail order, including improved efficiency and reduced prescription drug costs accruing to payers, there is evidence to suggest that mail order pharmacy use is associated with improved adherence because of greater convenience. However, a study by Khandelwal et al. (2011) found only a 1 percentage point difference in medication possession ratio (MPR) comparing patients receiving 90-day supplies dispensed in community versus mail order pharmacies, and a study by Liberman et al. (2011) found that mandatory mail order benefit design was associated with decreased patient adherence. Health plans may require use of specialty pharmacy distribution channels for costly medications associated with complex management issues, including medication adherence, because of a belief that the “high-touch” services offered by specialty pharmacies (e.g., patient education, identification of sources of financial assistance) provide a therapeutic benefit to the patient. Of the 74% of employers that offered a specialty pharmacy benefit in May 2011, 48% required specialty drugs to be channeled through a designated specialty pharmacy (either community-based or mail order). Similarly, 14 ADAPs used central pharmacy distribution, and 18 ADAPs had designated ADAP pharmacies for pick-up in June 2010. Adherence to antiretroviral therapy (ART) is a challenge for persons living with HIV (PLWH), with an estimated 40% dropping out of care within the first 2 years of starting treatment. In a variety of therapeutic classes, inconsistent adherence is associated with poor clinical outcomes, treatment failure, and increased health care costs. In general, patients utilizing specialty community pharmacies receive more personalized care and have better adherence rates compared with those in nonspecialty community pharmacies. A pilot study found that Medi-Cal beneficiaries with HIV who received medication therapy management (MTM) in community pharmacies that specialized in providing HIV-intensive MTM services had higher adherence rates that persisted over 3 years, compared with patients in pharmacies not providing these services. Although the dispensing of 90-day prescription supplies in community pharmacies is generally increasing, mail order pharmacy may be appropriate for PLWH who are stabilized on therapy and comfortable with their medication regimens, and may be more attractive than community-based pharmacy services for those patients who prefer online ordering of medication. The impact of mail order pharmacy compared with community-based pharmacy on ART adherence is unknown. While the primary focus in the pharmacy literature and in public health and insurance policy decision making has been differences between mail order and community-based specialty versus traditional pharmacies, less is known about the adherence promotion practices of specialty mail order and community pharmacies. In particular, little research attention has focused on adherence promotion activities in mail order settings offering differentiated products—traditional versus specialty mail order—or compared adherence promotion practices and patient health outcomes in community-based specialty and mail order specialty pharmacies. This information might be important in light of a recent pharmaceutical industry report that 60% of employers are covering 90-day supplies of maintenance medications in community pharmacies, and 90% offered mail order pharmacy services. Khandelwal et al. found that patients filling 90-day supplies of maintenance medications (e.g., antiasthmatics, antidiabetics, diuretics) in community-based pharmacies had a slightly higher mean medication possession ratio compared with those who filled their prescriptions by mail order (77.0% vs. 76.0%, respectively). Patwardhan et al. (2011) found slightly higher adherence rates and a reduced rate of gaps in therapy exceeding 30 days among patients filling prescriptions at a worksite pharmacy compared with mail order service and attributed this finding in part to the pharmacist-patient interaction.