How can outpatient pharmacies reduce hospital readmissions?

We’ve reported the following statistical finding elsewhere in this forum, but it bears repeating: Up to 70% of all preventable outpatient hospital readmissions are due to prescription non-compliance. Making matters worse for hospitals, the analytics generated by ProxsysRx’s proprietary software indicate that average hospital readmissions from prescription non-compliance are often significantly more expensive than other readmissions.

The three leading causes of outpatient medication non-compliance

MEDICATION COSTS. For far too many patients (particularly Medicare & Medicaid patients) the prohibitive, and ever-increasing, costs of prescription drugs are simply beyond their ability to pay. By some estimates, up to 60% of all prescriptions costing over $100 are never filled. Given the crushing costs of outpatient medication protocols, individuals on limited incomes are often left to choose whether they buy prescriptions drugs or food.

PREMATURE CESSATION. It’s an all-too-common problem: Patients stop taking their medication once they begin to feel better. In large part because they haven’t received proper counseling about the importance of following their prescription protocols to the letter — which only hurts hospital readmission rates in the long run.

CONFUSION / LACK OF INFORMATION. It’s also too common for outpatients to leave hospitals’ care entirely unsure about their medication protocols. Particularly when they are discharged from hospitals lacking well-managed Meds To Beds programs.

Critical pharmacy services every hospital should offer outpatients

MEDS TO BEDS. Ask any hospital with a robust bedside prescription delivery program: There is no more effective method for ensuring that patient prescriptions are captured before they leave your care. ProxsysRx has implemented and managed Meds To Beds programs for dozens of health systems over the years. The minimum reduction we’ve achieved in medication-related readmissions, among all the hospitals we’ve served, is 20%.

For one large Mississippi health system, ProxsysRx filled more than 18,000 discharge prescriptions in the first 12 months of service alone — during which time, readmissions decreased 79%, and pharmacy revenues increased 125%.

Equally important, a central component of ProxsysRx’s Meds To Beds programs is outpatient follow-up support — which includes finding, and coordinating, financial support for at-need patients of the hospitals we serve. We’ll work with hospitals to get eligible patients qualified for charity.

That said, in a well-run Meds To Beds program, discharge prescriptions are delivered either by a pharmacist, or a highly-trained employee capable of thoroughly discussing a patient’s prescription protocol — as well as the patient’s existing medications (to prevent medication conflicts or contraindications). For more tips on maintaining an effective Meds To Beds program, Click Here.

PATIENT FOLLOW-UP. Meds To Beds is just the first step in positively impacting outpatient readmission rates. Your MTB program should be supplemented by a Meds To Home program — reaching-out to patients during their first 30 days post-discharge, to ensure they’re following their prescription protocols — and to answer any new medication-related questions they may have. Your Meds To Home program should also have channels in place to connect patients with doctors or pharmacists, whenever necessary.

DISCOUNTED (OR NO CHARGE) PRESCRIPTIONS. As we noted earlier, cost is the number one reason behind patient prescription noncompliance. And while it goes without saying that providing at-need patients with below-cost or no-cost prescriptions is an expensive proposition, it’s still a fraction of the costs health systems incur from readmissions — not to mention the potential additional cost of reimbursement penalties that come with them.

MEDICATION ACCESS SUPPORT. The high cost of prescription drugs isn’t the only “affordability” factor that limits patient medication compliance. Lack of adequate transportation options and/or nearby pharmacies is often a problem for many patients. Which is why your outpatient pharmacy should also offer home prescription delivery.

The pharmacist’s role in reducing healthcare costs

(Below are key passages from a 2017 article published by the National Institutes of Health)

The high prevalence of medication errors and inappropriate prescribing is a major issue within healthcare systems, and can often contribute to adverse drug events, many of which are preventable. As a result, there is a huge opportunity for pharmacists to have a significant impact on reducing healthcare costs, as they have the expertise to detect, resolve, and prevent medication errors and medication-related problems.

Pharmacist-provided services and clinical interventions have been shown to reduce the risk of potential adverse drug events and improve patient outcomes, and the majority of published studies show that these pharmacist activities are cost-effective or have a good cost / benefit ratio.

The role of the pharmacist has evolved substantially in recent decades. Nowadays, pharmacists also ensure the rational and cost-effective use of medicines, promote healthy living, and improve clinical outcomes by actively engaging in direct patient care and collaborating with many healthcare disciplines.

The increased number of medicines being consumed by the elderly, as well as the rising cost of newer pharmacotherapies, has intensified the pressure on healthcare organizations to identify and implement cost-control measures. Pharmacists have a major role in lowering costs by critically reviewing the pharmacotherapy of multimorbid elderly patients. The reduction of inappropriately prescribed medicines not only produces savings in the cost of each individual medicine but also reduces the risk of adverse drug events (ADEs) that often contribute to prolonged and expensive hospital admissions.

With their unique knowledge of medicines, pharmacists are central figures in decreasing healthcare expenditure through cost savings on medicines and cost avoidance. An example of this would be a pharmacist suggesting the discontinuation of a potentially inappropriate medicine in an elderly patient which could result in a future ADE, hence reducing the potential cost of a general practitioner (GP) referral or hospital admission, as well as eliminating the actual cost of the medicine.

Medication errors and inappropriate prescribing are recognized as major problems, both clinically and economically, for the healthcare system.

Patients affected by an ADE have their hospital admission prolonged by an average of 2 days, at an additional expense of ~US$2,000–$2,500.

Most primary care physicians do not have enough time to provide all of the preventive and chronic disease services that patients require, and this is where other members of the multidisciplinary team can make a valuable contribution in picking up any shortfalls. Pharmacists can play a vital role in filling many of these gaps, as they have more time and the appropriate expertise to provide high-quality patient-centered health care.

How pharmacists can positively impact chronic disease management

Chronic diseases are the leading cause of death and disability worldwide, and their management accounts for more than two-thirds of global healthcare expenditure. Studies have shown that pharmacists in primary care have the skills to manage patients with long-term conditions, and this can result in both clinical and cost benefits for a variety of chronic illnesses, such as cardiovascular disease, chronic obstructive pulmonary disease, and diabetes.

Medication nonadherence is an economic burden world-wide, and it is estimated that the annual cost of nonadherence is $100 billion in the US alone.

Pharmacists play an important role in safeguarding their patients, especially the elderly, from potentially inappropriate use of OTC medicines. Pharmacists often provide advice or nonpharmacological approaches as first-line solutions, hence saving on the cost of purchasing an OTC item unnecessarily. If an OTC product is required, pharmacists help their patients choose a safe and appropriate option tailored to their individual needs.

Hospital pharmacists have had a major influence on the advancement of pharmacy practice in recent decades, and represent a key component of the multidisciplinary team involved directly in patient-centered care.

Medicines reconciliation and transitions of care

Studies have established that best possible medication histories attained by pharmacists are more precise and more comprehensive than those obtained by other healthcare practitioners. Furthermore, pharmacist-led reconciliation has been shown to have the highest expected cost benefits when compared with other reconciliation processes.

Impact of a community pharmacy transitions of care program on 30-day readmission rates

(Below are key passages from a 2018 article published by the National Institutes of Health, originally published by the Journal of the American Pharmacists Association)

The primary objective of this study was to evaluate the impact of a Transitions of Care (TOC) program on both all-cause and related 30-day hospital readmission. The secondary objective was to evaluate which patient-specific factors, if any, are predictive of 30-day hospital readmission.

1,219 encounters were examined. Compared to those patients without TOC participation, those who did utilize the TOC program had a 67% decreased odds of all cause 30-day readmission and a 62% decreased odds of a related readmission.

Approximately 20% of Medicare patients are unexpectedly readmitted within 30 days of hospital discharge, amounting to a cost of $41.3 billion in fiscal year 2011. The Hospital Readmissions Reduction Program, created by the Patient Protection and Affordable Care Act (PPACA) of 2010, permits reduced payments to hospitals with excess readmission rates (ERR) in several categories. This legislation has reinforced the need for development and expansion of TOC programs.

Research has revealed that after patient discharge, inclusion of clinical pharmacists amongst multiple system-wide interventions helps dramatically reduce readmission rates. Following discharge from the hospital, adverse events are most frequently medication related, with non-adherence at the forefront of major episodes and readmission.

The Prescriptions Plus program filled prescriptions for 13,482 patients during the study period. The TOC program attempted to contact 1,219 patients from June to November of 2017; 780 of those patients participated in the TOC program. TOC program participants experienced less all-cause and related 30-day readmission 6.54% vs 16.86% and 3.59% vs 12.30%, respectively.

In the current pharmacy economy, it is exceedingly difficult for outpatient pharmacies to make a profit on prescription filling alone, due to, in part, poor reimbursement from insurance vendors. While there are likely to be some start-up costs involved, implementation of additional clinical services can become a supplemental stream of income for outpatient pharmacies.

With the implementation of Medicare Star ratings, the healthcare system has refocused on quality of service, rather than quantity, serving as a motivator for providers to ensure more comprehensive and individualized care for each patient. Although pharmacies do not receive their own Star ratings, they may act as an intermediary between payers and patients to help optimize medication regimens. Insurance companies therefore offer various pay-for-performance programs to compensate pharmacies for helping improve their quality measures.

In addition to improved patient outcomes, the savings on readmission costs can further extrapolate to decreases in associated CMS fines and increases in reimbursement, and improve the facility’s national readmission and STAR ratings.

Our retrospective study compared 30-day hospital readmission among those who participated with the transitions of care program and those who did not. In this evaluation, the benefit of participation with the program resulted in over 60% decreased odds of readmission within 30 days. These findings thus substantiated the hypothesis that an outpatient pharmacy transition of care program could have a major impact on hospital readmission rates. Moreover, this decrease in 30 day readmissions can be summed to immense cost savings for the hospital system in associated costs, including potential Medicare fines or reimbursement cuts.