More analytic firepower is being directed at the US medication-adherence problem

CVS Caremark (Woonsocket, RI), a leading pharmacy benefit manager (PBM), has released the second edition of its State of the States: Adherence Report. Derived from data in its book of business in 2012, combined with analysis of refill rates, medication possession ratios (MPRs, a measure of actual to potential number of days a patient has drug on hand)—and with some data on generic substitution levels, the report gives plan managers and public health administrators a guide to where medication adherence is functioning well, and where it could be improved. The study focuses specifically on four therapy areas: diabetes, hypertension, dyslipidemia and depression; in theory, these can be a marker for overall adherence levels; the study also broke out data based on the type of healthcare coverage: health plans; employer plans; and Medicare Part D.

The “winning” states, with the highest MPRs and highest rates of generic substitution, were Maryland, Vermont and Maine, which had MPRs of, respectively 81.9% (health plans in that state); 84.7% (employer plans); and 86.3% (Medicare). The highest generic dispensing rates (GDRs) were found in Minnesota and Massachusetts, with rates in the range of 92-93.4%, depending on the type of coverage. The lowest states for MPR were Alaska, North Dakota and Wyoming, with health-plan MPRs of, respectively, 60.9%, 62.0% and 66.1% (MPRs for employer plans and Medicare were significantly higher). The worst-performing states for GDRs, based on employer plans, were Connecticut and West Virginia, tied at 78.3%, and Mississippi, with a rate of 78 .5% (GDRs for health plans and Medicare were higher). There is one GDR outlier, however: New Jersey, whose health-plan MPR is 77.0% (in the high middle range), but whose GDR is 70.8% for health plans and 73.8% for employer plans—both significantly below all other states. This is all the more surprising because New Jersey scores highest among all states for access to the CVS Caremark Pharmacy Advisor, a service of the company to perform adherence outreach and education. (Could beneficiaries in that state be especially attuned to GDRs because there are so many pharma workers there?)

Across all types of plans, patients with depression generally had the lowest adherence rates, while Medicare beneficiaries generally had the highest MPR rates across the therapy areas. Geographically, adherence rates for health plans in the Midwest were the lowest, while adherence rates were lowest in the South for employer and Medicare plans.

CVS Caremark also made a couple passes at estimating healthcare cost savings with better MPRs and more generic substitution—the former is worth at least $6.5 billion, while the latter is nearly double that. Texas, with California close behind, has the highest potential savings to in-state coverage with better MPRs, potentially saving $686 million and $652 million, respectively, if MPRs could average above 80%. (Other, broader-based estimates, however, peg the national cost for poor adherence at nearly $300 billion.) “There is a good deal of regional variation in adherence rates,” says Dr. Troyen Brennan, EVP and chief medical officer at CVS Caremark, “and this is going to be a critical issue going forward.”

What are the implications in all this for pharma? Many manufacturers support adherence programs for branded products, and the industry is a notable participant in the Prescriptions for a Healthy America program recently announced. But especially for the disease states studied by CVS Caremark in this report, chronic-care medications are usually generics. Support for better adherence is a factor in healthcare-provider performance under the Affordable Care Act, and PBMs as well as payers are giving it more attention; but both of these actors will look for continuing support from pharma.

The full report is available here, along with a companion research compendium, Advancing Adherence & the Science of Pharmacy Care, compiled by CVS Caremark. The company also offers more-detailed analysis to clients on request.