The pros and cons of mail-order pharmacy

March 15, 2010

Whether mail-order pharmacy is a blessing or a bane depends on whom you ask.

Mail-order pharmacy is a:

A. Great leap forward for medication delivery

B. Plague on patients, pharmacists, and prescribers

D. Potential killer

The most complete answer is all of the above. But your first response probably says more about your place in pharmacy than it says about mail order.

Pharmacy benefit managers, payers, and most major chains are likely to choose answer A. Independent pharmacists, patients who have been forced into mail programs, and some prescribers would prefer B. Some patients have already chosen C. Practitioners in oncology and other specialty areas worry that D is correct.

"People tend to have very strong views about mail-order pharmacy," said Julie Schmittdiel, PhD, a research scientist with Kaiser Permanente Northern California (KPNC) in Oakland, Calif. "Much of it is based on economics, not research. There are estimates that up to one-third of all chronic medications are being delivered by mail, but we really don't know much about how it is being done or the effects it is having. It behooves us from a policy perspective to find out what the impact of mail-order pharmacy really is."

Schmittdiel was part of a team that studied mail-order pharmacy and adherence among KPNC patients with diabetes. The observational study grew out of a larger research program looking at ways to enhance quality of care for patients with diabetes at the University of California Los Angeles (UCLA) David Geffen School of Medicine. According to UCLA physician and lead author Kenrick Duru, MD, MSHS, in Los Angeles, Calif., researchers found that KPNC patients with diabetes who refilled their prescriptions by mail showed better adherence than patients who used a brick-and-mortar pharmacy. The study, "Mail-Order Pharmacy Use and Adherence to Diabetes-Related Medications," was published in the January issue of American Journal of Managed Care.

"This new empirical evidence shows that (mail order) can improve outcomes for patients with chronic conditions," said Mark Merritt, president and chief executive officer (CEO) of the Pharmaceutical Care Management Association (PCMA), Washington, DC, in a prepared statement. "This should be an eye-opener for any policymaker who wants to address the chronic-care crisis in America."

For Edith Rossato, senior vice president, pharmacy affairs, National Association of Chain Drug Stores (NACDS), in Alexandria, Va., the study's findings do not come as a surprise. Many NACDS members offer mail-order programs.

"Pharmacy is all about patient choice," she said. "We sell ourselves, as an industry, on low cost and convenience. It shouldn't be a surprise if people who are busy turn to mail order."

The UCLA-Kaiser researchers are taking a cautious approach.

"We are far from trying to mandate mail for everyone," Dr. Duru told Drug Topics. "That would not be a wise move. What this study says is that in some cases, mail may be an appropriate alternative for certain subgroups of patients."

What the study does not say is why some patients prefer to use mail order or why diabetes patients who use it tend to be more adherent. The study team is planning focus groups to pose those questions directly to patients.

To mail or not to mail

About 20% of patients in the study used mail order, 2,595 out of 13,922 patients who received a new antiglycemic, antihypertensive, or lipid-lowering index medication. In the mail-order group, 84.7% of patients showed good medication adherence compared to 76.9% in the group purchasing medications through a local pharmacy; this amounted to a statistically significant 7.8% advantage.

Adherence was measured by refills. There was no attempt to assess whether patients actually took medications as directed or simply refilled prescriptions on time. There was no comparison of health outcomes or care-related costs between the mail-order and local-pharmacy groups. KPNC offers mail order as an alternative delivery channel for chronic medications but does not require it. Patients who choose mail order are self-selecting - and distinctive.

"These mail-order patients tend to be white, relatively affluent, and have a financial incentive to use mail compared to brick-and-mortar pharmacy users," Dr. Duru said.

Mail users in the study are also less likely to use insulin, more likely to use a brand-name medication, more likely to have more than a 90-day supply per fill, more likely to have been on medication longer, and are likely to live farther from a pharmacy compared to patients using a local pharmacy.

"There are a lot of patients for whom regular contact with a pharmacist is valuable, even necessary, such as older patients, patients on multiple drugs, and patients with multiple comorbidities," Schmittdiel said. "It's not about forcing people to use mail; it's about making access to medication easier. To the extent that benefit managers can make access easier, adherence may improve."