Maggie McKay (Host): Have you ever gone to the pharmacy, picked up a prescription, taken it home only to be confused by all the instructions and warnings? How do we figure it all out? Today, our guests are Dr. Katherine Mattlock, BMG Family Medicine physician at Indian Rocks, and Dr. Teresa Dowdell, population health clinical pharmacist for BayCare Plus.

Host: This is Pop Health Chat. I'm your host, Maggie McKay. Welcome, Dr. Mattlock and Dr. Dowdell, it's so nice to have you here today. I can't wait to hear more about the importance of medication adherence in value-based care because I'm one of those people who look at those daunting instructions and say, "What?" And then, I call the pharmacy. So, just to start off, Dr. Dowdell, what is medication adherence, understanding that there are different ways to define it? You have one through the managed care pharmacist perspective where the focus is on a specific quality measure. And then, you have one on the physician side where the focus is on making sure the patient is taking a prescription as prescribed.

Dr Teresa Dowdell: So, medication adherence, according to the managed care pharmacist's perspective, is based upon quality or stars measures. What the star measures do is they are going to see what patients are compliant 80% of the time for specific categories of medications, that's diabetics or diabetes medications, RAS antagonists and/or statins. And the patient needs to be adherent or compliant for 80% of the time. So, it is important for the patient to take that medication for whatever 80% of the time is from the first refill or the first fill of that medication. So, it's based upon how many days that patient takes the medication throughout the year.

Host: And Dr. Mattlock, from your perspective?

Dr Katherine Matlock: Thank you so much for having me. So from our perspective, we want to make sure that the patients are taking the medications as we prescribe them, which, as you alluded to, can sometimes be difficult. So when they come into the office for their appointment, we'll go over their med list with them every time to make sure that their medication list is matching our list. And then, we'll spend some time going over with each patient how they're taking it. So, are they taking it once a day? Are they taking the full dose? Are they missing doses? And so, we'll spend some time on going over that information. We also spend time on going over that list during a hospitalization or a follow up after a hospitalization, as the meds can frequently change after that time period.

If the patient is unsure of the medications that they're taking, we have some processes in place that we can implement to help them out. For instance, we can print a list for them and have them go over the list at home. Or we can utilize resources such as home health or the medication assistance program to help patients work through any issues that they might have or things that aren't clear if we can't answer that in the office. But of course, we're always happy at any time to answer questions for the patients.

Host: So, it sounds like medication adherence is important for not just quality or the star ratings you were talking about, but it's an extremely important aspect of patient care and chronic condition management. So, what are some reasons or barriers that patients may not be compliant?

Dr Teresa Dowdell: There are several barriers to a patient being adherent. One could be that they are hitting the donut hole for Medicare, which puts them in a financial burden to pay for those copays for those particular medications that are of a higher tier in their formulary. A lot of those medications are of the diabetic nature like Ozempic or Jardiance or Farxiga. They just become non-affordable for these patients to pay those copays. Another reason could be that they just don't understand why it's so important to take their medications as prescribed by the physicians. They don't understand that they feel that they feel good, they don't need to take those blood pressure medications because they feel okay, they don't realize that that hypertension is a silent killer. They just forget to take their medications. So, there are a variety of different obstacles that the patients might face.

Dr Katherine Matlock: I'd just like to add also that a lot of the medications that are on the stars list that are being tracked are medications that have lots of side effects that patients experience. And so when they come into the office, we definitely want to spend time with them going over those medications. So for example, statins, a lot of patients might have muscle aches with them, or with metformin, which is a diabetes medication, a lot of times they might have diarrhea, which they might be embarrassed to talk about, but they're not taking their medication as prescribed because of these side effects. So, we definitely want to spend time going over the medications with them when they come in, seeing if we can change or alter the medications to help them through these side effects. Maybe we can address some of those side effects and give them some examples of things to reduce the side effects and make them feel better.

Secondly, if the patient is taking a statin, let's say they're only able to tolerate a half of a pill a day, then we should update our list as long as that is okay and the patient is cardiovascularly okay from that standpoint, we wouldn't want to update our medication list so that it would appropriately reflect how the patient might be filling it, which would affect the stars measures. So, there's a lot of different things that we can do from a physician standpoint to make sure that we overcome any barriers that the patients might be having.

Host: And what are some strategies that manage care pharmacists and physicians use today to improve medication adherence? What else can our physicians be doing to support it?

Dr Teresa Dowdell: Well, the physicians could be prescribing 90-day supplies at this time, which would alleviate the patient going to the pharmacy every month. If you think about it, they have to go to the pharmacy 12 times a year in order to be compliant. So if they only have to go four times a year, that's a lot easier to maintain their compliance. So a lot of times if we see that the patient is on a 30-day supply, we will message the physician to see if they would be willing to change that to a 90-day supply if they're stable. If they're just starting out on a prescription, you don't want to start off with 90 days because you want to make sure that they can handle the medication, that there's no side effects, that they can take the medication properly. So, there are times that you will ramp that up from 30 days to maybe 60 days to 90 days to have the patient become more compliant as the time goes on.

Dr Katherine Matlock: Yeah. Those are great points. And then also, I'd just like to add, for our three medication adherence measures, statins, diabetes medications and ACE inhibitors, we can, as physicians, just remind the patients why they're taking the medication. So specifically with statins, we want to go over with them how they're reducing the morbidity and mortality of any cardiovascular events in both primary and secondary prevention. And so, we want to remind them not only just focusing on the side effects, but why they're taking the medication.

And also if a patient cannot tolerate one statin, it doesn't mean that they can't tolerate another statin. So, we just want to remind them 70-90% of patients with statin intolerance will be able to tolerate another statin, and that is based on published evidence. So, some of our more lipophilic statins penetrate the muscle and cause more myopathy such as atorvastatin, lovastatin and simvastatin, so maybe we switch them to another statin to try to reduce that myopathy that they might be having or potentially we start them with a lower intensity statin and then titrate them up in order to get them to the high intensity statin. So, there's a lot of things that we can do to try to improve the adherence of the medications.

When we look at diabetes, for instance, metformin, we know that if we go low and slow, so maybe if we start at half of a 500-milligram pill a day, then they're more able to tolerate any of the side effects, and then we can titrate them up from there just to make sure that we go nice and slow and they tolerate the medication better. And then, we can always add medications on the end if they're continuing to have side effects from statins such as CoQ10, which has been shown to help reduce myopathy. So, we can work with the patients on whatever their needs are to help address each specific patient and how we can address those concerns and hopefully allow them to continue in a scenario where they're meeting the medication adherence and being the best version of themselves.

Host: Dr. Dowdell, you mentioned having to go to the pharmacy physically 12 times. Aren't there some medications that you could order online and they can just be mailed to you?

Dr Teresa Dowdell: Yes, they can all be mailed to them if the patient wants to do that. They would have to set up an account with the mail order pharmacy, and that does require a 90-day supply for most mail order pharmacies. So if you're just starting out with a medication, you're going to go to your local pharmacy to get that. But a good way to meet compliance is to get the 90-day supply on order refill, which would help the patient because it would automatically get refilled about seven days prior to the prescription becoming due so that the patient will never miss a dose. But they do need to set up an account with the mail order pharmacies in order for that to occur.

On another note, to piggyback onto Dr. Mattlock's statements, if the dose is going to change to every other day dosing for statins or three times a week dosing for statins, if the prescriber would actually order that and fill out a new prescription, that would be very helpful, instead of giving the statin daily as the prescription, that will make the patient look like they're not compliant if they take it three times a week. So, it's really important to change the actual prescription to match the directions for use. Otherwise, it will look like the patient should be taking it every day, but they're really only taking it three times a week. So, it's important to send in a new prescription, although may not be monetarily best for the patient at that point.

Host: In what ways can technology support medication adherence?

Dr Teresa Dowdell: Well, there are several different apps that they can use on their phone if they should have a smartphone and are technologically savvy. There's Siri they can use with their iPhones. There's Alexa if they have that within the home. Alexa, the problem with that is that if they're outside the home when their medication is due, it will not remind them to take it. But there are several different apps like Mango Health, which has games that they can play on it. If you get a hundred percent adherence, it gives you a prize basically. MyMeds, Medisafe, Dosecast and Pill Reminder are all different apps that have really good feedback about them. So, that would be helpful to actually have the patient become compliant.

Dr Katherine Matlock: And then, just a few more options that are not tech savvy, I mean, we can't forget to-go pillbox, right? So, it's such a great resource and tool to use when you put your pills in there and then, you know, if it's empty, that you've gotten all of your meds out and you've taken your medications for the day, so always a good tool as well.

Host: Dr. Mattlock, are you talking about the Monday, Tuesday, Wednesday, Thursday, Friday pill box?

Dr Katherine Matlock: I totally am.

Host: Yeah, true. So, we have a lot of options, right? No excuse not to adhere to our medication. Thank you both so much. Is there anything else either of you would like to add in closing?

Dr Katherine Matlock: Thank you so much for having us today. We appreciate your time.

Dr Teresa Dowdell: Yes. And just know that medication adherence, although across many different planes, will help the patient basically stay healthier and more adherence allows the patient to stay healthy and out of the hospital.

Host: So true. Thank you so much for explaining some things we may not have heard of or thought of before, but can be crucial when it comes to our medications. Again, that's Dr. Mattlock and Dr. Dowdell. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. This is Pop Health Chat, presented by BayCare PHSO. Thank you for listening.