I finally had a chance to read the study on mail and community pharmacy preferences published in The Journal of the American Pharmaceutical Association, an article which has been the focus of much discussion over the last several weeks. The study, published by CVS Caremark, examined member’s choice of channel in the first 4 months after being converted from an incentivized or mandatory mail program to their Maintenance Choice program, which offers an equal financial incentive for mail and 90-day retail.
The study was well-done methodologically and the conclusions did not over-interpret the data. What has been surprising to me is that the study is being discussed by some stakeholders as evidence that members, when equally incentivized, will choose mail over community pharmacy. This conclusion is not supported by the study, was not a conclusion made by the authors, and in fact, a detailed review of the study suggests the opposite conclusion.
The basis for this inference seems to be the finding that 56% of patients who were new to therapy (i.e., had never filled that particular medication at either a mail or community pharmacy) chose mail service for their prescription, a slight majority. However, if you read the study details, 76% of those patients had previously used mail for OTHER medications. Accordingly, when results are examined by whether or not the member had previously used mail for any medication, only 32% of patients with NO prior mail use chose mail for the new prescription and 63% of those with prior mail use chose mail for their new prescription. In other words, community pharmacy was the preferred choice for the majority of patients who had not previously used mail for any prescriptions.
The data for ongoing users can be broken down the same way, showing that 21% of patients with NO prior mail use chose mail for their refill and 75% of those with any prior mail use chose mail for their refill. Again, when you examine data points for both new and ongoing users, community pharmacy appears to have a slight advantage in terms of percent choosing. Furthermore, the authors note that the most important predictor of selecting mail service pharmacy was recent use of mail for another medication. Specifically, the odds ratio for selecting community pharmacy was 3.77 for community pharmacy users compared to prior mail users.
Also note that this study did not examine whether the members’ spouse had previously used mail, which I have found in previous research to be a strong predictor of mail use. Reason being, much of the initial paperwork is already in place and there is a familiarity with the mail service, reducing the barriers to use. Inclusion of this covariate would likely increase the odds ratio for prior mail use.
All that said, the authors conclusion, which focused on the diversity of preferences rather than which channel had an inherent preference advantage, was on point—“Patient behavior indicates that certain patients prefer to access prescription medications via mail service and others through community pharmacy.” Bottom line: if your PBM offers competitive 90-day retail rates, take advantage of them, with the caveat that you will need to make sure that your formulary and generic promotion programs remain effectively in place.