May 17, 2018
By Lorraine L. Janeczko
NEW YORK (Reuters Health) - Medicaid patients in states where they are covered for nicotine replacement patches may need to make more than one trip to the pharmacy to get them, but a few changes can help more of them succeed on their first try, according to a new study.
"This pilot study found that many beneficiaries left pharmacies without a prescription in hand. Successful same-day fills varied markedly by store type," Dr. Kimber P. Richter of the University of Kansas Medical Center in Kansas City and colleagues write in the Journal of the American Pharmacists Association, online April 22.
"For people with low incomes, transportation presents a major barrier for delayed pick-up. In addition, delays can fuel ambivalence toward quitting," they note.
Dr. Richter and her colleagues recruited nine adult smokers who were enrolled in Kansas Medicaid to serve as "secret shoppers" at their local pharmacies.
The participants were given paper prescriptions for over-the-counter nicotine patches by their provider and were escorted by study staff to any of 18 pharmacies in one community who were open to the public and accepted Medicaid: four chain pharmacies; five independent pharmacies; six in supermarkets; and three in mass-merchant stores, such as Walmart or Target.
At each encounter, a staff member who did not appear to be together with the patient stood a few feet away and entered details of the attempt into an online database via smartphone.
All four chain pharmacies filled the prescription during the patient's first attempt. Of the seven (39%) pharmacies that did not fill them, two were independent pharmacies, three were supermarket pharmacies and two were mass-merchant pharmacies.
All but one pharmacy offered to order the patch for pickup on another day.
The authors' recommendations include that providers request the pharmacy to notify them when any of their patients cannot have their prescription filled, and that providers transmit their prescriptions electronically one day before the patient picks it up.
Dr. Lisa Kroon, chair of the department of clinical pharmacy in the School of Pharmacy and co-director of the Fontana Tobacco Treatment Center at the University of California, San Francisco, told Reuters Health by email, "While the Affordable Care Act expanded coverage for smoking-cessation medications in Medicaid-expansion states, other insurers do put up barriers for patients attempting to quit smoking to readily obtain cessation medications. These can include requiring prior authorizations or putting quantity limits within a time period."
"These barriers need to be eliminated," urged Dr. Kroon, who was not involved in the study. "Nicotine addiction is a chronic condition for which we have medications that are proven to be effective. This is not just a habit or about one's will power. Many people take multiple quit attempts before they are successful. Therefore people may use the cessation medications for multiple attempts, and this is where placing limits on the quantity of the medication is very problematic."
"Why an insurer would put limits or barriers on treating tobacco dependence is perplexing," Dr. Kroon noted, "as the cost of treating a heart attack, for example, caused from smoking is much higher."
Dr. Kroon added that these days, pharmacy students often receive extensive training about smoking cessation, so they are better equipped to assist people who want to quit.
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"In fact in many states, pharmacy law allows pharmacists to prescribe nicotine replacement products (such as the patch, gum, lozenge and oral inhaler), even varenicline and bupropion, providing better access to these first-line treatments when people are ready to quit."
Dr. Steve Dudley of Arizona Poison and Drug Information Center at the University of Arizona College of Pharmacy in Tucson, told Reuters Health by email, "Contrary to the authors' original beliefs, obtaining a prescription for nicotine replacement therapy is a fairly successful process, but like with any drug, there is a risk for a small delay given that the pharmacy is a finite space and some drugs will be out of stock. As a generalization, the smaller the pharmacy, the higher the risk for this scenario to be true."
"It is important to note that this study is far too underpowered to be generalizable and that there can be significant differences in Medicaid drug formularies from state to state," added Dr. Dudley, who also was not involved in the study. "This study has too small a sample size to affect even the Midwest town where it took place. It does open the door for bigger studies to address some of the questions and confirm the findings of this study."
"I believe this study fails to realize that most chain pharmacies are separate from their front end, meaning that any over-the-counter drugs (nicotine replacement therapy, ibuprofen, vitamins, etc.) are normally ordered separately by the front end and not by the pharmacy," he explained. "The pharmacy has no idea of an up-to-date inventory count without manually leaving the pharmacy and checking the shelves."
"If same-day prescription filling is important, the provider or the patient can call ahead and ask to see if the drug is in stock, thus saving a trip for the patient, who may not have reliable access to a personal vehicle," he advised.
The authors acknowledge that these results can't be generalized to other communities or pharmacy settings. And they suggest further research to explore whether patients who don't receive a same-day prescription ever get their prescription filled, and if not, how much this barrier contributes to their success or failure.
The study did not have commercial funding, and the authors declared no conflicts of interest.
Dr. Richter was not available for comment.
J Am Pharm Assoc 2018.
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