Thursday, August 11, 2011

A Controversial New Study on Mandatory Mail

While we're on the subject of mandatory mail this week, here’s a new article from The American Journal Of Managed Care that's sure to cause controversy: Adherence to Medication Under Mandatory and Voluntary Mail Benefit Designs.

Why? The study found that patients who were new to mail had much lower adherence with mandatory mail compared to a voluntary mail benefit design.

The results will surely be exaggerated by foes of mail order pharmacy, although the negative findings only apply to patients “without previous mail service pharmacy experience” and with benefits managed by CVS Caremark (NYSE:CVS). Patients with previous experience using a mail pharmacy had similar levels of adherence whether the use of mail was voluntary or mandatory.

The results highlight a challenge for Pharmacy Benefit Managers (PBMs) in growing mail pharmacy participation rates. Or perhaps the results show an as-yet-unrecognized problem in the way CVS Caremark introduces patients to mail order?

UPDATE: Read Express Scripts' response to the article.


The study focused on "therapy initiators"—people in their first year of therapy. The data came from employer-sponsored pharmacy insurance plans that offered either mandatory (n=85) or voluntary (n=240) mail pharmacy benefits managed by CVS Caremark between July 1, 2008, and March 31, 2010. The study looked at seven therapeutic classes for either anti-diabetic or cardiovascular therapies.

In addition to the standard metric of adherence (Medication Possession Ratio, MPR), the authors also computed the proportion of patients persistent on each day during the follow-up period. Persistence was based on the patient having available drug therapy on a particular day during the study period. Full details of the methodology are described in the paper.

While not stated in the paper, voluntary mail benefit design presumably refers to plans that encourage consumer use of mail pharmacies by reducing co-payments by about $17 per tier 2 brand prescription (per PBMI survey data).


The mandatory mail cohort took the biggest hit after the 90th day of therapy, which the authors speculate could be an important transition point between retail and mail delivery. Figure 2 summarizes the results. Click the chart to enlarge.

As you can see, persistence was similar for the voluntary mail participants and mandatory mail participants with mail experience. However, mandatory mail participants without previous mail use had significantly lower persistence versus the other three groups.

Yes, that's the sad-looking purple line below the others.


PBMs already face a challenge in boosting mail volume given the growth of “mail pricing at retail” models. See Chains in 2010: Winning. An inability to transition new-to-therapy patients after the second or third fill would be another hurdle.

This "degree of mail experience" segmentation also highlights a very subtle sample selection bias in other published studies that document higher adherence from mail pharmacy.

Namely, other studies include patients who are already comfortable and familiar with mail pharmacy and exclude those who dropped out of the mail cohort. Mail persistence levels (the blue and green lines above) would presumably remain above retail persistence when measured over a longer period of time. This bias would also be present in the adherence data that populate PBM investor presentations.

Keep in mind that the results above are not an indictment of mail. The data do not compare adherence at retail pharmacies versus mail pharmacies. Here are two interesting papers if you are interested in that topic:
  • When out-of-pocket costs are equivalent, previous mail users tended to stick with mail and previous community pharmacy users tended to stick with community pharmacy. See Surprising Data on the Mail vs. Retail Choice, written by some of the same authors.

Just my $0.02, but the authors give insufficient consideration to the fact that only patients with benefits managed by CVS Caremark are included. As a result, the results are less generalizable than the paper I discuss in Co-Payments and Prescription Abandonment.

Note that the study period coincided with many of the public challenges for CVS Caremark, so I’m curious to know if the same phenomenon shows up in the behavior of patients with benefits managed by Express Scripts (NASDAQ:ESRX) or Medco Health Solutions (NYSE:MHS).

The authors are unabashedly pro-Maintenance Choice, which is notable since the study was funded by CVS Caremark and some of the authors are/were employees. They write:
"These facts, in combination with the recent growth of 90-day retail pharmacy programs, highlight the importance of implementing pharmacy benefit designs that preserve access to mail and retail pharmacies while allowing the convenience of 90-day-supply prescriptions via either channel."
Both foes and fans of mail-order will have something to say about this new study.


The image above comes from the totally awesome Mental Floss t-shirt collection.


  1. but ofcourse they do adam, who would't want to protect they opague business model!!!

  2. Adam,

    Thanks for posting and analyzing this intriguing study. This study has its limits; yet if you allow yourself to consider the
    wider "patient behavior trends" which this study samples, there should
    be serious concerns about the effects of mandatory mail on un-acclimated
    patients. I mostly concur with Jim above, particularly concerning the examination of care outcomes when considering the costs associated with different distribution channels.

    I think these issues are especially acute in specialty pharmacy, and some of ESI's counter arguments don't hold water with specialty patients. Express Scripts is of course correct to counter that the study's selected patient group (e.g. new to therapy) tends to be at higher risk for non-adherence when forced to switch. Yet the characteristics of this study's selected population coincide with many if not the majority of specialty patients. Most specialty patients are new to treatment, and diseases like Hep C often require therapy changes. Further, ESI allows specialty patients only one courtesy fill at their retail pharmacy, not two, meaning the parameters of this study are more applicable to ESI's specialty patients than their non-specialty.

    Finally, disruptions in treatment and/or non-adherence generally have much more serious consequences to health in specialty treatment - hospitalization is not uncommon - and the long term cost consequences (pharmacy and medical) of such disruptions are significantly greater. It will be interesting to see how much traction this study gets in specialty circles.

  3. Harvey I. BurmanAugust 15, 2011


    The lack of continuity of care in this country has become more fragmented then at  any other time in my Pharmacy career which dates back to 1959. This despite the incredible technology we have access to today. Take a look at the treating algorithym's for the new triple therapy for Hepatitis C -Its short term- there are many possible stopping rules- you get 1 chance at treatment- there is no room for error -
    75% cure rate- NO ROOM FOR ERROR
    Harvey Burman RPh
    Burmans Specialty Pharmacy LLC