Should Payers Incentivize Pharmacies to Blister-Package Chronic Medications?

ABSTRACT

Medication nonadherence is prevalent among patients taking acute and/or chronic medications. It has been associated with poorer health outcomes, increased mortality, and higher costs for payers and the health care system. Numerous factors contribute to medication nonadherence, with forgetfulness being the primary reason. Payers have a vested interest in improving patient adherence to medications to mitigate overall health care costs by enhancing disease management, and they typically offer programs and initiatives aimed at improving medication adherence. One intervention that has had success in improving medication adherence and patient outcomes across a variety of disease states is putting patients’ medications in blister packs. Although there is decades’ worth of evidence demonstrating the success of blister packaging, utilization outside of the long-term care setting in the US is limited, likely due to the fragmentation of the health care system. Even though putting medications in blister packs has the potential to improve outcomes, pharmacies are the institutions that would have to implement this initiative while not seeing the financial savings from the reduced health care costs. Although it may improve their patients’ outcomes, they would not be capturing the cost savings required to implement a potential new workflow and/or offset additive costs. Therefore, payers should consider incentivizing pharmacies to put medications in blister packs. Because payers would realize cost savings from the reduction in health care costs, they could reinvest some of that money toward blister packaging at their pharmacies and/or provide preferred contracting and network status for independent pharmacies that blister-package medications to help improve their population’s health.

Am J Manag Care. 2025;31(6):In Press

Takeaway Points

Payers should consider providing higher reimbursement rates and/or preferred pharmacy networking status for pharmacies that provide patients with chronic medications in blister packaging.

• Increased adherence to chronic medications can lead to a reduction in health care resource utilization and health care costs.
• Decades’ worth of evidence demonstrates blister packaging’s effectiveness in improving medication adherence.
• The use of blister packaging in the US is limited, likely due to the fragmentation of the health care system.
• Payers should consider incentivizing pharmacies to blister-package medications, which could improve patient outcomes.

One of the most significant challenges in the US health care system is ensuring that patients adhere to their prescribed medication regimen(s).1 Medication nonadherence is prevalent among patients taking acute and/or chronic medications, and it has been associated with poorer health outcomes, increased mortality, and higher costs for patients, payers, and the health care system.2 Numerous factors contribute to medication nonadherence, with forgetfulness being the primary one.1 Extensive research has shown that although improving medication adherence raises pharmacy costs for payers because patients are taking their medication more regularly, the resultant reduction in overall health care costs from improved disease management and better clinical outcomes more than offsets the pharmacy cost increase.3,4

Examples of Payer Medication Adherence–Enhancing Interventions/Programs

Payers have a vested interest in improving patient adherence to medications to mitigate overall health care costs by enhancing disease management. Additionally, for Medicare Advantage prescription drug (MA-PD) health plans, their reimbursement from CMS is contingent on their performance on the Medicare Star Ratings,5 which include 3 quality measures on medication adherence.6 Performance on the 2 Part C intermediate measures has also been shown to be correlated to their adherence measure counterparts.5,7 Consequently, payers offer a host of programs and interventions aimed at promoting and enhancing medication adherence for their beneficiaries.6 These programs include prescriber outreach refill reminders,6,8 prescriber outreach for 90-day prescription fills,8 patient outreach refill reminders,8-10 patient medication reconciliation calls,9,10 medication therapy management,6 automatic medication refills,9 medication home delivery,9 and reduction or elimination of prescription out-of-pocket costs,11 among other strategies.

Intervention of Blister Packaging

Blister-packaged medications have existed for decades to help promote medication adherence. Blister packaging was recommended as a strategy at the 2017 CDC Grand Rounds on improving medication adherence.1 Blister packs are an effective intervention to help patients remember to take their medication, and they make a patient’s medication regimen and directions more straightforward. Blister packs can be provided in unit-dose or multidose packages. Research has shown that blister-packaging medications helps improve adherence and/or outcomes across a variety of diseases, including cardiovascular conditions, with a 12% increase in patients becoming adherent12 and significant reductions after 6 months in systolic blood pressure (3.3 mm Hg; P = .02) and low-density lipoprotein cholesterol (4.9 mg/dL; P = .001)13; behavioral health, with patients receiving medications in blister packs being 59% closer to perfect adherence (95% CI, 6.6%-112.2%) than those receiving their medications in vials14; and diabetes, with an absolute reduction in hemoglobin A1c of 0.80 (P = .0026)15; as well as in a study assessing the composite effect of blister-packaging all chronic medications.16 Patients have reported high satisfaction with blister packs,17 but no comparative assessment with traditional vials could be identified.

Additionally, 2 recently published economic models attempted to model, from both a commercial payer and an MA-PD perspective, the potential impact on total health care costs by blister-packaging chronic medications.18,19 The analysis from the MA-PD perspective found net reductions in total health care costs of $3.19 per member per month (PMPM) for renin-angiotensin system (RAS) antagonists, $4.02 PMPM for statins, and $0.68 PMPM for oral antidiabetics,18 whereas the analysis from the commercial perspective found net reductions of $0.73 PMPM for RAS antagonists, $0.29 PMPM for statins, $0.07 PMPM for oral antidiabetics, and $0.10 PMPM for oral anticoagulants.19 Although these analyses assessed the impact on medical and drug costs, they did not account for the potentially increased cost of materials and machinery required for blister-packaging medications from the pharmacy perspective.18,19 The cost of using blister-packaged materials, compared with the cost of using traditional vials, is estimated at $0.10 to $0.25 more per prescription,17 whereas the cost of proprietary machinery needed for full implementation is not publicly available but could be in the tens to hundreds of thousands of dollars, depending on dispensing needs. These costs typically are borne not by the patient or payer but almost exclusively by the pharmacy.

Blister Packaging in Current Practice

Despite several decades of evidence demonstrating its effectiveness in promoting adherence, blister-packaging medications has not been a widely implemented strategy in the US, outside of long-term care settings.20 Although there is no consensus on the reason, it likely stems from the increased costs of blister-packaged materials compared with the cost of traditional vials, along with a potential change in pharmacy workflow to implement this initiative. Although the reduction in health care costs may outweigh the slight increase in packaging costs, a primary reason for limited uptake is also likely due to the fragmentation of the US health care system,21 with pharmacies incurring the added costs of blister-packaging materials and technology, whereas payers see the health care resource utilization reductions and cost savings. Pharmacies thus have only a small direct incentive to change their dispensing and workflow practices to implement blister-packaging medications. One potential incentive for pharmacies is that increased medication adherence could lead to a higher dispensing volume.22

Medications Requiring High Adherence Often Come in Manufacturer Blister Packs

Outside of long-term care settings, most medications are not blister-packaged, despite evidence of its effectiveness. However, medications requiring high adherence for treatment success or specialty medications with high costs that are part of value-based contracts (VBCs) often come in manufacturer blister packs. Some of these medications include oral contraceptives, certain oral oncolytic drugs, hepatitis C medications, and HIV medications. In the case of high-cost medications for which manufacturers have VBCs with payers, where treatment success is tied to medication reimbursement from the payer, manufacturers have been providing their medications in blister packs directly to the pharmacy, allowing the medications going to the patient to be blister-packaged. This reinforces the point that blister packaging is an effective intervention to promote medication adherence by helping patients remember to take their medication and making a patient’s medication regimen and directions more straightforward. When financials are directly tied to treatment success and outcomes, blister-packaging medications becomes a frequently utilized intervention. One potential unintended consequence of increased blister-packaging adoption is that it may encourage manufacturers to provide medications in blister packs at a higher cost. The impact of increased blister-packaging medications on the environment is unknown; some materials used in the packaging may have a greater impact than others.

Financial Implications of Blister-Packaging Medications for Payers

Implementing medication adherence packaging for chronic medications can result in cost savings and increased reimbursement for health plans. Medication adherence packaging, such as blister packs, can increase medication adherence,1,14-18 and patients who are adherent to their medications have improved health outcomes and lower health care costs.3-5 For commercial self-insured health plans, improved medication adherence can enhance worker quality of life and productivity.23,24 In MA-PD plans, better adherence can lead to higher reimbursement and payments from CMS due to improved Medicare Star Ratings. The Star Ratings have 3 specific measures assessing adherence to statins, noninsulin antidiabetic medications, and RAS antagonists. Additional Star Rating measures are linked to performance on the adherence measures.8,25 MA-PD plans that receive an overall rating of 4.5 or 5.0 stars receive a 70% rebate, plans that achieve an overall rating of 3.5 or 4.0 stars receive a 65% rebate, and plans with less than 3.5 overall stars receive a 50% rebate.26 In addition, MA-PD plans that achieve at least a 4.0 overall star rating receive a 5% quality bonus payment (QBP),26 with CMS paying more than $12.8 billion in QBPs in 2023.27MA-PD plan enrollment has also been associated with performance on Medicare Star Ratings, with increased enrollment leading to increased revenue.28

Ways Payers Can Incentivize or Implement Blister Packaging

Although payers may not directly implement medication adherence packaging or blister-packaging medications on the health plan or pharmacy benefits manager (PBM) level, several strategies can achieve this goal. Payers that own mail-order pharmacies can implement blister-packaging medications at these pharmacies. The top 6 PBMs account for approximately 96% of the PBM market share, with all 6 operating their own mail-order pharmacy.29 Of the top 6 PBMs, 5 are vertically integrated with health plans, which can benefit financially from improved medication adherence through reduced health care costs and/or improved Medicare Star Ratings.29 PBMs that blister-package medications can promote this initiative when negotiating their services with independent health plans. The largest PBM by market share is vertically integrated with a health plan and owns and operates the largest retail pharmacy chain, providing another avenue to implement this initiative.29 Integrated delivery networks or health systems that are self-insured can implement blister-packaging medications in their outpatient pharmacies, potentially realizing financial benefits from health care cost savings from employees who fill their medications at these pharmacies.

In addition to implementing this service at their pharmacies, health plans and PBMs can also incentivize outpatient, independent, and retail pharmacies to provide medication adherence packaging.Payers could give preferred contracting to pharmacies that blister-package chronic medications. With the increasing utilization of pay-for-performance reimbursement between payers and pharmacies, pharmacies that implement blister packaging or medication adherence packaging may ultimately receive higher reimbursement from payers because of improved performance on medication adherence measures.30 Payers often create high-quality pharmacy networks to reward high-performing pharmacies, driving improved patient care and better outcomes.30 By incentivizing pharmacies who provide blister-packaging services with preferred contracting and/or pay-for-performance reimbursement, payers have an opportunity to lead the way in promoting the medication packaging initiative.

Conclusions

Medication adherence to chronic medications is significantly tied to treatment success and reductions in adverse outcomes and health care costs. Enhanced medication adherence packaging, such as blister-packaged medications, has consistently demonstrated its effectiveness in improving patient adherence. This adherence can translate into cost savings and increased reimbursement for payers. Therefore, incentivizing pharmacies to implement blister-packaging chronic medications or establish in-house blister-packaging capabilities presents a strategic opportunity for improving patient outcomes and achieving economic efficiencies. 

Author Affiliations: Becton, Dickinson and Company, San Diego, CA (EPB, IB), Durham, NC (PS, NEB), and Franklin Lakes, NJ (JDL).

Source of Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author Disclosures: Dr Borrelli was an employee of Becton, Dickinson and Company during the time of the study, and Dr Barnes is an employee of Becton, Dickinson and Company. Drs Saad, Beer, and Lucaci are employees and shareholders of Becton, Dickinson and Company. Becton, Dickinson and Company manufactures automated blister-packaging technology.

Authorship Information: Concept and design (EPB, PS, JDL); acquisition of data (EPB); analysis and interpretation of data (EPB, PS, NEB, IB, JDL); drafting of the manuscript (EPB, NEB, JDL); critical revision of the manuscript for important intellectual content (EPB, PS, NEB, IB, JDL); provision of patients or study materials (EPB); administrative, technical, or logistic support (EPB, JDL); and supervision (EPB, IB, JDL).

Address Correspondence to: Eric P. Borrelli, PhD, PharmD, MBA, Becton, Dickinson and Company, 3750 Torrey View Ct, San Diego, CA 92130. Email: EricBorrelli@gmail.com.

REFERENCES

1. Neiman AB, Ruppar T, Ho M, et al. CDC Grand Rounds: improving medication adherence for chronic disease management — innovations and opportunities. MMWR Morb Mortal Wkly Rep. 2017;66(45):1248-1251. doi:10.15585/mmwr.mm6645a2

2. Watanabe JH, McInnis T, Hirsch JD. Cost of prescription drug-related morbidity and mortality. Ann Pharmacother. 2018;52(9):829-837. doi:10.1177/1060028018765159

3. Campbell PJ, Axon DR, Taylor AM, et al. Hypertension, cholesterol and diabetes medication adherence, health care utilization and expenditure in a Medicare supplemental sample. Medicine (Baltimore). 2021;100(35):e27143. doi:10.1097/MD.0000000000027143

4. Poonawalla IB, Chung L, Shetler S, Pearce H, Dixon SW, Racsa P. Medication adherence star ratings measures, health care resource utilization, and cost. Am J Manag Care. 2024;30(5):210-217. doi:10.37765/ajmc.2024.89538

5. Medicare 2024 Part C & D Star Ratings Technical Notes. CMS. Updated March 13, 2024. Accessed June 8, 2024. https://www.cms.gov/files/document/2024technotes20230929.pdf

6. Kogut SJ. A primer on quality measurement and reporting in pharmacy benefit plans. J Manag Care Spec Pharm. 2024;30(4):386-396. doi:10.18553/jmcp.2024.23240

7. Ta JT, Erickson SC, Qiu WA, Patel BV. Is there a relationship between Part D medication adherence and Part C intermediate outcomes star ratings measures? J Manag Care Spec Pharm. 2016;22(7):787-795. doi:10.18553/jmcp.2016.22.7.787

8. Leslie RS, Gilmer T, Natarajan L, Hovell M. A multichannel medication adherence intervention influences patient and prescriber behavior. J Manag Care Spec Pharm. 2016;22(5):526-538. doi:10.18553/jmcp.2016.22.5.526

9. Leslie RS, Tirado B, Patel BV, Rein PJ. Evaluation of an integrated adherence program aimed to increase Medicare Part D star rating measures. J Manag Care Spec Pharm. 2014;20(12):1193-1203. doi:10.18553/jmcp.2014.20.12.1193

10. Hong M, Esse T, Vadhariya A, et al. Evaluating success factors of a medication adherence tracker pilot program in improving Part D medication adherence metrics in a Medicare Advantage plan: importance of provider engagement. J Manag Care Spec Pharm. 2020;26(5):662-667. doi:10.18553/jmcp.2020.26.5.662

11. Ahern DK, Aberger EW, Wroblewski JP, et al. Behavior-based diabetes management: impact on care, hospitalizations, and costs. Am J Manag Care. 2021;27(3):96-102. doi:10.37765/ajmc.2021.88597

12. Zedler BK, Joyce A, Murrelle L, Kakad P, Harpe SE. A pharmacoepidemiologic analysis of the impact of calendar packaging on adherence to self-administered medications for long-term use. Clin Ther. 2011;33(5):581-597. doi:10.1016/j.clinthera.2011.04.020

13. Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. JAMA. 2006;296(21):2563-2571. doi:10.1001/jama.296.21.joc60162

14. Gutierrez PM, Wortzel HS, Forster JE, Leitner RA, Hostetter TA, Brenner LA. Blister packaging medication increases treatment adherence in psychiatric patients. J Psychiatr Pract. 2017;23(5):320-327. doi:10.1097/PRA.0000000000000252

15. Simmons D, Upjohn M, Gamble GD. Can medication packaging improve glycemic control and blood pressure in type 2 diabetes? results from a randomized controlled trial. Diabetes Care. 2000;23(2):153-156. doi:10.2337/diacare.23.2.153

16. Navin S. Blister packaging medications for adherence for American Indians/Alaska Natives in the outpatient setting. J Pharm Pract. 2021;34(1):97-102. doi:10.1177/0897190019851357

17. Bosworth HB, Brown JN, Danus S, et al. Evaluation of a packaging approach to improve cholesterol medication adherence. Am J Manag Care. 2017;23(9):e280-e286.

18. Borrelli EP, Saad P, Barnes N, Dumitru D, Lucaci JD. Estimating the economic impact of blister packaging on medication adherence and health care costs for a Medicare Advantage health plan. J Manag Care Spec Pharm. 2024;30(12):1442-1454. doi:10.18553/jmcp.2024.24179

19. Borrelli EP, Saad P, Barnes N, Dumitru D, Lucaci JD. Impact of blister packaging on health care costs: an economic analysis of medication adherence in chronic disease management for a commercially insured health plan. Clinicoecon Outcomes Res. 2024;16:733-745. doi:10.2147/CEOR.S480890

20. Gaunt MJ. Checking long-term care blister packs and bingo cards. Pharmacy Times. 2014;80(11):46-47. Accessed July 14, 2024. https://www.pharmacytimes.com/view/checking-long-term-care-blister-packs-and-bingo-cards

21. Seabury SA, Gupta CN, Philipson TJ, Henkhaus LE; PhRMA Medication Adherence Advisory Council. Understanding and overcoming barriers to medication adherence: a review of research priorities. J Manag Care Spec Pharm. 2014;20(8):775-783. doi:10.18553/jmcp.2014.20.8.775

22. Raju G, Sarkar P, Singla E, Singh H, Sharma RK. Comparison of environmental sustainability of pharmaceutical packaging. Perspect Sci (Neth). 2016;8:683-685. doi:10.1016/j.pisc.2016.06.058

23. Giffords B, Geppert P, Zayance R, Lin R. The impact of medication adherence on workplace productivity outcomes: a review of the scientific evidence and example for calculating savings from improved adherence. Integrated Benefits Institute. August 2018. Accessed June 18, 2024. https://www.ibiweb.org/resources/the-impact-of-medication-adherence-on-workplace-productivity-outcomes

24. Majeed A, Rehman M, Hussain I, et al. The impact of treatment adherence on quality of life among type 2 diabetes mellitus patients - findings from a cross-sectional study. Patient Prefer Adherence. 2021;15:475-481. doi:10.2147/PPA.S295012

25. Rose JZ. Contributor: medication adherence is a “force multiplier” for Medicare Advantage profitability, enrollment, Star Ratings. AJMC. January 9, 2023. Accessed July 3, 2024. https://www.ajmc.com/view/contributor-medication-adherence-is-a-force-multiplier-for-medicare-advantage-profitability-enrollment-star-ratings

26. Advance notice of methodological changes for calendar year (CY) 2024 for Medicare Advantage (MA) capitation rates and Part C and Part D payment policies. CMS. February 1, 2023. Accessed June 18, 2024. https://www.cms.gov/files/document/2024-advance-notice-pdf.pdf

27. Fuglesten Biniek J, Damico A, Neuman T. Spending on Medicare Advantage Quality bonus payments will reach at least $12.8 billion in 2023. KFF. August 9, 2023. Accessed July 12, 2024. https://web.archive.org/web/20240524050641/https://www.kff.org/medicare/issue-brief/spending-on-medicare-advantage-quality-bonus-payments-will-reach-at-least-12-8-billion-in-2023/

28. Borrelli EP, Park MA, Leslie RS. Impact of star ratings on Medicare health plan enrollment: a systematic literature review. J Am Pharm Assoc (2003). 2023;63(4):989-997.e3. doi:10.1016/j.japh.2023.03.009

29. Fein AJ. Mapping the vertical integration of insurers, PBMs, specialty pharmacies, and providers: a May 2024 update. Drug Channels. May 7, 2024. Accessed August 28, 2024. https://www.drugchannels.net/2024/05/mapping-vertical-integration-of.html

30. Pharmacy Pay-for-Performance Principles: Performance-Based Reimbursement and Direct and Indirect Remuneration (DIR) Fees. Academy of Managed Care Pharmacy. March 2022. Accessed July 8, 2024. https://www.amcp.org/sites/default/files/2022-05/PayforPerformance_Apr2022.pdf