Authors: Lee Holland, PharmD, MPH; Mel L. Nelson, PharmD, CPHQ; Kimberly Westrich, MA; Patrick J. Campbell, PharmD, PhD; Matthew K. Pickering, PharmD
Publication: Journal of Managed Care and Specialty Pharmacy, December 2021
Many Americans face challenges in accessing needed medications, from delays in getting diagnosed and prescribed effective treatment to navigating insurance and cost barriers. The Pharmacy Quality Alliance (PQA), with support from the National Pharmaceutical Council (NPC), developed a framework that defines a patient’s medication access journey and characterizes barriers frequently encountered while seeking medication access.
A new paper in the Journal of Managed Care and Specialty Pharmacy, co-authored by NPC's Vice President of Health Services Research Kimberly Westrich, describes the framework, including seven main areas that patients encounter while seeking access to medications as well as the structural, financial and personal barriers that they face within each area.
The seven areas are:
- Perceived need: Patient becomes aware of illness/condition.
- Help seeking: Patient attempts to schedule a medical appointment or checks with insurer for lists of in-network providers or covered disease states and/or treatments.
- Encounter: Patient interacts with health care provider and presents concerns for assessment and possible treatment.
- Prescribing: Provider selects an appropriate medication (if needed).
- Prescription adjudication: Insurer pays or denies submitted prescription claim, possibly implementing utilization management tools that may disrupt the timeliness of receiving medication.
- Prescription dispensing: Patient interacts with the pharmacy that provides the medication.
- Adherence: Patient follows the provider’s recommendations to take medication as prescribed.
The authors also outline 18 barriers that patients may face in the process of accessing medications, including patient and organizational health literacy, medication-related costs, and insurance. This framework provides a patient-focused, holistic view of medication access and offers a structure to consider key opportunities for interventions and measurement to address medication access challenges.
The framework is the centerpiece of a PQA report, Access to Care: Development of a Medication Access Framework for Quality Measurement, released in March 2019. The report is the product of PQA’s Access to Care Roundtable, a multi-stakeholder panel of experts in social determinants of health, health care quality improvement and quality performance measurement.