Users' Perceptions of Mail-Service Pharmacy This survey of users found that 92% were satisfied with mail order pharmacy) citing prompt) good service and low copayment. by Kimberly K. Birtcher, MS, and Marvin D. Shepherd, PhD
n increasing numbers, Americans are purchasing their prescription medications from mail-service pharmacies. Mail-service prescription revenues have increased 50% each year since 1981, from less than $100 million in 1981 to $750 million in 1986.1,2 As an example, Medco Containment Service, Inc., contracts with employers or major health care providers to provide prescription drug services to employees or members. In 1987, Medco's sales volume was $300.5 million; in 1988 the sales volume increased 67% to $502.5 million. The number of people covered by Medco grew from 12 million to 16 million. 3 Although less than 3% of the 1.5 billion prescriptions sold annually are purchased from mail order providers, 4 sales are predicted to grow by 30% each year, reaching $2.8 billion and accounting for 10% of pharmaceutical prescription sales in
I
the United States by 1991.2 By 1995, the American Managed Care Pharmacy Association (AMCPA) predicts that mail-service providers will have total sales of $6 billion, or approximately 15% of the total prescription dnlg market. 5 However, others predict that the market share for mail-service pharmacy will stay about 10% of the market. 6 Even AMCPA admits that mail-service pharmacy may not reach the predicted 15% of the market. 6 With community pharmacies increasing their competitiveness, drug manufacturers offering one price to all providers, and state regulation increasing, the market for mailVol. NS32, No. 12 December 1992/967
AMERICAN PHARMACY
Table 1
service phannacy has been and may continue to be stifled. Large corporations that offer prescription medication benefits to employees and retirees are purchasing mail-service phannacy programs. 7 In an attempt to contain costs of prescription medication benefit plans, many employers are offering incentives for or mandating use of mail-service phannacy by their employees.8-12 Many groups are asking questions about mail-service users: • Employers want to know if employees are satisfied with the mail-service phannacy. • Consumers considering a mail order service want to know if their infonnation needs will be adequately met. • Mail-service providers want to know how they can improve their services to attract more consumers. • Community pharmacists want to know how they can retain and continue to serve consumers attracted to mail-service phannacy. To answer these questions, University of Texas employees who have used the mail-service pharmacy option of their major health insurance coverage were studied.
Demographic Information of Respondents Characteristic
Frequency
0/0
Age (in years)
Qver65
48
2,5 .4
57 to 65
46
24.3
46 to 66
48
25.4
47
24.9
45 or less Total Mean Standard deviation Range
~89
55.3
ye~rs
±13.2 years 26-82 years
Health status
Excellent
62
32.3
103
53.7
21
10.9
Poor
6
3.1
Total
192
100.0
White
173
90.1
Black
Good Fair
Methods
Race/ethnicity
A questionnaire was used to collect infonnation on patient demographics, "locked-in" factors (such as having families with young children or poor health), and structural and attitudinal factors that might have influenced the decision to use the mail order phannacy. Questions were developed to measure respondents' satisfaction with the service and to collect data on previous patterns of phannacy patronage. The specific objectives of this study were to: • Develop a descriptive profile of demographic and stnlCtural variables associated with mail-service phannacy use. • Determine the association between patient satisfaction with previous phannacy use and the use of mail-service pharmacy. • Determine how users of mail-service pharmacy obtain dnlg infonnation. • Ascertain why patients choose mail-service phannacy. • Determine patients' satisfaction with the mail-service phannacy option. Because the university has several campuses throughout the state, focus was placed on four campuses. From a mailing list of 1,572 mail-service phannacy users, 125 names were randomly selected from campus A, 125 names from campus B, 71 names from campus C, and 54 names from campus D to receive the questionnaire. The survey instrument included attitudinal questions that explored the mail-service user's satisfaction with prior pharmacy use; the reason they chose to use the mail order pharmacy; and their satisfaction with the mail order phannacy. AMERICANPHARMACY
13
6.8
Chicano
4
2.1
Other
2
1.0
192
100.0
Total Sex
115
60.2
Male
76
39,8
Total
191*
100.0
Female
Education level
Less than high school
5
2.6
High school/equivalent
18
9.5
Some college
58
30.5
College gradUate
21
11.1
1
3.7
81
42.6
190
100.0
PhD
45
55.6
Master's
28
34,.5
MD/DDS
8
9.9
Some gr:aduate school Graauate degree Totar Graduate degrees
Total
81
100.0 (continued)
Em
December 1992/ 968
vol. NS32, No. 12
Table 1
Demographic Information of Respondents (continued)
"Enabling" questions explored how the user learned about the mail order pharmacy option and how the user received drug information. In addition, the survey instrument included questions to collect sociodemographic information. The survey instrument was pretested on 10 pharmacy employees, then mailed to the sample chosen. No follow-up mailing was made. All data obtained from returned surveys were entered into a computer file and analyzed using SPSS/pCT programs.
Results Of the 372 mailed surveys, 204 usable questionnaires were received, for a response rate of 54.8%. The response rates for the different campuses were: campus A, 59.2%; campus B, 48.8%; campus C, 57.1%; and campus D, 48.1%. Table 1 summarizes the respondents' demographic information. The sample was predominately white, with an average age of 55.3 years. Nearly 88% of the sample had received education beyond high school, and 30% indicated that they were retired. Only 25.8% of the sample reported total household income to be less than $25,000. Thus, the sample represented a well-educated, white group of people with an above-average income. The mail-service pharmacy users had an average family size of 2.2 persons. Only 11.3% (N = 23) of the respondents had preschool children and 23.0% (N = 47) had children in sixth grade or less-not surprising, when one considers the average age and the large proportion of retirees in the sample. More than 85% of all the respondents indicated either "good" or "excellent" health status. In response to the average number of prescriptions filled per month by the mail-service pharmacy, 33.9% (N = 64) of the respondents indicated less than one; 40.2% eN = 76) reported one or more but less than two; 15.9% eN = 30) reported two to three prescriptions; and 10% eN = 19) reported more than three. These numbers can be misconstrued because mail-service users receive three-month supplies of their chronic medications rather than the one-month supply usually provided by community pharmacists.
Prior Experience Respondents were asked where they obtained their prescription pharmaceutical products before they began using the mail order service. Responses showed that they previously used all types of community pharmacies, with nearly half indicating a major chain-store pharmacy. A total of 71.8% eN = 145) indicated that before choosing the mail order service, they were primarily using only one community pharmacy. Only 21.8% eN = 44) of the mail-service pharmacy users Vol. NS32, No. 12 December 1992/969
AMERICAN PHARMACY
Satisfaction with Service Respondents were satisfied with mail-service pharmacy; 91.9% (N = 179) rated their satisfaction as "excellent " or "good" (Table 4). Those who reported "excellent" satisfaction commented about the mail-service pharmacy's prompt service, low costs, and good service. Those who reported "fair" satisfaction indicated "slow service" as the predominant reason for this rating ; five cited the mail-service pharmacy's inability to fill all preTable 3
Primary Reason for Selecting the Mail Order Prescription Option
scription orders. Respondents were also asked if they planned to continue their mail-service prescription plan the following year. A total of 90.4% (N = 179) reported "yes. " Only 3.0% (N = 6) indicated "no," and 6.1 % (N = 12) reported "do not know. "
Drug Information Source
indicated that they had used a mail-service pharmacy plan before using the one that the university provides. Of respondents who indicated that they had previously used only one pharmacy, 96.4% rated the service provided by that pharmacy as excellent or good (Table 2).
Mail-Service Pharmacy Information Source A total of 154 respondents (75.5%) reported that they received information about the availability of the mail order prescription option solely from the university's benefits office. Fourteen respondents indicated that the insurance carrier was the sole provider of the information. An additional 15 respondents reported that both the university's benefits office and the insurance carrier provided the information. Using an open-ended question, respondents were asked: "What was the primary reason you decided to use the mail order option?" Cost savings was the overwhelming response (Table 3). AMERICAN PHARMACY
Thirty-nine percent (N = 78) indicated they received drug information brochures with all their prescriptions and 37.5% (N = 75) indicated they received brochures with some of their prescriptions. Of the respondents who had received drug information brochures, 91.5% (N = 140) rated the information as "excellent" or "good. " When asked to comment on their satisfaction with the information, 35.4% of the respondents stated that the "information was complete, " 22.9% indicated that the information was appreciated, and 14.6% indicated that they wanted written dnlg information with all prescription medications. Using a closed-ended question, respondents were asked: "Who do you talk with or call to get more information or ask questions about your prescriptions filled from the mail order pharmacy?" The most frequently reported answers were physicians and mail order pharmacists (fable 5). Only 10.3% (N = 21) indicated their "local pharmacist"; however, 24.0% (N = 49) reported "no one." It was not determined if the respondents who answered "no one" needed additional information.
Discussion This study's respondents had an average age of 55.2 years, and 30% were retired. The data on their medication use supDecember 1992/ 970
Vol. NS32, No. 12
port claims that older patients use more medicaRespondents' Satisfaction lNith the tions, especially medications Mail-Service Pharmacy to treat chronic conditions, and may use mail-service pharmacy for the treatment of chronic health concerns. More than 40% of the respondents had a graduatelevel education and more than half the sample had household incomes more than $ 3 5,000. This aboveaverage ranking may be an artifact of the employee group being studied. Poor health was not a reason for choosing the mail-service option. Only six reported their health status as "poor"; four of these six reported "cost" as the reason they selected mail-service pharmacy. The remaining two respondents indicated "convenience" and "large quantity of medications." This shows that the locked-in variable of health status was not a major determining factor for using the mail-service pharmacy option. Satisfaction or dissatisfaction with prior pharmacy use did not appear to affect the respondents' choice of the mail-service option. In general, the three main community pharmacy settings-independent, chain, and grocery-drug combination stores-were mentioned as previously used pharmacies, although almost half of the mail-service pharmacy users had been patronizing a major chain pharmacy. The fmding that respondents learned about the availability of the mail-service option through the university's benefits office supports a Tennessee study that found employer encouragement an important factor in employees' selection of mail-service programs. 13 A comparison of the coverage for prescription drugs by the current and former insurance plans shows why respondents indicated cost as the primary reason for selecting a mail-service pharmacy. The major medical plan formerly used had a $200 deductible and a 20% coinsurance; the mail-service plan requires a $5 copayment for generic drugs and a $10 copayment for brand-name products, and there was no deductible. Thus, respondents perceived the mail-service program to be Vol. NS32, No. 12 December 1992/971
Table 4
AMERICAN PHARMACY
less costly. This is even more significant when you consider that mail-service pharmacies provide a three-month supply of a chronic medication, whereas community pharmacies usually dispense only a one-month supply. Nearly 77% of the respondents who received drug information brochures with prescriptions stated that the information was complete, and many wished that they received dnlg information with all prescriptions. Thus, it appears that the brochures meet some of the respondents' drug information needs, but it was not determined to what extent the needs were satisfied. One often-mentioned criticism of mail-service pharmacies is the perceived lack of pharmacist interaction with patients about their therapy or health care condition. When the mailservice users were asked who they contacted to get more information about their prescriptions, almost one-third indicated a mail order pharmacist. The mail-service program offered by the University of Texas gives patients a telephone number to get information, and based on patients' responses, it appears that many do use this service. Another 25% of the respondents indicated that their physicians were their information source. It was not determined if the respondents called their physicians more often, spent more time with their physicians, or asked more questions of their physicians after they started using the mail-service pharmacy. It may be that since they know they will not be seeing a pharmacist, they are obtaining more of their drug information from physician. More research is needed to determine if mailservice pharmacy has shifted the demand for drug information from a community pharmacists to physicians. Approximately 24% of the respondents said they asked "no one" for drug information. It may be that respondents who marked "no one" have no drug information expectations from mail-service pharmacies because they never or infrequently received drug information from their previous pharmacies. In an exploratory analysis to determine where those respondents who indicated "no one" had previously obtained their prescription drugs, it was found that 60.6% had purchased them from major chain pharmacies, 27.3% from independent pharmacies, and 12.1 % from grocery-drug combination stores.
Limitations As with many research projects, this study has some limitations. First, there may be a nonresponse bias. Only 54.8% of the questionnaires mailed were returned. It is unknown if the nonrespondents had views or characteristics similar to those of the respondents. Second, the data represent only employees or retirees from one large employer in Texas. To what extent this population is similar to other large employAMERICAN PHARMACY
ers is unknown. Third, only beneficiaries who have used the mail-service pharmacy option were surveyed. No comparisons were made with employees who did not select this benefit option. Fourth, only one mail-service pharmacy provider was examined in the study. Finally, the respondents may have interpreted the questionnaire items differently. These study demographics limit generalizations of the results to other populations and settings.
Conclusions Although this study provided only data from users of one mail-service pharmacy provider, the results show that mailservice pharmacy patrons are satisfied with the service they have received. Mail-service pharmacy has found a unique niche in the marketplace, and the providers will undoubtedly try to maintain and expand their market share. Perceived cost savings was the primary reason given for using the mail order pharmacy. For community pharmacies to enhance their competitive position, they must be given equal opportunity to participate under the same plan guidelines extended to mail-service pharmacy providers. Community pharmacists must not be automatically locked out of employers' contracts for pharmacy services because of differences in beneficiary out-of-pocket costs or other components of the plans. To be more competitive, community pharmacies may want to consider offering drug information brochures similar to those provided by the mail service, and mail-service providers may want to enhance this service. In addition, community pharmacists may want to have a 24hour telephone number for use in emergencies. Both community and mail-service pharmacists and managers can learn from studies of this nature. Information presented can enhance the competitive positions of both types of pharmacy operations. Kimberly K Birtcher, MS, is a pharmacist at Methodist Hospital, Houston, Tex. Marvin D. Shepherd, PhD, is professor, pharmacy administration, College of Pharmacy, The University of Texas at Austin, Austin, Tex.
References 1. Mail order drugs: who's managing the store? Am Pharm. 1987;NS27:46. 2. Wygod M. Testimony presented to Senate Governmental Affairs Subcommittee on Government Efficiency, Federalism, and the District of Columbia. Washington, DC: Oversight hearings on the safety and soundness of mail order pharmaceutical industry. August 6, 1987. 3. Mail order: top 250. Direct Marketing. July 1989;(3):39. 4. Enright SM. Mail order pharmaceuticals. Am J Hosp Pharm. 1987;44:1870-3. 5. The mail order prescription drug industry origins and growth. Pharm Business. April 1991:12. December 1992/972
Vol. NS32, No. 12
6. Mail ordering bombing? Drug Topics. July 20, 1992:57. 7. Welling KM. Rx for hot stocks. Why Porex and Medco sell at eye-popping PIEs. Barron's. April 13, 1987; 47:13,22- 26,86. 8. Barberi MJ. Halting the runaway cost of prescription coverage. Business Insurance. February 11, 1985;19:17,18. 9. Innovation in controlling prescription cost. Nat Underwriter (life/health). May 7, 1983;87:45,48-9.
10. Drury SJ. Mail order drugs can cut the cost of prescription plans. Business Insurance. March 21, 1983;17:1,30. 11. Fox P, Goldbeck W, Spies J. Health Care Cost Management. Private Sector Initiatives. Ann Arbor, MI: Health Adm inistration Press; 1984:25. 12. Baker Je, Sauer MA. Look what the postman delivered. Business Health. March 1988;5:16-8. 13. Roberts KB, Fitzgerald WL. Evaluation of consumer opinions of prescription drug services from community and mail order pharmacies. Tenn Pharm. August 1986;22:14-25.
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MARION MERRELL DOW INC. PRESCRIPTION PRODUCTS DIVISION KANSAS
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Vol. NS32, No. 12 December 1992/ 973
6272B2
AMERICAN PHARMACY
n increasing numbers, Americans are purchasing their prescription medications from mail-service pharmacies. Mail-service prescription revenues have increased 50% each year since 1981, from less than $100 million in 1981 to $750 million in 1986.1,2 As an example, Medco Containment Service, Inc., contracts with employers or major health care providers to provide prescription drug services to employees or members. In 1987, Medco's sales volume was $300.5 million; in 1988 the sales volume increased 67% to $502.5 million. The number of people covered by Medco grew from 12 million to 16 million. 3 Although less than 3% of the 1.5 billion prescriptions sold annually are purchased from mail order providers, 4 sales are predicted to grow by 30% each year, reaching $2.8 billion and accounting for 10% of pharmaceutical prescription sales in
I
the United States by 1991.2 By 1995, the American Managed Care Pharmacy Association (AMCPA) predicts that mail-service providers will have total sales of $6 billion, or approximately 15% of the total prescription dnlg market. 5 However, others predict that the market share for mail-service pharmacy will stay about 10% of the market. 6 Even AMCPA admits that mail-service pharmacy may not reach the predicted 15% of the market. 6 With community pharmacies increasing their competitiveness, drug manufacturers offering one price to all providers, and state regulation increasing, the market for mailVol. NS32, No. 12 December 1992/967
AMERICAN PHARMACY
Table 1
service phannacy has been and may continue to be stifled. Large corporations that offer prescription medication benefits to employees and retirees are purchasing mail-service phannacy programs. 7 In an attempt to contain costs of prescription medication benefit plans, many employers are offering incentives for or mandating use of mail-service phannacy by their employees.8-12 Many groups are asking questions about mail-service users: • Employers want to know if employees are satisfied with the mail-service phannacy. • Consumers considering a mail order service want to know if their infonnation needs will be adequately met. • Mail-service providers want to know how they can improve their services to attract more consumers. • Community pharmacists want to know how they can retain and continue to serve consumers attracted to mail-service phannacy. To answer these questions, University of Texas employees who have used the mail-service pharmacy option of their major health insurance coverage were studied.
Demographic Information of Respondents Characteristic
Frequency
0/0
Age (in years)
Qver65
48
2,5 .4
57 to 65
46
24.3
46 to 66
48
25.4
47
24.9
45 or less Total Mean Standard deviation Range
~89
55.3
ye~rs
±13.2 years 26-82 years
Health status
Excellent
62
32.3
103
53.7
21
10.9
Poor
6
3.1
Total
192
100.0
White
173
90.1
Black
Good Fair
Methods
Race/ethnicity
A questionnaire was used to collect infonnation on patient demographics, "locked-in" factors (such as having families with young children or poor health), and structural and attitudinal factors that might have influenced the decision to use the mail order phannacy. Questions were developed to measure respondents' satisfaction with the service and to collect data on previous patterns of phannacy patronage. The specific objectives of this study were to: • Develop a descriptive profile of demographic and stnlCtural variables associated with mail-service phannacy use. • Determine the association between patient satisfaction with previous phannacy use and the use of mail-service pharmacy. • Determine how users of mail-service pharmacy obtain dnlg infonnation. • Ascertain why patients choose mail-service phannacy. • Determine patients' satisfaction with the mail-service phannacy option. Because the university has several campuses throughout the state, focus was placed on four campuses. From a mailing list of 1,572 mail-service phannacy users, 125 names were randomly selected from campus A, 125 names from campus B, 71 names from campus C, and 54 names from campus D to receive the questionnaire. The survey instrument included attitudinal questions that explored the mail-service user's satisfaction with prior pharmacy use; the reason they chose to use the mail order pharmacy; and their satisfaction with the mail order phannacy. AMERICANPHARMACY
13
6.8
Chicano
4
2.1
Other
2
1.0
192
100.0
Total Sex
115
60.2
Male
76
39,8
Total
191*
100.0
Female
Education level
Less than high school
5
2.6
High school/equivalent
18
9.5
Some college
58
30.5
College gradUate
21
11.1
1
3.7
81
42.6
190
100.0
PhD
45
55.6
Master's
28
34,.5
MD/DDS
8
9.9
Some gr:aduate school Graauate degree Totar Graduate degrees
Total
81
100.0 (continued)
Em
December 1992/ 968
vol. NS32, No. 12
Table 1
Demographic Information of Respondents (continued)
"Enabling" questions explored how the user learned about the mail order pharmacy option and how the user received drug information. In addition, the survey instrument included questions to collect sociodemographic information. The survey instrument was pretested on 10 pharmacy employees, then mailed to the sample chosen. No follow-up mailing was made. All data obtained from returned surveys were entered into a computer file and analyzed using SPSS/pCT programs.
Results Of the 372 mailed surveys, 204 usable questionnaires were received, for a response rate of 54.8%. The response rates for the different campuses were: campus A, 59.2%; campus B, 48.8%; campus C, 57.1%; and campus D, 48.1%. Table 1 summarizes the respondents' demographic information. The sample was predominately white, with an average age of 55.3 years. Nearly 88% of the sample had received education beyond high school, and 30% indicated that they were retired. Only 25.8% of the sample reported total household income to be less than $25,000. Thus, the sample represented a well-educated, white group of people with an above-average income. The mail-service pharmacy users had an average family size of 2.2 persons. Only 11.3% (N = 23) of the respondents had preschool children and 23.0% (N = 47) had children in sixth grade or less-not surprising, when one considers the average age and the large proportion of retirees in the sample. More than 85% of all the respondents indicated either "good" or "excellent" health status. In response to the average number of prescriptions filled per month by the mail-service pharmacy, 33.9% (N = 64) of the respondents indicated less than one; 40.2% eN = 76) reported one or more but less than two; 15.9% eN = 30) reported two to three prescriptions; and 10% eN = 19) reported more than three. These numbers can be misconstrued because mail-service users receive three-month supplies of their chronic medications rather than the one-month supply usually provided by community pharmacists.
Prior Experience Respondents were asked where they obtained their prescription pharmaceutical products before they began using the mail order service. Responses showed that they previously used all types of community pharmacies, with nearly half indicating a major chain-store pharmacy. A total of 71.8% eN = 145) indicated that before choosing the mail order service, they were primarily using only one community pharmacy. Only 21.8% eN = 44) of the mail-service pharmacy users Vol. NS32, No. 12 December 1992/969
AMERICAN PHARMACY
Satisfaction with Service Respondents were satisfied with mail-service pharmacy; 91.9% (N = 179) rated their satisfaction as "excellent " or "good" (Table 4). Those who reported "excellent" satisfaction commented about the mail-service pharmacy's prompt service, low costs, and good service. Those who reported "fair" satisfaction indicated "slow service" as the predominant reason for this rating ; five cited the mail-service pharmacy's inability to fill all preTable 3
Primary Reason for Selecting the Mail Order Prescription Option
scription orders. Respondents were also asked if they planned to continue their mail-service prescription plan the following year. A total of 90.4% (N = 179) reported "yes. " Only 3.0% (N = 6) indicated "no," and 6.1 % (N = 12) reported "do not know. "
Drug Information Source
indicated that they had used a mail-service pharmacy plan before using the one that the university provides. Of respondents who indicated that they had previously used only one pharmacy, 96.4% rated the service provided by that pharmacy as excellent or good (Table 2).
Mail-Service Pharmacy Information Source A total of 154 respondents (75.5%) reported that they received information about the availability of the mail order prescription option solely from the university's benefits office. Fourteen respondents indicated that the insurance carrier was the sole provider of the information. An additional 15 respondents reported that both the university's benefits office and the insurance carrier provided the information. Using an open-ended question, respondents were asked: "What was the primary reason you decided to use the mail order option?" Cost savings was the overwhelming response (Table 3). AMERICAN PHARMACY
Thirty-nine percent (N = 78) indicated they received drug information brochures with all their prescriptions and 37.5% (N = 75) indicated they received brochures with some of their prescriptions. Of the respondents who had received drug information brochures, 91.5% (N = 140) rated the information as "excellent" or "good. " When asked to comment on their satisfaction with the information, 35.4% of the respondents stated that the "information was complete, " 22.9% indicated that the information was appreciated, and 14.6% indicated that they wanted written dnlg information with all prescription medications. Using a closed-ended question, respondents were asked: "Who do you talk with or call to get more information or ask questions about your prescriptions filled from the mail order pharmacy?" The most frequently reported answers were physicians and mail order pharmacists (fable 5). Only 10.3% (N = 21) indicated their "local pharmacist"; however, 24.0% (N = 49) reported "no one." It was not determined if the respondents who answered "no one" needed additional information.
Discussion This study's respondents had an average age of 55.2 years, and 30% were retired. The data on their medication use supDecember 1992/ 970
Vol. NS32, No. 12
port claims that older patients use more medicaRespondents' Satisfaction lNith the tions, especially medications Mail-Service Pharmacy to treat chronic conditions, and may use mail-service pharmacy for the treatment of chronic health concerns. More than 40% of the respondents had a graduatelevel education and more than half the sample had household incomes more than $ 3 5,000. This aboveaverage ranking may be an artifact of the employee group being studied. Poor health was not a reason for choosing the mail-service option. Only six reported their health status as "poor"; four of these six reported "cost" as the reason they selected mail-service pharmacy. The remaining two respondents indicated "convenience" and "large quantity of medications." This shows that the locked-in variable of health status was not a major determining factor for using the mail-service pharmacy option. Satisfaction or dissatisfaction with prior pharmacy use did not appear to affect the respondents' choice of the mail-service option. In general, the three main community pharmacy settings-independent, chain, and grocery-drug combination stores-were mentioned as previously used pharmacies, although almost half of the mail-service pharmacy users had been patronizing a major chain pharmacy. The fmding that respondents learned about the availability of the mail-service option through the university's benefits office supports a Tennessee study that found employer encouragement an important factor in employees' selection of mail-service programs. 13 A comparison of the coverage for prescription drugs by the current and former insurance plans shows why respondents indicated cost as the primary reason for selecting a mail-service pharmacy. The major medical plan formerly used had a $200 deductible and a 20% coinsurance; the mail-service plan requires a $5 copayment for generic drugs and a $10 copayment for brand-name products, and there was no deductible. Thus, respondents perceived the mail-service program to be Vol. NS32, No. 12 December 1992/971
Table 4
AMERICAN PHARMACY
less costly. This is even more significant when you consider that mail-service pharmacies provide a three-month supply of a chronic medication, whereas community pharmacies usually dispense only a one-month supply. Nearly 77% of the respondents who received drug information brochures with prescriptions stated that the information was complete, and many wished that they received dnlg information with all prescriptions. Thus, it appears that the brochures meet some of the respondents' drug information needs, but it was not determined to what extent the needs were satisfied. One often-mentioned criticism of mail-service pharmacies is the perceived lack of pharmacist interaction with patients about their therapy or health care condition. When the mailservice users were asked who they contacted to get more information about their prescriptions, almost one-third indicated a mail order pharmacist. The mail-service program offered by the University of Texas gives patients a telephone number to get information, and based on patients' responses, it appears that many do use this service. Another 25% of the respondents indicated that their physicians were their information source. It was not determined if the respondents called their physicians more often, spent more time with their physicians, or asked more questions of their physicians after they started using the mail-service pharmacy. It may be that since they know they will not be seeing a pharmacist, they are obtaining more of their drug information from physician. More research is needed to determine if mailservice pharmacy has shifted the demand for drug information from a community pharmacists to physicians. Approximately 24% of the respondents said they asked "no one" for drug information. It may be that respondents who marked "no one" have no drug information expectations from mail-service pharmacies because they never or infrequently received drug information from their previous pharmacies. In an exploratory analysis to determine where those respondents who indicated "no one" had previously obtained their prescription drugs, it was found that 60.6% had purchased them from major chain pharmacies, 27.3% from independent pharmacies, and 12.1 % from grocery-drug combination stores.
Limitations As with many research projects, this study has some limitations. First, there may be a nonresponse bias. Only 54.8% of the questionnaires mailed were returned. It is unknown if the nonrespondents had views or characteristics similar to those of the respondents. Second, the data represent only employees or retirees from one large employer in Texas. To what extent this population is similar to other large employAMERICAN PHARMACY
ers is unknown. Third, only beneficiaries who have used the mail-service pharmacy option were surveyed. No comparisons were made with employees who did not select this benefit option. Fourth, only one mail-service pharmacy provider was examined in the study. Finally, the respondents may have interpreted the questionnaire items differently. These study demographics limit generalizations of the results to other populations and settings.
Conclusions Although this study provided only data from users of one mail-service pharmacy provider, the results show that mailservice pharmacy patrons are satisfied with the service they have received. Mail-service pharmacy has found a unique niche in the marketplace, and the providers will undoubtedly try to maintain and expand their market share. Perceived cost savings was the primary reason given for using the mail order pharmacy. For community pharmacies to enhance their competitive position, they must be given equal opportunity to participate under the same plan guidelines extended to mail-service pharmacy providers. Community pharmacists must not be automatically locked out of employers' contracts for pharmacy services because of differences in beneficiary out-of-pocket costs or other components of the plans. To be more competitive, community pharmacies may want to consider offering drug information brochures similar to those provided by the mail service, and mail-service providers may want to enhance this service. In addition, community pharmacists may want to have a 24hour telephone number for use in emergencies. Both community and mail-service pharmacists and managers can learn from studies of this nature. Information presented can enhance the competitive positions of both types of pharmacy operations. Kimberly K Birtcher, MS, is a pharmacist at Methodist Hospital, Houston, Tex. Marvin D. Shepherd, PhD, is professor, pharmacy administration, College of Pharmacy, The University of Texas at Austin, Austin, Tex.
References 1. Mail order drugs: who's managing the store? Am Pharm. 1987;NS27:46. 2. Wygod M. Testimony presented to Senate Governmental Affairs Subcommittee on Government Efficiency, Federalism, and the District of Columbia. Washington, DC: Oversight hearings on the safety and soundness of mail order pharmaceutical industry. August 6, 1987. 3. Mail order: top 250. Direct Marketing. July 1989;(3):39. 4. Enright SM. Mail order pharmaceuticals. Am J Hosp Pharm. 1987;44:1870-3. 5. The mail order prescription drug industry origins and growth. Pharm Business. April 1991:12. December 1992/972
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6. Mail ordering bombing? Drug Topics. July 20, 1992:57. 7. Welling KM. Rx for hot stocks. Why Porex and Medco sell at eye-popping PIEs. Barron's. April 13, 1987; 47:13,22- 26,86. 8. Barberi MJ. Halting the runaway cost of prescription coverage. Business Insurance. February 11, 1985;19:17,18. 9. Innovation in controlling prescription cost. Nat Underwriter (life/health). May 7, 1983;87:45,48-9.
10. Drury SJ. Mail order drugs can cut the cost of prescription plans. Business Insurance. March 21, 1983;17:1,30. 11. Fox P, Goldbeck W, Spies J. Health Care Cost Management. Private Sector Initiatives. Ann Arbor, MI: Health Adm inistration Press; 1984:25. 12. Baker Je, Sauer MA. Look what the postman delivered. Business Health. March 1988;5:16-8. 13. Roberts KB, Fitzgerald WL. Evaluation of consumer opinions of prescription drug services from community and mail order pharmacies. Tenn Pharm. August 1986;22:14-25.
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