Probably everyone who has ever had a prescription has, at one time or another, forgotten to pick it up at the pharmacy. We leave our doctor’s appointment – which might be virtual, these days – and wait for a notification from the pharmacy that our medication is ready to pick up. But when we receive that message or call, we might be in the middle of a meal, a phone call, or driving through traffic.
Suddenly it’s the end of the day and we’re forgotten about the prescription. Days later, the pharmacy tries again to get our attention. “I’ll go tomorrow,” we think. And we keep thinking that, until weeks pass and the prescription is considered abandoned.
At that point the pharmacy gives up, takes our prescription off of the shelf, and returns the pills to the stock bottles. That process is called return to stock (RTS) and it is a thorn in the side of pharmacies. Reversing a dispensed medication wastes time, money, and resources.
That said, some RTS is always expected. Sometimes prescriptions are electronically sent to the pharmacy without the patient’s knowledge, or set to auto-fill even though the patient doesn’t need refills. But high rates of RTS can be a symptom of serious problems for the patient, pharmacy, and prescriber.
RTS: Bad for Pharmacies
Think of what goes into a single prescription: the medication itself, a plastic bottle, a label, leaflets about the medication, and a paper bag. All of that costs the pharmacy money, but they expect to recoup the cost of the medication, at least, from the patient’s insurance or out-of-pocket payment.
But when a prescription is returned to stock, most of that is wasted. Bottles can’t be reused for another medication. Labels must be destroyed to keep patient information private. Leaflets and bags are hopefully recycled, but they are still a waste of printer toner and packaging.
If the medication itself is an oral solid, like tablets or capsules, or pre-packaged, like birth control or eye drops, then at least the medication won’t be wasted. But pills must be returned to the correct stock bottle to avoid future errors. For example, if a drug comes in 20mg, 40mg, and 60mg strengths, returning a 60mg pill to a 20mg stock bottle could endanger a future patient. Return to stock brings additional risk into the pharmacy, and mistakes could ruin the pharmacy’s reputation.
The prescription itself isn’t the only expensive thing about RTS. The time spent dispensing a medication includes multiple costs to the pharmacy:
- Costs of ordering, stocking, packaging, labeling, and dispensing the medication;
- Costs for administrative and professional service, like patient counseling;
- Overhead costs, including insurance, rent, software, and taxes.
One study on closed-door, long-term care pharmacies found the cost for dispensing prescriptions to be about $14. For retail pharmacies, the cost is likely higher, because pharmacy staff must spend time contacting the patient to pick up their medication. We can assume that the time spent returning the medication, destroying the label, and reversing the insurance claims is a similar cost to that of dispensing.
As another study showed, because RTS eats into the time of pharmacists and pharmacy techs, their hourly wages need to be included in the cost. In one Midwestern pharmacy, both roles were involved in making pick-up phone calls to patients and ultimately returning the pills to stock bottles. By adding in the cost of their time, the average cost per returned prescription bumped up to approximately $25.
However, the worst part of returning abandoned prescriptions to stock isn’t the process itself but what it signifies. High rates of RTS mean that something went wrong during the patient journey, and it’s likely not a one-off problem. It’s something systemic.
RTS: Bad for Patients
When patients abandon their prescriptions, their health is inevitably affected. If they abandon a first fill of a medication, they will end up starting their therapy later than expected, or not at all. If they abandon a refill they need for a chronic illness, they could end up experiencing a serious health crisis.
Either way, abandonment could lead to a worsening of their condition, a hospital visit, expensive lab work and testing, and overall poor health. Being sick obviously impacts a patient’s daily life, too: they might miss work or school and struggle with everyday tasks. But it’s not an individual problem alone. High rates of non-adherence, or the failure to take prescriptions, is believed to result in $300 billion of avoidable health care costs every year.
Causes & Solutions
There are a lot of reasons that patients don’t pick up prescriptions. These reasons revolve around three themes: cost, education, and access. Each person involved in the patient journey has a role to play within these themes.
- Cost: Be aware of the general price of the medications you are prescribing. Talk to your patient about their drug coverage or lack thereof. If the patient can’t afford their prescription, they will probably never take it.
- Education: Patients need to know why their prescriptions are important, what they will do for their health, what side effects to expect, and that it’s okay to ask questions once they start therapy. If you are changing a patient’s regimen, confirm that they understand the new regimen and why it has changed before your interaction ends.
- Access: To ensure patients can start therapy as soon as possible, keep track of which medications require a prior authorization. It’s usually more efficient to start that process in your office rather than wait for the pharmacy to start the PA. Prescribers who are e-prescribing should also double-check the patient’s preferred pharmacy; medications dispensed at the wrong pharmacy won’t be picked up.
- Cost: If your medication is too expensive, ask your pharmacist if it would be cheaper out of pocket. If it’s still too pricey, talk to your doctor about affordable alternatives. Search for cost-saving measures like discount cards, manufacturer copay cards, or patient assistance programs.
- Education: Not sure why you’re taking a certain medication? Not sure how or when to take it? Talk to your doctor or pharmacist right away. Ask about side effects, what will happen if you miss a dose, and how long you will need to take the medication. The more you know about your prescriptions, the more likely you are to take them properly and not abandon them.
- Access: If you’re avoiding unnecessary errands due to COVID-19, too sick to leave home, or too busy to visit the pharmacy, ask your pharmacy about your options. They may already have delivery or shipping service available, or at least curbside pick-up. If not, tell them about ScriptDrop delivery.
- Cost: If a patient’s medication would be cheaper out of pocket, tell them. A bill rescinding “gag orders” was passed in 2018 and went into effect January 1, 2020.
- Education: Patient counseling is a useful tool. Even strategic questions can be an opportunity to educate the patient, such as “How do you plan to take this medication?” during a first fill interaction, or “When was the last time you took this medication?” during a refill transaction. If your pharmacy offers medication synchronization or adherence packaging, it might be worth offering to patients who struggle to refill or take their medications on time.
- Access: Many patient populations struggle to get to the pharmacy due to chronic illness, mobility problems, lack of transportation, or busy lives. Add those reasons to the ongoing pandemic, and it’s no surprise patients abandon their medications. Cut through it all with delivery! Shipping is an affordable option for maintenance medications and patients who live far from the pharmacy, whereas on-demand or same-day delivery is ideal for antibiotics, pain medications, unexpected refills, and other urgent needs.
Prescribers, patients, and pharmacists need to work together to reduce prescription abandonment and RTS. The root causes are deep, and there are many ways to approach solving them. But it's better to spend time developing solutions for those root causes than waste time returning pills to stock.