Aetna Relies on Automation to Speed Mail Orders

Patients get prescriptions faster, and that may encourage better compliance.


Mail-order and central-fill bag sortation systems directly interface to the manifest and packaging systems.
The Aetna Way entails “helping people achieve health and financial security by providing easy access to safe, cost-effective, high-quality healthcare and protecting their finances against health-related risks,” shares the insurer on its Web site.


Part of fulfilling Aetna’s mission is ensuring that its patients remain persistent in their prescribed drug therapies, explains Duane Barnes, division president, Aetna Rx Home Delivery and Aetna Specialty Pharmacy. The company boasts an extensive patient outreach system intended to encourage compliance. But sophisticated packaging automation at Aetna’s mail-order fulfillment centers plays an important role, too.


Barnes manages three facilities dedicated to filling mail-order prescriptions. The orders primarily consist of prescriptions to treat chronic therapies in 90-day supplies. Two operations—one in Kansas City, MO, and a next-generation location in Pompano Beach, FL—together handle 90% of the orders of the mainly oral pharmaceuticals utilizing off-the-shelf automation. The remaining 10% of the orders, mostly temperature-sensitive drugs that demand specialty handling, are fulfilled by a third facility, Aetna Specialty Pharmacy in Orlando, FL.


At the Kansas City and Pompano Beach locations, Aetna employs Dual Bottle-Pac, Dual Pharma-Pac, and Multi-Pac Bottle systems from Maverick Enterprises (Longmont, CO). All systems utilize postal-weight approximation software, finished bag check weighing, and integrated postal manifesting and sortation.


Feeding these packaging systems are thousands of feet of conveyors that carry bottles filled at McKesson Baker cells, which are essentially bottle fillers dedicated to one product and one strength (i.e., National Drug Code [NDC]). Each NDC requires its own dispensing station or pick location, and Aetna dispenses nearly 5000 NDCs in this manner. “The bottles travel in RFID-tagged pucks along what amounts to a highway,” says Barnes. “A lot could go wrong if the systems weren’t automated.”


When a prescription comes into Aetna’s system, a pharmacist verifies the prescription, and Aetna’s system generates a patient- and NDC-specific bar coded label and applies it to a bottle. The bottles travel to NDC-specific cells, are filled, and then enter staging areas where they await other prescribed items. Photo eyes control filling and staging through bar code verification.


When patient orders are complete and have been verified by a second pharmacist review, they move to one of the three automatic systems—Dual Bottle-Pac, Dual Pharma-Pac, and Multi-Pac Bottle. Bruce Johnson, vice president of sales and marketing for Maverick, details the automatic packaging machines as follows:


• Bottle-Pac Systems are capable of running single-bottle prescriptions at up to 400 orders per hour automatically with four-point product-literature-bag-patient verification in the space of a little over one manual pack station. The machines also print, quarter-fold, validate, and insert up to 10 pieces of literature and insert one to three envelopes, brochures, and/or medication guides. With a footprint of about 4 × 8 ft, the system has optional bottle depucking, bottle order sequencing, in-line bottle weighing with manifest or postal rate shipping interface, operator graphical color touch screen with machine self-diagnostics, mail sortation systems, and easy SQL database integration into pharmacy host software. Off-the-shelf replacement parts are used and always available. Maverick has an installed base of multiple customers with both this and the Pharma-Pac systems. In a nutshell, companies can eliminate up to four operators per shift and use half the floor space, often resulting in a return on investment in one year or less.


• Multi-Pac Systems are the workhorses of the industry for automated multiple-bottle or tote-order packaging. These systems are capable of processing up to 750 prescription orders per hour with the four-point validation and up to 18 pieces of literature and up to three envelopes. One system replaces about seven manual packers per shift, adding one operator back. Options include items like safety-cap insertion, bottle and tote-order sequencing, bottle depuck systems, in-line bottle weighing, postal-rate estimation software with finished bag checkweighing, color graphic operator touch screen, easy host pharmacy interfacing, off-the-shelf replacement parts, and mail sortation.


• Pharma-Pac Systems are tote-based semiautomated packaging stations that essentially triple the output of an operator while halving the needed floor space. The system features the capabilities of a Bottle-Pac system; it does require an operator to scan final product and drop it into the bag. A light curtain also counts each item going into the bag as an added safety precaution to prevent an operator who confirmed an order through bar code scanning from entering in the wrong number of items into the bag. A Super Tote option allows operations to place a large volume of single-item orders in the tote and an operator to scan and package each one very quickly. The Pharma-Pac system handles a minimum of 250 orders per hour; with the Super Tote, it can handle more than 275. (Maverick also offers optional automated tote packaging, utilizing a tote infeed similar to that of the Multi-Pac, with 100% tote product verification prior to packaging.)


Dual Bottle-Pacs from Maverick Enterprises can process single-bottle prescriptions at a combined rate up to 800 orders per hour.
Aetna employs dual Bottle-Pacs and dual Pharma-Pacs in Pompano Beach and single units of all three systems in Kansas City, says Johnson. Barnes adds that one operator manages all lines in each location.


Barnes joined Aetna in the summer of 2006. “It was good timing, because Aetna did not have a lot of volume in Pompano Beach—just about 10–15%. We had an older automation system in place in Kansas City, which was an acquired site, and wanted to increase prescription volumes without increasing real estate or workforce. And we didn’t want to have to constrain our throughput. If people have to wait for prescriptions and run out of their medications, there is a break in compliance.”


Multi-Pac systems can handle multiple-bottle or tote-order packaging at rates up to 750 orders per hour.
After doing a throughput analysis, Barnes found that there were constraints at Aetna’s existing packaging stations. Barnes knew updated automation could help Aetna process more while increasing accuracy and efficiency. He suggested first outfitting the newer Pompano Beach location, which had been built about three or so years ago, with Maverick’s systems. “Pompano Beach was built to suit, but it didn’t have quite the level of automation I would have wanted to see. Some thought I was putting the cart before the horse by increasing the capacity of a location that was only handling 15% of our orders. But you need capacity before volume if you want to run optimally.”


Totes with infeed systems carry multiple-item orders to downstream bagging systems.
Barnes liked the idea of using Maverick’s off-the-shelf systems. “Your operators can troubleshoot over the phone and solve problems with off-the-shelf parts. You can’t always do so with custom-built systems. You need to staff engineers experienced with the custom system.”


After equipping Pompano Beach with the lines from Maverick, Barnes oversaw Kansas City’s transformation.


As a result, Aetna has added millions more in prescription capacity per year, reports Barnes. Pompano Beach is handling about 52% of the orders now, with the rest handled at Kansas City or processed through specialty handling.


Barnes reports that using these systems gives Aetna “a level of efficiency given their footprints beyond anything that could be done manually.” With the combined efforts of the Bottle-Pac, Pharma-Pac, and Multi-Pac systems at each facility, an average of 1000–1200 orders are processed each hour, per facility, he says.


Semiautomated tote based packaging can process prescriptions at more than 250 orders per hour direct or 300 orders per hour as a Super-Tote system.
To accomplish the same volume manually, Barnes says Aetna would need approximately 20 manual packaging stations per facility to meet the same level of throughput. “But it would take three times the space, and I would not achieve the same level of quality,” he says.


Automation is important to Barnes and his team because he says that “anything I can automate, I can improve in quality and in turnaround. I also improve capacity if you think in terms of being able to remove constraints.”


Removing constraints helps Aetna get prescriptions mailed to patients sooner. “If we can get prescription orders and more information out to patients faster, we can help them maintain adherence. Coupled with our patient counseling, our careful monitoring of patient queues, and our direct clinical interventions, it makes up a holistic approach to better patient outcomes,” he says.


When asked whether mail-order prescription fulfillment itself leads to better outcomes, Barnes said that “leveraging our assets allows us to observe refill behaviors and determine whether patients stay on therapies. We have ways of doing this when patients use retail pharmacies, but we encourage the mail service because we do not have the same level of robust and time-sensitive data for all retail prescription transactions. The data we do have suggest that compliance rates are significantly higher when patients utilize mail service.”
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