Medication Therapy Management Program Research Articles

Potential Health Implications of Medication Therapy Management Eligibility Criteria in the Patient Protection and Affordable Care Act Across Racial and Ethnic Groups.

The Medicare Prescription Drug, Improvement, and Modernization Act requires Part D plans to establish programs to provide medication therapy management (MTM) services starting from 2006. MTM services have been found to improve patient outcomes from pharmacotherapy, reduce emergency room visits and hospitalizations, and reduce health care costs in a cost-effective fashion. However, previous research found that non-Hispanic blacks (blacks) and Hispanics may be less likely to be eligible for MTM services than non-Hispanic whites (whites) among the Medicare population, according to current Medicare MTM eligibility criteria. This finding is because Medicare MTM eligibility criteria are predominantly based on medication use and costs, and blacks and Hispanics tend to use fewer prescription medications and incur lower prescription medication costs. The Patient Protection and Affordable Care Act (PPACA) laid out a set of MTM eligibility criteria for eligible entities to target patients for MTM services: "(1) take 4 or more prescribed medications ...; (2) take any 'high risk' medications; (3) have 2 or more chronic diseases ... or (4) have undergone a transition of care, or other factors ... that are likely to create a high risk of medication-related problems." To (a) examine racial/ethnic disparities in meeting the eligibility criteria for MTM services in PPACA among the Medicare population and (b) determine whether there would be greater disparities in health and economic outcomes among MTM-ineligible than MTM-eligible groups. This was a retrospective cross-sectional analysis of the Medicare Current Beneficiaries Survey (2007-2008). To determine medication characteristics, the U.S. Food and Drug Administration's Electronic Orange Book was also used. Proportions of the population eligible for MTM services based on PPACA MTM eligibility criteria were compared across racial and ethnic groups using a chi-square test; a logistic regression model was used to adjust for population sociodemographic and health characteristics. Health and economic outcomes examined included health status (self-perceived good health status, number of chronic diseases, activities of daily living [ADLs], and instrumental activities of daily living [IADLs]), health services utilization and costs (physician visits, emergency room visits, and total health care costs), and medication use patterns (generic dispensing ratio). To determine difference in disparities across MTM eligibility categories, difference-in-differences regressions of various functional forms were employed, depending on the nature of the dependent variables. Interaction terms between the dummy variables for minority groups (e.g., blacks or Hispanics) and MTM eligibility were included to test whether disparity patterns varied between MTM-ineligible and MTM-eligible individuals. The sample consisted of 12,966 Medicare beneficiaries, of which 11,161 were white, 930 were black, and 875 were Hispanic. Of the study sample, 9,992 whites (86.4%), 825 blacks (86.3%), and 733 Hispanics (80.6%) were eligible for MTM. The difference between whites and Hispanics was significant (P less than 0.050), and the difference between whites and blacks was not significant (P greater than 0.050). In multivariate analyses, significant disparity in eligibility for MTM services was found only between Hispanics and whites (odds ratio [OR] = 0.59; 95% CI = 0.43-0.82) but not between blacks and whites (OR = 0.78; 95% CI = 0.55-1.09). Disparities were greater among the MTM-ineligible than the MTM-eligible populations in self-perceived health status, ADLs, and IADLs for both blacks and Hispanics compared with whites. When analyzing the number of chronic conditions, the number and costs of physician visits, and total health care costs, the authors of this study found lower racial and ethnic disparities among the ineligible population than the eligible population. Hispanics are significantly less likely than whites to qualify for MTM among the Medicare population, according to MTM eligibility criteria stipulated in the PPACA. PPACA MTM eligibility criteria may aggravate existing racial and ethnic disparities in health status but may remediate racial and ethnic disparities in health services utilization. Alternative MTM eligibility criteria other than PPACA MTM eligibility criteria may be needed to improve the efficiency and equity of access to Medicare Part D MTM programs.

Impact of a comprehensive pharmacist medication-therapy management service

Objective:This proof of concept study aimed to determine whether a pharmacist-managed medication therapy management (MTM) program in a private endocrinologist physician’s practice reduced healthcare services utilization and related costs 6 months after patients’ discharge from an institution with a transition of care service.Methods:Patients were included in the study if they were English-speaking, ages >18 years, had type 1 or 2 diabetes, and had a recent transition of care experience (inpatient hospital stay or emergency department/urgent care/paramedic or other acute care visit). The study had a non-randomized design where intervention patients, enrolled July 1, 2012–September 30, 2013, were administered MTM at four visits over 6 months and were compared to historical control patients with available electronic medical records from August 8, 2008 to March 15, 2012. The primary study end-point was the rate of 30-day hospital readmissions, as related to the reason for the index admission. Secondary end-points included the cumulative rate of all-cause hospitalizations, emergency department, paramedic and urgent care visits at 30, 60, 90, and 180 days post-discharge as well as imputed total costs, including prescription medication costs, at 180 days. Propensity score weights were constructed to balance covariate characteristics between the intervention and control groups. Weighted multivariate negative binomial and generalized linear regressions were used to model cumulative utilization rates and log-transformed costs, respectively.Results:The intervention (n = 28) and control (n = 73) groups had 0% hospital readmissions at 30 days post-discharge. In propensity score weighted multivariate analyses, cumulative utilization rate was not different between the two groups (IRR = 1.61, p = 0.72 at 180 days) while costs in the intervention group were lower but not statistically different (cost ratio = 0.65, p = 0.13 at 180 days).Conclusions:Further studies should investigate whether the integration of pharmacists in transition of care models could reduce readmission and healthcare utilization rates post-discharge.

Cost-effectiveness of comprehensive medication reviews versus noncomprehensive medication review interventions and subsequent successful medication changes in a Medicare Part D population.

An estimated 1.5 million preventable medication-related adverse events occur annually, with some resulting in serious injury and even death. To help address this issue, the Centers for Medicare Medicaid Services (CMS) now require medication therapy management (MTM) programs to offer comprehensive medication reviews (CMRs) to all Medicare Part D beneficiaries at least once a year. During a CMR, patients receive an extensive amount of medication and educational information. In contrast, noncomprehensive medication reviews (non-CMRs) are more targeted and focus on resolving a particular medication-related problem (MRP) via short patient consultations, patient letters, and direct provider interventions. To conduct a cost-effectiveness analysis comparing CMRs with non-CMR interventions on successful medication regimen changes and reductions in adverse drug events (ADEs). This decision analytic model compared the cost-effectiveness of CMRs with other intervention methods (non-CMRs) from a payer's perspective. For this model, a successful outcome was defined as a beneficiary case devoid of an ADE due to MRPs. The model was extensively tested and subjected to a thorough one-way sensitivity analysis and a second-order probabilistic sensitivity analysis with 10,000 iterations from the variable distributions. Non-CMR interventions were less costly and more effective than CMRs. The point estimate for direct medical costs was $193 for CMRs and $157 for non-CMRs, and the estimated probability of avoiding an ADE was 0.93 and 0.94 for CMRs and non-CMRs, respectively. The 10,000 iteration-Monte Carlo simulation scatterplot and cost-effectiveness acceptability curve (CEAC) revealed a dominance by non-CMRs in preventing harmful ADEs from cost and effectiveness perspectives; however, there was an overlap in the 95% CIs for both cost and ADEs prevented. Despite this, a non-CMR intervention saved estimated $5,377.08 per ADE prevented. One-way sensitivity analysis indicated the results were sensitive to the cost of treating a preventable ADE. In 100% of cases, the CEAC demonstrated that non-CMRs were likely the most cost-effective intervention regardless of the health plan's willingness to pay. The cost-effectiveness acceptability curve suggests that non-CMR interventions were less costly and more effective than CMRs; however, there was overlap in the 95% CIs for costs and ADEs prevented. In all cases, the CEAC demonstrated that non-CMRs were the most economical intervention with regard to time and cost. Non-CMRs show promise as a viable method to address MRPs, reduce ADEs, and improve patient-related health outcomes.

Understanding reasons for nonadherence to medications in a medicare part d beneficiary sample.

Poor medication adherence is a predictor of poor health outcomes, especially in populations with chronic diseases. Although several self-reported measures of medication adherence exist, the scope of each is limited. To identify barriers to medication adherence in order to facilitate effective delivery of telephone-based medication therapy management (MTM) services to beneficiaries of contracted Medicare Part D plans. This study used a cross-sectional telephone-based questionnaire designed to elicit reasons for low medication adherence. Patients were eligible to participate if they were identified as nonadherent for an antilipidemic, antihypertensive, or antidiabetic agent. Nonadherence was defined as less than 80% of proportion of days covered (PDC). The questionnaire included 17 items pertaining to medication use and 3 demographic items. Data were collected between September 2012 and February 2013. Data analyses included descriptive statistics and Rasch analyses. A total of 124 patients participated in the telephone survey. Of those completing the survey, the majority were patients (97.6%); only 3 surveys (2.4%) were completed by caregivers. The sample population had a mean age of 69.8 years (SD = 9.9), and more than half of participants (60.4%) were female. Nineteen percent of respondents received their medications by mail. Medication nonadherence generated alerts mostly associated with antilipidemic agents (n = 50, 40.3%), followed by antihypertensive drugs (n = 36, 29.0%), and antidiabetic medications (n = 23, 18.5%). The response categories for medication belief items were collapsed from 4 to 3 categories to achieve acceptable Rasch model fit (to fit the model and approximate interval level data). Ten percent of participants reported having medications prescribed either that they did not get or that they obtained but did not use. Almost 30% of patients reported having medications prescribed that they started using but stopped. However, only 4% of patients reporting adherence issues were related to the alert triggering for chronic medications; 96% of reports were linked to unrelated medications that did not generate an alert. The most common reason cited for medication nonadherence was experiencing side effects. Most participants reported positive beliefs about medications and did not report adherence issues related to those triggering alerts. MTM programs offer potential solutions to a number of barriers to medication adherence and a unique opportunity to raise awareness about the importance of medication adherence among members.

Teamwork Needed To Improve Medication Safety in PA/LTC

Teamwork Needed To Improve Medication Safety in PA/LTC

Pharmacists' experiences with a telephonic medication therapy management program for home health care patients.

This study was designed to better understand perceived barriers and facilitators to providing medication therapy management (MTM) services by pharmacists who recently provided telephonic MTM services to home health care patients. These services were provided as part of a randomized, controlled trial (RCT) to develop suggested quality improvement strategies for future service design. This was a qualitative study. A semi-structured individual interview format was used to elicit responses. Interviews were conducted by phone with participants. All pharmacists who recently provided telephonic MTM services as a part of an RCT participated in this study. Pharmacists were asked questions regarding their perceptions of the services, training opportunities, patient perceptions of the services, interactions with physicians, and suggestions for improvement. General demographic information was collected for each pharmacist and summarized using descriptive statistics. Interview data were analyzed using inductive qualitative methods to reveal key themes related to facilitators and barriers of MTM services in home health care patients. The main outcome measures were major themes identified from pharmacist interviews pertaining to barriers, facilitators, and quality improvement strategies for telephonic MTM delivery. A total of four pharmacists (i.e., 100% of those who participated in the prior RCT) were interviewed. Several themes emerged from the analysis, including: communication and relationships, coordinating care and patient self-management, logistics, professional fulfillment, service delivery and content, and training opportunities. This study provides possible strategies to overcome barriers and facilitate service provision for future telephonic MTM services.

The Importance of Pharmacist Providing Patient Education in Oncology

The world’s increasing diversity requires health care professionals to adjust delivery methods of teaching to accommodate different cultural values and beliefs. The ability to communicate effectively across languages and various cultural practices directly affects patient education outcomes. Pharmacist should be aware of varying modalities and considerations when counseling a patient diagnosed with cancer and undergoing chemotherapy. In more recent years, the medical profession has seen an increase in patient outcomes due to using the multidisciplinary team approach and has benefited by implementing Medication Therapy Management (MTM) programs at various institutions. For the clinical pharmacist, this would mean documentation for these services should be precise and accurate based on the specific patients needs. There are several factors involved in the care and therapy of the patient with cancer. Clinical oncology pharmacist should be aware of the ever-changing role in oncology and be able to implement new practices at their facility for better patient outcomes.

Best Practices: Improving Patient Outcomes and Costs in an ACO Through Comprehensive Medication Therapy Management

One of the most important and often overlooked challenges for accountable care organizations (ACOs) is ensuring the optimal use of pharmaceuticals, which can be accomplished by utilizing pharmacists' skillsets and leveraging their full clinical expertise. Developing capabilities that support, monitor, and ensure appropriate medication use, efficacy, and safety is critical to achieving optimal patient outcomes and, ultimately, to an ACO's success. The program described in this article highlights the best practices of Fairview Pharmacy Services' Medication Therapy Management (MTM) program with additional thoughts and considerations on this and similar MTM programs provided by The Working Group on Optimizing Medication Therapy in Value-Based Healthcare. Fairview Pharmacy Services utilizes 23 MTM pharmacists (approximately 18 full-time equivalents) working in 30 locations, who conduct pharmacotherapy workups as part of the MTM services that Fairview provides. Pharmacists focus on patients in a comprehensive manner and assess all of their diseases and medications. Responsibilities include (a) identification of a patient's drug-related needs with a commitment to meet those needs; (b) an assessment and confirmation that all of a patient's drug therapy is appropriately indicated, effective and safe, and that the patient is compliant; (c) achievement of therapy outcomes and ensuring documentation of those outcomes; and (d) collaboration with all members of a patient's care team. Since 1998, pharmacists have cared for more than 20,000 patients and resolved more than 107,000 medication-related problems which, if left unresolved, could have led to hospital readmissions and emergency visits. Since becoming a Pioneer ACO, Fairview pharmacists have focused on the highest-risk members and have seen over 670 ACO patients, resolving over 2,780 medication-related problems. In terms of clinical outcomes, MTM contributed to optimal care in complex patients with diabetes. A review of 2007 data found that the percentage of diabetes patients optimally managed (as measured by a composite of hemoglobin A1c, low-density lipoprotein, blood pressure, aspirin use, and no smoking) was significantly higher for MTM patients (21% vs. 45%, P less than 0.01). The Fairview MTM also showed a 12:1 return on investment (ROI) when comparing the overall health care costs of patients receiving MTM services with patients who did not receive those services. Developing an MTM program to manage and optimize pharmaceuticals will be a cornerstone to managing the health of a population. Important lessons have been learned that may be helpful to other health systems developing MTM programs. In an accountable care environment measuring the return on the investment of all care interventions, including MTM will be essential to maintain the program. The ACO will also have to be able to correctly identify which patients are candidates for MTM services and provide pharmacists with enough autonomy, including scheduling face-to-face interactions with patients and the ability to change prescriptions if necessary, to ensure that timely and effective care is delivered. In order for an ACO to deliver high quality patient-centered medication services, there must be clear lines of communication between providers, pharmacists, and the other care providers within the organization. Finally, a strong and visionary leader is critical to ensuring the success of an MTM program and ultimately the ACO itself. While there is a plethora of literature touting the benefits of either in-person or telephonic-based MTM, there is little research to date that directly compares these 2 MTM delivery types. It is critical for research to address the direct and indirect costs associated with starting and maintaining an MTM program. Information such as technologies required to start a program and length of time until a program breaks even or meets a sufficient ROI can be helpful for health care providers in similar health systems pitching a similar type of program. Finally, there has yet to be significant empirical research into the cost savings of utilizing a pharmacist and MTM services associated with meeting quality and cost benchmarks in an accountable care payment arrangement.

Medication therapy management programs: promises and pitfalls.

Medication therapy management (MTM) is one form of a medication benefit program offered by public and private health providers and insurers. Although the term was first coined in 2003, MTM in its earlier forms has been used since the 1990s as a mechanism to improve health metrics for medically complex patients. Its role expanded with the passage of Medicare Part D, as a mandated component to help patients with multiple chronic conditions, high drug costs, and high utilization to improve the effectiveness and safety of their medication treatments. To review the evidence on MTM effectiveness in order to (a) provide information on its establishment and goals and (b) summarize research findings under 3 outcomes: economic, clinical, and humanistic. PubMed, a search engine service of the National Center for Biotechnology Information was utilized by trained research assistants to search for articles with the following key words: MTM, randomized controlled trials on MTM, evaluation of MTM, comprehensive medication review, medication action plan, special needs population, special needs plans, Medicaid, disease management, adherence, non-adherence, compliance, chronic conditions, disabling chronic conditions, and disability. Additional searches were conducted for key articles in references listed in the most recent review articles. The initial search identified nearly 300 articles. When evaluated, most studies found economic benefits, but the quality of research design and end point measures varied considerably across evaluations. Clinical outcomes encompassed a wide range of potential metrics, from service utilization, to individual patient and population outcomes, and quality of care. Quality measures such as provider-prescribing habits and medication adherence were frequently found to improve. As noted with the economic outcomes studies, overall rigor of study design was suboptimal, and often underpowered. Few studies have focused on humanistic outcomes such as improved patient quality of life. Evidence suggests that MTM services are a promising way to manage complex patients, but there are gaps in the literature largely because of the limited number of studies with strong designs. Stronger evaluation of MTM programs is warranted.

Designing and Implementing a Cost-effective TEAM Hypertension Service in Pharmacies: Building on Tools and Lessons from the Wisconsin TEAM Trial

Many hypertension patients do not adhere to their drug regimens and blood pressure (BP) remains poorly controlled in many countries. Studies demonstrate that pharmacists can improve adherence and BP control. However, most BP interventions are long in duration (O12 months), require multiple visits and professional time (60 minutes/ initial visit, 30 minutes per follow-up visit), lack sustained effects after intervention discontinuation, lack testing in minority populations, and have not been implemented widely in busy pharmacies where staff lack brief tools for quickly and efficiently monitoring and facilitating adherence, BP control, and feedback to patients and physicians. To address these issues, we designed and evaluated a “systems intervention” for pharmacy staff and African-American patients in typical pharmacies. Our intervention is called the Team Education and Adherence Monitoring (TEAM) model and includes: 1-day training for one pharmacist and 1-2 technicians per pharmacy; distribution of novel toolkits for quickly and efficiently monitoring and facilitating adherence, BP control, and pharmacist feedback to patients and physicians; and modest compensation for interventions. The TEAM toolkits include: tools for brief assessment and tracking of hypertension patients and barriers to adherence; brief tools for increasing patient awareness and feedback to physicians; and brief tools for documenting interventions, plans, and time spent. Toolkits were designed to achieve high “intervention fidelity”(extent to which pharmacy staff actually implement intervention as intended). Blinded project assistants screened 1250 African-American patients at 28 pharmacies in the cluster-randomized Team Education and Adherence Monitoring (TEAM) trial. Of those screened, 576 had treated but uncontrolled hypertension and were eligible for a 6-month intervention. TEAM patients met monthly with a pharmacist technician team using TEAM tools; patients at control pharmacies received printed information only. Outcomes were assessed using refill records, surveys, and blinded BP measurements at baseline, month 6 (end of intervention), and month 12 (6 months after discontinuation). Results showed good intervention fidelity and sustained improvements in refill adherence and systolic BP. Aims of workshop: Aims are to: 1) briefly describe core elements, intervention tools, and strategies for achieving “intervention fidelity” by pharmacy staff; 2) provide an overview of intervention outcomes, costs, and fidelity results; and 3) stimulate discussion about how others might apply a TEAM approach within a Medication Therapy Management (MTM) program or other environment or health system. Learning Objectives: After workshop, participants will be able to: 1) describe how to access and implement at least 1-2 TEAM tools for improving adherence, BP control, and teamwork in typical pharmacies and other environments and 2) describe at least one opportunity for improving hypertension care in other environments. Workshop Activities: The workshop includes: 25-minute presentation (with QA 25-minute presentation (with QA and 40-minute open discussion about whether/how to apply or build on a TEAM approach in other environments and opportunities for improving hypertension care worldwide. Additional information: Organizers will need a PowerPoint projector and 4 flipcharts.

Predictors of medication-related problems among medicaid patients participating in a pharmacist-provided telephonic medication therapy management program.

To identify predictors of medication-related problems (MRPs) among Medicaid patients participating in a telephonic medication therapy management (MTM) program. Retrospective analysis of data from patients enrolled in a previously published study. Two Medicaid administrative claims file databases (for health care utilization and prescription dispensing information) and one pharmacy organization file for MTM program information. Seven hundred twelve adult Medicaid patients who participated in a statewide pharmacist-provided telephone-based MTM program and who received an initial medication therapy review. The primary dependent variable was the number of MRPs detected during the initial medication therapy review. Secondary dependent variables were the detection of one or more MRPs related to indication, effectiveness, safety, and adherence. Predictor variables were selected a priori that, from the literature and our own practice experiences, were hypothesized as being potentially associated with MRPs: demographics, comorbidities, medication use, and health care utilization. Bivariate analyses were performed, and multivariable models were constructed. All predictor variables with significant associations (defined a priori as p<0.1) with the median number of MRPs detected were then entered into a three-block multiple linear regression model. The overall model was significant (p<0.001, R(2) =0.064). Significant predictors of any MRPs (p<0.05) were total number of medications, obesity, dyslipidemia, and one or more emergency department visits in the past 3months. For indication-related MRPs, the model was significant (p<0.001, R(2) =0.049), and predictors included female sex, obesity, dyslipidemia, and total number of medications (p<0.05). For effectiveness-related MRPs, the model was significant (p<0.001, R(2) =0.054), and predictors included bone disease and dyslipidemia (p<0.05). For safety-related MRPs, the model was significant (p<0.001, R(2) =0.046), and dyslipidemia was a predictor (p<0.05). No significant predictors of adherence-related MRPs were identified. This analysis supports the relative importance of number of medications as a predictor of MRPs in the Medicaid population and identifies other predictors. However, given the models' low R(2) values, these findings indicate that other unknown factors are clearly important and that criteria commonly used for determining MTM eligibility may be inadequate in identifying appropriate patients for MTM in a Medicaid population.

APhA honors 2014 Immunization Champions

Pharmacists are uniquely positioned to educate patients on the importance of vaccines and to provide many of those vaccines themselves. They expand the "immunization neighborhood"—an APhA-coined term—and increase the accessibility and convenience of vaccines for patients from all walks of life. Their work eliminates the perceived barriers of appointments, physicians' offi ces, and prescriptions.

PHS164 - Trends In Medicare Part D Medication Therapy Management Eligibility Criteria

To increase the enrollment rate of medication therapy management (MTM) programs in Medicare Part D plans, the US Centers for Medicare & Medicaid Services (CMS) lowered the allowable eligibility thresholds based on the number of chronic diseases and Part D drugs for Medicare Part D plans for 2010 and after. However, an increase in MTM enrollment rates has not been realized. To describe trends in MTM eligibility thresholds used by Medicare Part D plans and to identify patterns that may hinder enrollment in MTM programs. This study analyzed data extracted from the Medicare Part D MTM Programs Fact Sheets (2008-2014). The annual percentages of utilizing each threshold value of the number of chronic diseases and Part D drugs, as well as other aspects of MTM enrollment practices, were analyzed among Medicare MTM programs that were established by Medicare Part D plans. For 2010 and after, increased proportions of Medicare Part D plans set their eligibility thresholds at the maximum numbers allowable. For example, in 2008, 48.7% of Medicare Part D plans (N = 347:712) opened MTM enrollment to Medicare beneficiaries with only 2 chronic disease states (specific diseases varied between plans), whereas the other half restricted enrollment to patients with a minimum of 3 to 5 chronic disease states. After 2010, only approximately 20% of plans opened their MTM enrollment to patients with 2 chronic disease states, with the remaining 80% restricting enrollment to patients with 3 or more chronic diseases. The policy change by CMS for 2010 and after is associated with increased proportions of plans setting their MTM eligibility thresholds at the maximum numbers allowable. Changes to the eligibility thresholds by Medicare Part D plans might have acted as a barrier for increased MTM enrollment. Thus, CMS may need to identify alternative strategies to increase MTM enrollment in Medicare plans.

Accountable Care Organizations: Impact on Pharmacy

The Patient Protection and Affordable Care Act (PPACA) has considerably transformed the approaches being used to deliver health care in the United States. It was enacted to expand health insurance access, improve funding for health professions education, and reform patient care delivery. The traditional fee-for-service payment system has been criticized for overspending and providing substandard quality of care. The Accountable Care Organization (ACO) was developed as a payment reform mechanism to slow rising health care costs and improve quality. Under this concept, networks of clinicians and hospitals share responsibility for a population of patients and are held accountable for the financial and clinical outcomes. Due to high rates of medication misuse, nonadherence to therapeutic medication regimens, and preventable adverse drug events, pharmacists are in an ideal position to manage drug therapy and reduce health care expenditures; as such, they may be valuable assets to the ACO team. This article discusses the role of the pharmacist in the era of ACOs specifically and health care reform globally. It outlines pharmacy-related quality of care measures, medication therapy management (MTM) programs (which may provide the foundation for pharmacist involvement in ACOs), and pharmacist functions in patient-centered medical homes (through which ACO services may be organized). The article concludes with a description of successful ACO models that have incorporated pharmacists into their programs.

Impact of a Discharge Medication Therapy Management Program in an Extended Care Hospital

To study the feasibility and effectiveness of a discharge medication therapy management program. Quasi-experimental pre-post study design. Thirty-six-bed hospital within an extended care hospital. All patients admitted to facility from January 2009 to December 2009 (control) and February 2010 to January 2011 (program). Pharmacist review of anticipated discharge following 18-20 days of stay, with suggested medication changes communicated to physicians via patient chart. Agreed changes were implemented on the next day. Patient readmissions within 30, 60, and 90 days into the hospital system. Medication interventions were quantified as to type. During the control period, 432 patients were followed, and during the intervention period, 369 patients were followed, with similar lengths of stay. In the intervention period, 565 medication interventions were attempted on 216 patients, with an 85.3% acceptance rate. The major intervention was discontinuation of medications. Mean maintenance medications per patient decreased from 10.57 to 9.46 in the intervention group, and daily medication doses per patient decreased from 17.95 to 15.73 (P < 0.001). Readmission rates were lower at 30 and 60 days in the intervention group, with a 90-day overall decrease in system readmission rate from 51% to 39% (P < 0.001). The discharge medication management program was successful in decreasing both number and type of discharge medications via pharmacist intervention. Overall, patient system readmission rates were also significantly decreased in the intervention period.

Improving Medication Adherence Among Patients With Type 2 Diabetes

Type 2 diabetes mellitus (T2DM) accounts for the vast majority of diagnosed diabetes cases and is a considerable burden to the US health care system. However, patients with T2DM often fail to adhere to treatment for numerous reasons including concerns about administration, mode, timing, convenience, adverse events, and cost. As the prevalence of T2DM and the complexity of therapeutic regimens increases, the role of pharmacists in educating patients about treatment benefits, administration techniques, dosage flexibility, and avoiding side effects is critical and may optimize care by increasing the likelihood of treatment adherence. In addition, pharmacists are in a unique position to assess which patients are not taking medications as they are prescribed and can therefore determine the most effective methods to promote adherence. This article will examine the causes of nonadherence in T2DM and the integral role that pharmacists can play in improving medication adherence and persistence. Strategies for improving adherence, such as patient education, motivational interviewing, medication therapy management programs, and collaborative management, will also be considered.

Medication Therapy Management and Complex Patients With Disability

Drug therapy problems, adverse drug events (ADEs), and symptom burden are high among adults with disabilities. To compare the effects of a modified medication therapy management (MTM) program within a self-efficacy workshop versus the workshop alone or usual care on symptom burden among adults with activity limitations. Three-group randomized controlled trial among adults (age 40 and older) with self-reported activity limitations in community practice. 8 weekly Living Well With a Disability (LWD) 2-hour workshop sessions with and without a collaborative medication management (CMM) module. mean number of moderate to very severe symptoms from a list of 11 physical and mental symptoms. Process measures: changes in medication regimens and self-reported ADEs. general linear mixed models (continuous outcomes) and generalized estimating equations (categorical outcomes). Participants had high symptom burden, low physical health, and took many medications. There was a significant increase in ADE reporting in the LWD + CMM group relative to the other 2 groups (Study group × Time P = .014), and there were significantly more changes in medication regimens in the LWD + CMM group (P = .013 LWD only vs LWD + CMM). The oldest third of participants had significantly fewer mean symptoms but received more intense CMM. There was no difference between the LWD-only, LWD + CMM, and usual care groups in symptom burden over time. Pharmacist MTM practices and MTM guidelines may need to be modified to affect symptom burden in a population with physical activity limitations.

CMS report affirms pharmacist-provided MTM

If CMS invests money in medication therapy management (MTM) programs for Medicare patients, do these programs improve the quality of chronic care management and reduce health care expenditures? That was the ultimate question behind the major new Medication Therapy Management in Chronically 1ll Populations: Final Report prepared for the CMS Center for Medicare & Medicaid Innovation, according to an APhA Fellow’s analysis of the August 2013 report. The APhA Fellow is Maj. Ann D. McManis, BSPharm, MPA, U.S. Air Force, Biomedical Sciences Corps. ■A major CMS report shows MTM improves adherence, quality of prescribing.■MTM programs that maintained or lowered drug costs were in integrated health systems that used an electronic health record. ■A major CMS report shows MTM improves adherence, quality of prescribing.■MTM programs that maintained or lowered drug costs were in integrated health systems that used an electronic health record. The 242-page report is available at http://innovation.cms.gov/Files/re-ports/MTM_Final_Report.pdf. The report suggests both that “there’s a huge untapped source of improving our health care system that’s not being taken advantage of” because Part D MTM should be available to more people than the current very narrow criteria allow, and that “when there’s coordination of care between the community pharmacist and a physician and a patient, that’s what really helps make the intervention successful,” said APhA President-elect Matthew C. Osterhaus, BSPharm, FASCP, FAPhA, a co-owner of Osterhaus Pharmacy in Maquoketa, I A. The study investigated how Medicare Part D MTM programs in 2010 affected Medicare patients’ adherence, quality of prescribing, drug safety, resource utilization, and costs of hospital and emergency department care. The study focused on patients with congestive heart failure, chronic obstructive pulmonary disease, and diabetes. This is the first MTM study targeting chronically ill Medicare patients. Previous research on MTM has been conducted by private organizations and payers, and self-starters doing research. Although Part D started in 2006, offering an annual comprehensive medication review (CMR) to en- rollees did not become mandatory until 2010. The CMR was completed for 11% to 14% of patients enrolled in MTM programs in the study population, according to the report. “They compared several MTM programs. Some were more successful than others at reducing overall costs.... Adherence across the board improved” as well as quality of prescribing (use of evidence-based guidelines). When a CMR was completed, the results were even greater,” McManis said. Osterhaus added that the CMR is part of “that ongoing relationship that the pharmacist has with a patient.” While most MTM programs increased drug costs, the best-performing organizations were able to improve medication adherence and quality of prescribing while keeping health care costs, including drugs, from rising. MTM programs that maintained or lowered drug costs were in integrated health systems that also used an electronic health record, according to McManis. MTM programs that decreased costs addressed patients’ cost barriers to adherence by suggesting lower-cost equivalent options to patients and pre- scribers; included MTM components that identify cost-avoidance opportunities; and established care coordina- tion—a working relationship between the provider and the pharmacist providing MTM. “As we move towards patient-centered medical homes and accountable care organizations, pharmacists are a critical member of those teams that can really show high impact [in] improving care and reducing costs,” Osterhaus said. The report “tells me that we’ve got great opportunity out there.” Osterhaus continued, “If we were actually able to provide the services to all the patients who would benefit from it—these targeted patients whom this report shows benefit from it—that would make MTM much more workable at the level of the community pharmacy.” “Globally, [the report] showed that there is a wealth of supporting evidence—clinical, economic, and hu- manistic—that reinforced the role of pharmacists in providing direct patient care services,” said APhA Science Officer Patrick G. Clay, PharmD, FCCP, CCTI. But for any individual pharmacist reading it, “very specific studies” were included that “would be very meaningful to your practice setting.” Clay is Professor of Pharmacotherapy at University of North Texas System College of Pharmacy. “How you can take that report and use it in your own individual practice setting will require the individual to go through the report itself, identify those populations or settings or goals of that individual study that align with [your] specific setting, and see if the methods that were used in that particular project are feasible, align- able, amenable to [your] specific setting,” Clay said. “Instead of you trying to reinvent a wheel, it is a blueprint for you to replicate what has clearly been shown to be successful and beneficial to all parties involved.”

What’s new in Medicare Part D for 2014?

During Medicare’s annual Fall Open Enrollment Period that begins October 15 and ends December 7 (not to be confused with the October 1 start of open enrollment in the health insurance marketplaces established by the Affordable Care Act), people with Medicare can change their Medicare health and drug coverage options such as their Part D plan.Tabled 1Standard benefit20132014Deductible$325$310Initial coverage limit$2,970$2,850Out-of-pocket threshold$4,750$4,550Minimum cost sharing in the catastrophic phaseGeneric/preferred multisource medications$2.65$2.55Other drugs$6.60$6.35Source: CMS ensures greater value for people in Medicare drug and health plans. http://cms.gov/newsroom/ MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-04-01.html Open table in a new tab Source: CMS ensures greater value for people in Medicare drug and health plans. http://cms.gov/newsroom/ MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-04-01.html These weeks present an opportunity for pharmacists to continue to build relationships with their patients. Pharmacists can remind patients of the dates, talk to patients about what services pharmacists provide, make sure Medicare patients receive medication therapy management (MTM) and “star” ratings information from Part D plans, and explain MTM to patients.■Pharmacists can encourage Medicare patients to ask questions about the benefits included in their Part D plan.■Part D plans with high star ratings often use MTM to boost their score. ■Pharmacists can encourage Medicare patients to ask questions about the benefits included in their Part D plan.■Part D plans with high star ratings often use MTM to boost their score. “Encourage patients to ask questions about the benefits included in their plan,” said Stacie Maass, BSPharm, JD, APhA Senior Vice President of Pharmacy Practice and Government Affairs. “Many patients are eligible for MTM but are unaware of the benefit or do not take advantage of it. Patients who take advantage of their MTM benefit are overwhelmingly happy with the service.” The growing importance of MTM was emphasized in CMS’s advance notice and call letter for 2014—an annual guidance document for Medicare Advantage and Part D prescription drug plans that was released April 1. In the guidance, CMS also outlined a policy for avoiding fraud, waste, and abuse in mail-order services. In addition, the Part D “donut hole” will continue to close gradually in 2014. Medicare health and prescription drug plans are rated on their performance on a scale of one star (“Poor”) to five stars (“Excellent”). The overall star ratings are available at Medicare.gov/find-a- plan. These star ratings can be used to compare plans to find the best plan for the patient. “Star ratings should be highlighted in the discussion with the patient,” said Jillanne Schulte, JD, APhA Director of Regulatory Affairs. In the guidance for 2014, CMS reported that it is aware of high-performing plans using MTM services to improve their Part D star ratings. Of note, Medicare patients can switch to a Medicare prescription drug plan rated five stars during a 5-Star Special Enrollment Period from December 8,2013, to November 30,2014, according to the 2014 Medicare & You handbook. Patients can only switch to a five-star plan if one is available in their area, and can only use the Special Enrollment Period once during these dates. CMS will continue to promote beneficiaries’ awareness of MTM services through the 2014 Medicare & You hand book, on Medicare.gov, through the new MTM tab on the plan finder, and the requirement that plans have a dedicated “Medication Therapy Management Program” page linked from the Medicare drug plan website. In the guidance for 2014, CMS encouraged Part D plans to require mailservice and community pharmacies to obtain patient consent to deliver a new or refill prescription, before each delivery, including refills or new prescriptions received directly from the physician. The new policy doesn’t apply when the patient actively requests the new prescription or refill, according to Schulte. While the idea is to avoid fraud, waste, and abuse from unnecessary refills, APhA recommended in March 1 comments on the draft guidance that CMS consider additional steps in which a patient or caregiver could select their own preferences for use of an auto-refill or ship program to avoid generating too many phone calls to the patient. The Part D donut hole will continue to close gradually under the Medicare Coverage Gap Discount Program in the Affordable Care Act. In 2014, Medicare patients in the donut hole (who don’t qualify for the low-income Extra Help program) will pay 47.5% of the cost for brand-name drugs and 72% of the cost for generic drugs.

California provider status bill heads to governor

California provider status bill heads to governor