Catalyzing Change: Educating Healthcare Stakeholders on Pharmacist Care Programs

On June 3, 2008, the University of Connecticut (UConn) School of Pharmacy hosted the 2008 Harold G. Hewitt Symposium Value of Medicines, Value of Pharmacists in Portland, Connecticut. The speakers and the 50 invited participants addressed the platform question, “How can pharmacists collaborate with employers, payers, and other healthcare professionals to improve patient health outcomes, enhance medication adherence, and lower total healthcare costs?”

The 50 key decision makers who attended this invitation-only symposium represented diverse stakeholders in healthcare across Connecticut (

Table 1

). UConn’s School of Pharmacy held the symposium to educate invited attendees (called participants in the remainder of this article) about value-based insurance design, pharmacist-provided patient-centered services, and pharmacists’ potential contribution to healthcare value. Symposium organizers invited participants if they held a key position in one of Connecticut’s large health plans; held a leadership position with a professional, consumer, or provider organization or academic program; were pharmacy benefit decision makers with large employers in Connecticut; or were in a key healthcare state agency or legislative committee role.

The symposium’s format included a traditional lecture and response panel in the morning, followed by facilitated break-out groups in roundtable sessions. The organizers designed the roundtable sessions to catalyze open and frank discussions on medication-use topics. One of the authors (MAS) served as the event coordinator and symposium moderator.

After hearing presentations from experts, roundtable session participants developed 9 key messages that pharmacists and healthcare leaders can use to examine their own pharmacy practices and pharmacist care programs.

SYMPOSIUM FORMAT AND KEY MESSAGES

At the Hewitt symposium, 5 nationally known speakers who have successfully promoted a broader role for pharmacists in enhancing healthcare outcomes addressed participants. In addition, a reactor panel of Connecticut clinicians and healthcare administrators queried the speakers with incisive questions, extracting additional information from these experts. During the afternoon, speakers, panelists, and participants took part in moderated roundtable discussions where they addressed 6 topics (medication therapy management [MTM], medication checkups, medication adherence, medication outcomes research, pharmacoeconomic assessment, and e-prescribing). Participants were not assigned to topics, but selected those of interest to them and were allowed to switch topics as they wished.

From the roundtable discussions, the authors transcribed findings that addressed these questions:

• What are the burning issues or greatest needs related to the roundtable discussion topics?

• What would it take to create change in your organization?

• What steps can we take in the next 6 to 12 months to create forward movement, involving pharmacists to a greater extent in your organization?

Nine key points emerged from discussions among speakers, panelists, and participants. These are detailed below.

Point 1

Restoring the concept of wellness to the healthcare debate will create opportunities for all healthcare professionals to enhance patient care quality. Pharmacists can add untold and untapped value to medication management and outcomes. Testifying before the Senate Budget Committee on June 21, 2007, Peter Orszag, director of the Congressional Budget Office, reviewed available evidence that indicates that increasing healthcare expenditures in the United States does not always improve outcomes. More money does not buy more health or wellness.¹ Providing appropriate preventive care or promoting healthy choices (including medication use) should create more successful, balanced lives. Many healthcare systems fail to provide preventive, acute, or chronic care identified as central to wellness.^2-4 Underuse of appropriate medications is of particular concern.⁴

Medication nonadherence undermines wellness. Although data are inconsistent, much of it shows that shifting costs to patients often decreases essential and nonessential care. Studies suggesting a correlation have found that 50% of patients whose average monthly statin copayment was $10 or less discontinued their therapy within 3.9 years. Larger copayments were associated with discontinuation rates of 50% at 1 year,⁵ and payments higher than $20 were associated with more than 30% nonadherence in the year after initiation.^6-9

Other studies have reported similar results in diabetes mellitus and heart failure treatment.¹⁰ Low-income patients appear most sensitive to copayment changes, explaining some health disparities observed across socioeconomic groups.¹⁰

Strategies to improve and measure medication adherence and chronic care quality are sorely needed, especially since more than half of all insured Americans are taking prescription medication for chronic conditions.¹¹

Point 2

In a pharmacist-provided patient-centered care model, the pharmacist assumes responsibility for all medication use including appropriate use, effectiveness, safety, and cost-effectiveness. The outcomes can be excellent. Medication therapy management theoretically should improve outcomes and quality in healthcare by achieving evidence-based therapy goals. That is its value proposition. Brian Isetts, PhD, University of Minnesota College of Pharmacy, discussed Minnesota’s progress toward earning recognition and increasing pharmacists’ professional responsibilities. His discussion centered on a 12-year effort to establish the Minnesota-Medicaid MTM Care Law.¹² Minnesota’s program is based on the pharmaceutical care concept; pharmacists assume responsibility and accountability for all of a patient’s drugrelated needs. These services involve systematic medication therapy assessment, care planning, evaluation, and interdisciplinary communication.

One of the greatest challenges was helping the legislators understand that for pharmacists, MTM reimbursement should be resource based rather than time based. Minnesota currently reimburses pharmacists using a resource-based relative value scale based on 5 levels of patient complexity (eg, medical conditions, number of medications, drug therapy problems), similar to the scale used to pay physicians.

Minnesota pharmacists have tracked clinical, economic, implementation, and performance improvement outcomes data. In the first year, 34 pharmacists submitted claims for MTM services covering 431 encounters. Minnesota paid claims totaling $39,866 (an average of $92.50 per encounter). The project’s architects advocated determining quality and value by using town hall meetings and involving pharmacists participating in the program. They also audited 55% of patient encounters to verify that documentation was appropriate. Their analysis resulted in the following findings¹³:

• The average care recipient had 6.3 medical diagnoses and took 14.1 drugs; diabetes, hypertension, and elevated cholesterol were the most common conditions.

• Pharmacists identified and resolved 789 drug therapy problems; 73% were inadequate therapy (eg, dose was too low for effectiveness, patient needed additional preventive therapy, noncompliance).

• Among claims submitted, documentation matched the claim 59.7% of the time; when it did not, the most frequent issue was pharmacist underreporting. Using an electronic pharmaceutical care documentation program that facilitates and tracks resource-based relative value scale billing has since been shown to increase claims and reimbursement.

• Recipients with diabetes who received MTM services accrued an annual cost savings of $15,325.

Minnesota’s legislature found the data sound enough to formally establish MTM codes for pharmacist reimbursement in Minnesota.

Point 3

Most pharmacist-care medication management programs require pharmacists to complete specialized training, have additional credentials, or pass competency assessments. Some programs establish basic requirements for pharmacists to participate in pharmacist intervention programs, especially if they will be reimbursed for the service.

Ronald DeVizia, PharmD, KDI Health Solutions, LLC, in North Carolina, described KDI’s training and education requirements for MTM intervention, medication reviews, medication checkups, and pharmaceutical company—sponsored adherence programs. This MTM program documented a 6:1 return on investment (ROI) over 2 years. Their pharmacists generally have BS degrees, residencies, and specialty certificates; they collaborate with the University of North Carolina. KDI uses a mentoring program among pharmacists as well. Most credentialing is conducted via a formal quality improvement system that may include individual and program performance measures. In response to questions, presenters discussed processes used in their distinct geographic locations. Barry Bunting, PharmD, an Asheville Project developer, indicated that they gradually transitioned from a labor-intensive, paper system to electronic records that document the frequency and outcome of patient contacts. In Minnesota, Dr Isetts described bimonthly pharmacist network meetings and peer-review committee functions.

All programs had similar goals: to establish basic skill set and training requirements, and use peer review and supervisory controls to ensure performance remains exemplary.

Point 4

Implementing pharmacist-led programs will require excellent interprofessional and patient communication skills. The Minnesota MTM Program, an exemplar of good communication, provides well-organized and well-designed information to stakeholders on its state Web site. Available at www.dhs.state.mn using key words “medication therapy management,” these documents help patients and payers find pharmacists who provide MTM services and explain the program’s benefits.

Several presenters asked about physicians’ response to broader pharmacist-led services. Dr DeVizia indicated that initially a few physicians found pharmacists’ increased scope of activity somewhat threatening. KDI surveyed physicians about their concerns and developed an educational campaign. He emphasized scheduling face-to-face meetings with physicians to describe pharmacist-led patient care services, rather than telephonic or facsimile broadcast messages. Dr Bunting indicated that the Asheville Project won physician acceptance on an individual level by communicating about the program’s benefits and boundaries clearly. He, too, indicated that face-to-face communication is prudent. The Asheville Project also identified receptive physicians to serve as program champions with colleagues.

Dr DeVizia indicated that communicating with patients and measuring patient satisfaction are crucial. Not only did patients’ clinical indicators (eg, glycosylated hemoglobin, lipid levels) improve, but also approximately 83% of patients stated that they would pay for this service themselves and 97% would recommend it to others. Patients and clinicians found one intervention most valuable: a comprehensive personal medication record that patients carry with them.^14,15

Point 5

Return on investment is important, but it may not improve immediately. Jill Berger, Vice President of Health and Wellness, Marriott Corporation, described Marriott’s healthcare strategy for their 143,000 employees worldwide; of these, 108,000 are based in the United States and 80% are paid hourly (most are housekeepers, many with language/culture challenges). In 2007, Marriott delivered healthcare through 50 HMOs and 3 national PPOs; they spent $410 million, which represented a 7% increase over 2006. Ms Berger indicated that in the past, Marriott increased cost-sharing with employees. Each time, employee adherence to medication (and, consequently, presenteeism and productivity) decreased.

In 2004, Marriott engaged employees as partners in healthcare, simultaneously supporting prescribers with patient-specific information suggesting appropriate action. Using a database that incorporated self-reported patient information and disability data (which will soon include workers’ compensation), they strove for a value-based formulary. Although Marriott was concerned, patients did not find the new system intrusive. Patients, liaison nurses, and physicians soon identified a problem: patients found medications unaffordable. Marriott identified several classes of drugs for prevalent chronic conditions and reduced copayments for brand name medications and eliminated them for generics. Marriott’s pharmacy benefit manager identified patients eligible for the new benefit and ensured that pharmacies applied reduced copayments proactively.

To date, Marriott has found that the value-based concept is easiest to apply to prescription drugs. In the first year, direct spending for medications increased; productivity and disability savings were not measured. Regardless, Marriott has found that this approach identifies employees who should be taking medications but are not and encourages them to seek care. It also removes an important adherence barrier: copayments. Marriott expects to avoid hospitalizations, disease progression, and deaths. They have added smoking cessation and free preventive care components, and have initiated a “Know Your Numbers” campaign (eg, target cholesterol and blood pressure measurements).

Symposium participants were most interested in ROI. Ms Berger indicated that although it is too soon to tell if ROI is improving, Marriott remains committed. In addition to improved employee health, they expect improved retention, decreased turnover, and better productivity/ attendance with time. Improved productivity and attendance may be even more important for small employers who have less work force redundancy.

Point 6

Pharmaceutical companies may have a role in this transformation. With many participants reporting medication underutilization, discussion turned to pharmaceutical companies’ roles. Participants believed that companies with products demonstrating differentiated patient outcomes will welcome a movement toward greater value-based insurance design and more pharmacist involvement. Pharmaceutical companies will need to perform outcomes studies routinely to define the “value proposition” for the cost and formulary position of their products.

Point 7

Creating change will require key stakeholders to address specific opportunities now, even though knowledge gaps exist and funding may be limited. Barry Bunting, PharmD, presented a summary of the Asheville Project, a decade-old research project in Asheville, North Carolina. The project’s goals—determining the relationship between the time pharmacists spend with patients and health outcomes and achievement of financial savings—were pursued despite little funding. Two employers with a total of 12,000 employees

funded disease management programs, self-care education for patients, and regular face-to-face meetings between enrolled patients and designated pharmacists. They also eliminated copayments for certain diseaserelated medications and supplies.^16-19 The Asheville Project’s outcomes have been widely published and discussed^16-18:

• Diabetic patients’ average number of sick days decreased from more than 12 to 6 in the first year; this reduction has been sustained.

• Among patients with diabetes, emergency department visits now occur at a rate one-third of the national average.

• Average glycosylated hemoglobin decreased from 8% in the year prior to the program to between 6.6% and 7.3%.

• Low-density lipoprotein decreased from an average of 121 mg/dL before the study to an average of 95 mg/dL in the fifth year.

• Over 5 years, asthma patients’ emergency department visits decreased from an average of 22/100 people per year to 3.9/100 people per year, and annual work absenteeism decreased from 10.0 days to 2.6 days.

• Patients who had cardiovascular disease also benefited, with serious events decreasing from 93 to 50, and the cost per event fell from $14,343 to $9931.

The ROI was 4:1 for patients in the asthma and diabetes programs, and health plan costs stayed even or rose 1% in 2004 and 2005, and decreased 2.6% to 3% in 2006.^16-19

Point 8

Information systems can document pharmacist interventions and will drive success. Most performance improvement programs stress the triad of good leadership, a well-prepared quality improvement plan, and an adequate information system. All pharmacy care programs showcased at this symposium use data management/information systems to document pharmacist care interventions and program success, and some reported refining these systems over time as they needed additional data, or they identified cost-saving system improvements.

Point 9

Simple, well-planned health initiatives will be received best. When the moderator asked the reactor panel what idea or ideas they would like to steal shamelessly from the speakers, several embraced the idea of addressing problems with an infusion of common sense. One message resonated: the most expensive therapy is the one that does not work. Many speakers highlighted that pharmacist-led care programs focus on medication appropriateness and safety. With a comprehensive medication review, pharmacists can communicate identified drug therapy problems (eg, medication side effects, adverse reactions, drug interactions, or adherence challenges) and recommend resolutions to prescribers so that they can select appropriate and cost-effective therapy for the patient.

MOVING FORWARD

In roundtable sessions, participants and presenters discussed burning issues and greatest needs (see

Table 2

). By consensus, participants said that the largest, most widespread barrier is the lack of funding for pharmacist-led patient care programs, although most programs described reported ROIs from 3:1 to 6:1. Attendees indicated the potential ROI is not the problem. Rather, it is payers’ lack of willingness to find the “first dollar to invest.” All research is costly, and pharmacists who successfully create payer interest in and support of these programs must be able to describe the risks and benefits clearly, using practice-based models and well-designed trials.

Conducting pilot programs that specifically address various employers’ or payers’ needs will establish the value of pharmacist care programs. Recently, the Connecticut Pharmacists Association (CPA) established a Pharmacists Network for Excellence that will offer employers and payers a diverse array of patient-centric pharmacist care services to optimize medication use and patient outcomes. Employers and payers will contract with the pharmacist network to design and conduct targeted pharmacist-led patient care programs; network pharmacists with program-specific credentials (eg, diabetes, MTM) will provide the contracted services. They will measure clinical, economic, and humanistic outcomes.

Opinions about creating change revealed that increased stakeholder awareness and involvement are critical, as is candid discussion among stakeholders on “healthcare value.” Health service researchers must provide validated methods that can be used easily in real-world settings to measure indirect costs and assign value to quality of life. All stakeholders need more education about innovative pharmacy initiatives and their value to individuals, organizations, and society. Pharmacists, either individually or through their professional associations, must identify and pursue medication management opportunities. Pharmacists need to use technology to document patients’ medication therapy reviews, identify patients’ drug therapy problems, communicate patient-specific drug therapy recommendations to other healthcare professionals, evaluate the value of pharmacists’ interventions to resolve drug therapy problems, and to disseminate findings widely in both professional and consumer publications/media. Pharmacists also need to communicate programs’ purposes and advantages in a way that others can understand. If regulations need expansion or revision, pharmacists and pharmacy organizations need to work closely with legislators.

Connecticut healthcare stakeholders identified next steps to create forward movement in the following months:

• Value proposition: Pharmacists should first clarify payers’ and employers’ medication-related needs or problems. Pharmacists can benefit from collaborating with other healthcare professionals (especially perscribers) to identify needed medication-related quality initiatives. From there, specific programs can be designed with proper methods to evaluate desired outcomes.

• Pilot programs: Pharmacists should approach payers and employers proactively to promote their capabilities and offer pharmacist care programs that can improve medication outcomes. To address the issue of first-dollar investment, pilot programs that partner with state pharmacy organizations, pharmacy schools, or other established programs are good options.

• State initiatives: Healthcare regulators and legislators will be more likely to initiate reimbursement for pharmacist-led programs involving patients whose healthcare is covered by the state if pharmacists have some pilot program data or evidence from similar projects. Pharmacists who manage these programs need to develop communication avenues with regulators and legislators, and use them effectively.

CONCLUSION

The symposium educated diverse healthcare leaders and demonstrated the value of innovative pharmacist-led patient care programs. Since June 2008, 10 thought-leader attendees have explored partnerships for pharmacist-led patient care programs. As a result, UConn School of Pharmacy, working with the CPA Pharmacists Network, contracted with the Connecticut Medicaid program for a pilot program to (1) implement a pharmacist-led MTM program that creates a comprehensive medication profile to identify medication-related problems and (2) alert primary care providers of medication-related problems and pharmacists’ recommendations. In addition, a large primary care physician provider group is in discussion with the state pharmacy association pharmacist network to approach commercial payers to establish reimbursed MTM projects. Finally, pharmacy organizations in Connecticut are working with state legislators to expand collaborative practice in noninstitutional settings and to reimburse pharmacists for state beneficiaries’ MTM services.