The Affordable Care Act has succeeded in creating momentum in the world of medication therapy management (MTM), and with Medicaid programs expected to take on millions of additional Americans, the healthcare industry will become more reliant on pharmacy services. Through initiatives such as accountable care organizations and pay-for-performance models, the insurance marketplace is challenged to become more innovative and efficient.1
What does this mean for the community pharmacist? It means that the industry will expect pharmacists to embrace a larger role and continually enhance their ability to manage medications. Ultimately, the goal is to increase therapeutic outcomes while decreasing healthcare costs. As the number of physicians per patient is expected to decrease, the industry will become more reliant on pharmacy services, and pharmacists will have opportunities to become more involved in transitional care and in medication reconciliation.
Barriers to MTM
At the center of it all is MTM. Pharmacists are given the opportunity to promote safe medication use, decrease healthcare costs, and increase the quality of care.
In recent years, numerous studies demonstrated the economic costs associated with medication mismanagement. One recent study by the IMS Institute for Healthcare Informatics estimates that $200 billion in avoidable healthcare expenditures was attributed to irresponsible medication use in 2012.2 The report includes 6 areas of avoidable costs: nonadherence, misuse of antibiotics, delayed evidence-based treatment practices, medication errors, suboptimal use of generics, and mismanaged polypharmacy.
According to the study, there is an opportunity to eliminate $213 billion in healthcare costs with more responsible medication use; almost half of those costs were the result of medication nonadherence. One of the most effective ways for increasing adherence is simply by educating patients. The good news is that adherence is already improving. Since 2009, medication adherence in patients with diabetes, hypertension, or hyperlipidemia has increased from 3% to 7%.2 This can be attributed to decreasing costs of medications, as well as an increase in interventions by a multitude of healthcare professionals at varying levels in the healthcare system.
As a result of such studies, organizations have continued to develop ways for creating a more quality- versus quantity-focused system.3 The Centers for Medicare & Medicaid Services (CMS) is actively involved in the promotion of MTM services. For example, CMS will specifically monitor the completion success of comprehensive medication reviews, stating that “plan sponsors are expected to actively engage plan beneficiaries to increase the numbers of CMRs [comprehensive medication reviews] delivered to MTM enrollees, not just ‘offer’ CMRs.”1,4 Another initiative of the Affordable Care Act is the CMS Innovation Center, which includes MTM services as models to be tested, with the goal of testing innovative payment and delivery system models while slowing the rate of growth in program costs.4
With each new policy and report highlighting the cost-saving opportunities tied to medication mismanagement, the future of pharmacy practice becomes increasingly more defined. The Asheville project, a hallmark study, showed how an increase in pharmaceutical care by community pharmacists can be tied to a decrease in direct medical costs and lead to an increase in quality of care for patients with diabetes.5 Despite increasing data, there continues to be an underutilization of pharmacy services because of a lack of reimbursement structure.5 In addition, while pay-for-performance (PFP) programs historically focus on physician performance, there will likely be an increase in pressure from CMS for organizations to develop a standardized approach for reimbursing pharmacy services.
PFP can be defined as a “payment system in which providers are rewarded financially for quality of care. This is in contrast to the traditional fee-for-service system, which is based on quantity or volume of services provided, regardless of outcome.”5 This type of incentive is similar to CMS star ratings of the Medicare Part D programs, whereby increasing the payer’s quality of care leads to higher star status. Achieving a 5-star status is desirable, because the benefits for reaching and maintaining such status are tremendous (eg, year-end bonuses and year-long open enrollment, allowing payers to freely jump from a lesser rated plan to a 5-star plan at any point in the year).
How will CMS or other organizations develop a PFP model for pharmacy services? Will individual pharmacies have ratings similar to the stars program that determine reimbursement rates per pharmacy? Will pharmacists have their own rating? Only time will tell, but with the increasing interest in PFP models, things are likely to change. With traditional prescription reimbursement decreasing every year, it is crucial that pharmacies continue to expand MTM services and adjust their service models to accommodate for the changing environment. Developing the line of communication between physicians and pharmacists is one of the most crucial changes that needs to take place.
Ways to Enhance the Pharmacist–Patient Relationship
To appropriately manage the newly insured, there needs to be a more coherent relationship between healthcare professionals and patients. One way of enhancing this relationship is by using MTM software, such as Mirixa (Mirixa Corp, Reston, VA) and OutcomesMTM (Outcomes Inc, West Des Moines, IA). Contracting with such vendors provides an excellent opportunity to enhance therapeutic outcomes in a community setting and promote the much-needed line of communication between patient, physician, and pharmacist. In 2012, as a part of an environmental scan reviewing current
MTM trends, it was noted that the majority of candidates entering an MTM program were identified through such vendors.1
Both platforms offer the opportunity for pharmacists to perform a comprehensive medication review of beneficiaries’ medication profile, and maintain a list of their medications along with other patient-specific information. However, key restrictions in providing MTM services within a community setting still remain. These include a deficiency in patient interest, lack of staff support, and pharmacists simply not having enough time.1
It is important to note that these issues are not only being addressed by pharmacies through increasing clinical staff support, but vendors are also making platforms that are easily implemented into workflow. For example, OutcomesMTM creates “Tip claims” that the pharmacist can easily address when patients pick up their medication and later bill the insurance company for the provided service. These tip claims can range from contacting the patient’s physician and recommending a therapy change, to simply investigating the reason a patient has not been adherent. The pharmacist also has the ability to create a self-identified claim, such as an over-the-counter recommendation, or suggest a dosage increase to the patient’s physician.
Engaging the Patient
The most important takeaway is that community pharmacy is going to continue to move away from its traditional environment. Pharmacists will be expected to engage with their patients more, and insurance plans are going to demand a higher level of service. Opportunities continue to develop, and it is a very exciting time in the industry that we hope will be embraced by all pharmacists. This is a chance to further engage with patients and become a more integrated part of the healthcare system.
- American Pharmacists Association. Medication Therapy Management Digest: Pharmacists Emerging as Interdisciplinary Health Care Team Members. www.pharmacist.com/sites/default/files/files/MTMDigest_2013.pdf. March 2013. Accessed February 3, 2014.
- Aitken M, Valkova S; for the IMS Institute for Healthcare. Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using Medicines More Responsibly. IMS Institute for Healthcare Informatics. www.imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/IMS%20Institute/RUOM-2013/IHII_Responsible_Use_Medicines_2013.pdf. June 2013. Accessed February 5, 2014.
- Koenigsfeld C, Horning K, Logemann C, Schmidt G. Medication Therapy Management in the Primary Care Setting: A Pharmacist-Based Pay-for-Performance Project. J Pharm Practice. 2011;25:89.
- Guterman S, Davis K, Stremikis K, Drake H. Innovation in Medicare and Medicaid will be central to health reform’s success. Health Aff (Millwood). 2010;29(6):1188-1193.
- Fenter TC, Lewis SJ. Pay-for-performance initiatives. J Manag Care Pharm. 2008;14 (6):S12-S15.