Comprehensive Medication Management: Improve Cost and Health Outcomes
Medication therapy is part of 80% of all treatments, so it's no surprise that it represents a large percentage of ...
Published by Sandy Bonfin, PharmD, BCPS on Jan 19, 2023 12:56:12 PM
Adverse drug events (ADEs), one of the top causes of death in the United States, affect almost a quarter of patients in the primary care setting, with higher prevalence for older patients.
To curb those numbers in its Medicare population, the federal government implemented the Medicare Modernization Act in 2006, which required health plans to include a medication therapy management (MTM) program in their plan benefits.
Almost twenty years later, MTM programs show mixed results. Many studies have shown that MTM by pharmacists is effective, but the emergence of more expensive and complex treatments has complicated the work, and MTM, despite some initial promising results, challenges with service delivery, technology, and patient engagement has limited the impact on overall health outcomes.
These mixed results prompted the Medicare Payment and Advisory Committee to recommend against the expansion of the service under Part D in 2014. With the increased focus on value-based healthcare and the rapid increase in complex and costly specialty medications, health plans have to find ways to move beyond the check-the-box approach MTM offers.
This article proposes a future where at-risk patients receive an intervention at the right time before they need costly care. First, though, let’s take a deeper dive into the mechanics of MTM to better understand why these changes are significant and needed.
According to the Medicare Modernization Act, the goal of MTM is to optimize therapeutic outcomes through improved medication use. Pharmacists providing MTM, review all of a patient's medications to identify medication-related problems and create an action plan to resolve such problems with the patient, caregiver, and/or prescriber. They help improve medication adherence by addressing drug interactions, recommending dose adjustment when necessary, and ensuring that patients understand how to take their medications.
MTM is a group of services that target specific Medicare beneficiaries under the Medicare prescription drug Part D program. These beneficiaries usually have multiple chronic diseases, take multiple Part D drugs, and meet a cost threshold for covered Part D medications.
CMS requires that medication therapy management programs provide a minimum set of services that include interventions for both patients and their health care providers, an annual comprehensive medication review (CMR), and quarterly targeted medication reviews (TMR).
Medication therapy management includes several key elements.
During the CMR, the pharmacist collects information about the patient’s medications, identifies medication-related problems, and creates a plan to resolve them. The pharmacist can also provide training on how to take medications and educate patients on the importance of medication adherence.
PML is an updated list of the patient’s medications. It may include the indications and how the patient takes medication. The patient is encouraged to update their list as their medications change.
The TDL is a document that delineates actions that the patient can take to self-manage their medications. The recommendations included in the TDL are within the pharmacist’s scope of practice or have been agreed on by relevant members of the healthcare team.
The pharmacist intervenes on behalf of the patient either by contacting prescribers or referring patients to another healthcare professional. Some patients’ therapies may be highly specialized and require more complex interventions (e.g., chemotherapies, treatments of auto-immune health conditions).
MTM documentation is done in a standard format and includes a summary of the visit. It’s an essential component of MTM, for billing and reimbursement purposes, and allows the pharmacist to ensure continuity of care among different providers and care settings.
Plan sponsors may also offer follow up interventions such as communication with prescribers to resolve medication-related problems, or a targeted medication review focused on a specific or potential drug therapy issue.
It’s been almost two decades now since CMS implemented MTM and health organizations have adopted these services as a way to optimize patient medication use. At this point, we need to ask ourselves, has MTM achieved its goal? And if not, why not? As discussed above, the results are mixed.
There is strong evidence that MTM is effective. A review published in JAMA Internal medicine found that MTM improved medication adherence by 4.6% and medication appropriateness from 0.9 to 4.9 points on the medication appropriateness index. Specifically for patients with diabetes and chronic heart failure, MTM lowered the odds of hospitalization and decreased hospitalization costs by more than $300. The review also suggested that MTM could reduce the frequency of some medication-related problems, but the evidence wasn’t strong enough regarding health outcomes improvement.
In terms of return on investment, one study that looked at the impact of MTM over 10 years found that MTM resulted in healthcare cost savings of $1.29 per dollar spent on the services. Another study reported that the ROI to the payer was $1.67 per $1. However, this same study did not show a statistically significant difference in clinical outcomes.
Unfortunately, the impact MTM has had on medication use has been limited in scope. Where we do have data, the results suggest traditional MTM is not sufficient to drive the intended outcomes.
And looking at anticoagulant prescribing in the Medicare population, in 2018, many prescribers (19%) were still using warfarin as their main anticoagulant, despite well-established guidelines recommending direct oral anticoagulants as first-line therapy.
Another study found that potentially inappropriate medications (PIMs) continue to be prescribed at a high rate (34.4%) to older people. Another study found that in older populations with multiple conditions and polypharmacy, over 69% of patients use at least one PIM.
All things considered, MTM has had a limited impact on inappropriate medication use and has not benefited many of the patients it was intended for. In 2016, ten years after MTM was implemented, the cost of non-optimized medications, resulting from treatment failure and new medical problems, was estimated at $528 billion dollars.
MTM has achieved limited impact due to several challenges.
Between triaging patients, following CMS requirements, ensuring proper documentation, and incorporating MTM interventions in the workflow, organizations can find it difficult to implement medication therapy management services.
Other barriers to implementing and scaling MTM services are the lack of time, lack of trained support personnel and the excessive workload pharmacists may face. For example, pharmacists may have to comb through Excel spreadsheets to manually identify eligible patients and drug-related problems (DRPs). They then have to reach out to patients, perform MTM services and manually document their interventions; all while going back and forth between different platforms to look up relevant guidelines and create medication action plans.
Pharmacists providing MTM services are generally not integrated with other members of the health care team. As a result, they have access to only a limited amount of information such as prescription claim data, but may not have access to the medical or lab data of patients. This limited access to information creates challenges for pharmacists in fully assessing the patient, and the interventions they do provide have a limited impact on health outcomes.
Care teams delivering MTM services may have large amounts of data in the form of spreadsheets and patient registries, but no scalable way to glean data insights that help them prioritize members, identify medication-related problems, and prepare evidence-based care plans. The manual labor required to deliver this level of care to large populations is challenging given the restraints on pharmacists’ time and resources.
A very small portion of Medicare beneficiaries (8% in 2011) are actually eligible for MTM services. CMS has eased the minimum eligibility requirements since the program was created in 2006. While CMS requires health plans to automatically enroll eligible patients in their MTM programs, CMS requirements represent the minimum threshold. Health plans have the option to offer MTM services to more beneficiaries, but the challenges and expenses involved in delivering the services mean few plans go beyond the minimum requirements. As a result, MTM delivery rate stays low. For instance, in 2014, of the approximately 4.5 million of Medicare Part D MTM beneficiaries, less than 20% received a CMR. Out of the patients who were offered a CMR, 82.5% declined.
Part of the reason for the low delivery rate is likely the lack of financial incentives for health plans. MTM programs are a requirement for plan bids for a contract with CMS and are paid out of administrative funds. Health plans may only allocate limited funds to MTM programs to contain their costs and as a result, may not be able to serve a high number of beneficiaries.
The lack of resources has translated into a service that is focused on checking off the minimum CMS requirements on paper but that has a limited impact on patient health outcomes. MTM is measured based on how many CMRs are completed, not based on patient health outcomes that result from the service.
In order to move beyond the current limitations of MTM, health plans need to reevaluate their processes and utilize innovative technologies to put patients back at the center of medication management.
Medication intelligence gives care teams the data insights they need to ensure each patient takes the medication that is indicated, effective, safe, and best suited for their unique and evolving health needs. Whole-person data and actionable insights allow care teams to address all medication-related problems the patient may experience, not just the ones related to medication adherence. In essence, medication intelligence represents all the current MTM program is not but was intended to be when designed.Medication intelligence enables care teams to
To provide more impactful interventions to a larger number of patients, health plans need to identify members who can experience large improvements in health and economic outcomes with a small medication change. Predictive analytics can help in that regard by targeting patients based on their risk level and their care needs.
Arine’s platform integrates patient clinical and demographic data and uses predictive analytics to stratify patients based on their risk trajectories and to identify those most at risk of falling out of compliance.
Once patients are stratified based on the risk trajectories, medication intelligence pinpoints the next right action, enabling clinicians to provide relevant care to patients based on their actual clinical needs, rather than arbitrarily defining a quarterly outreach such as the TMR.
Take the example of Joe, an elderly male at risk for hospitalizations and disease progression. Joe had not visited his primary care provider, but had two recent hospitalizations and four emergency department visits for three different diagnoses. Using medication intelligence, Arine’s platform combined hospitalization history with prescription claim history to uncover a more complete clinical picture of Joe. Arine recommended optimizations to Joe’s heart failure medication, triaged him to a smoking cessation program, and also recommended a nicotine patch prescription. Arine also connected Joe to transportation for his physician appointments. As a result, Joe received the care and support he needed to manage his condition, was estimated to save $18,690 annually, and didn’t experience any additional admissions post-intervention. These interventions met Joe where he was, including his other needs such as transportation and care coordination.
Identifying interventions that result in improved outcomes is also an important part of scaling services and an area where health plans can utilize machine learning.
With a medication intelligence platform like Arine’s that continuously analyzes the result and the impact of each intervention, health plans can see their success rate continuously. They can also quickly identify which interventions drive the most impact to continuously optimize the care they deliver.
Automation can help clinical teams integrate medication optimization services into their workflow and reduce the administrative burden that’s often associated with MTM programs. For instance, Arine’s automated platform intelligently assigns tasks to members of the teams most qualified to complete them. The platform also uses automation to create personalized patient care plans and send customized recommendations to prescribers in a few clicks, allowing clinical teams to spend their time focused on non-administrative tasks.
By effectively triaging patients, gaining invaluable real-time insights, and using time-saving automated systems, health plans can focus their limited resources where they matter the most in terms of health outcomes and financial return of investment. Arine’s clients achieve up to 6 to 1 return on their medication optimization investment while still impacting health outcomes like hospital admissions rate or behavioral health polypharmacy.
It’s time to imagine a future where at-risk patients receive clinical interventions at the right time, preventing costly hospitalizations or emergency department visits. A clinical team leveraging powerful medication intelligence can improve health, quality, and economic outcomes.
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