Extent of services provided by pharmacists in the iowa medicaid pharmaceutical case management program.

RESEARCH

Extent of Services Provided by Pharmacists in the Iowa Medicaid Pharmaceutical Case Management Program Barry L. Carter, Elizabeth A. Chrischilles, David Scholz, Nobumasa Hayase, and Nancy Bell

Objective: To summarize the start-up experience with patients identified as eligible during the first four quarters of the Iowa Pharmaceutical Case Management (PCM) program and to characterize the extent of the services proved by pharmacists in the program.

Design: Prospective pharmaceutical care intervention project. Setting: One hundred seventeen community pharmacies in Iowa. Patients: Medicaid patients at high risk for drug-related problems based on using 4 or more nontopical medications and having 1 of 12 specific disease states. Intervention: To become eligible to provide PCM services, licensed pharmacists had to undergo training and submit five care plans to the Iowa Department of Human Services. Community pharmacists were provided names of newly eligible patients each calendar quarter for 1 year. For each patient, pharmacists were asked to indicate by fax whether they had met with the patient, performed a written work-up of the patient, sent recommendations to the patient’s physician, and whether the physician replied. When pharmacists were unable to provide the service, they were asked to state the reason. Both the pharmacist and the physician receive $75 for the initial assessment, with additional payments after each follow-up visit performed. Main Outcome Measures: An intensity score and the percentage of eligible patients for whom all steps were completed were calculated for each pharmacy. Results: Fax survey results were returned for 2,834 (96.7%) of the 2,931 patients eligible for PCM services. Pharmacists met with 943 (33.3%), worked up 763 (26.9%), sent recommendations to physicians for 500 (17.6%), and received replies from physicians for 327 (11.5%) patients. Pharmacists were unable to provide PCM services for 1,891 (66.7%) patients. The primary reasons given for this inability to provide services were patient access issues for 438 (23.2%) patients, pharmacy staffing or start-up issues for 419 (22.2%) patients, or no reason specified for 575 (30.4%) patients. A PCM intensity score was developed to represent the scope of services provided and the number of patients served. A higher intensity score indicated pharmacies that provided PCM to more patients and/or that offered higher levels of care (e.g., provided a written set of recommendations to the physician rather than simply assessing the patient without preparing or sending recommendations). Future evaluations will determine the validity of the score on the basis of patient outcomes. Conclusion: Some pharmacies implemented PCM services very effectively. However, 40% to 60% of the pharmacies provided little or no PCM services within 3 months of notification of patient eligibility. Future investigations will evaluate the quality of prescribing and quality of life for patients who received PCM services.

Keywords: Pharmaceutical care, physician–pharmacist collaboration, pharmacist assessment, drug-related problems, Medicaid. J Am Pharm Assoc. 2003;43:24–33. Received February 26, 2002, and in revised form April 30, 2002. Accepted for publication May 6, 2002. Barry L. Carter, PharmD, FCCP, FAHA, is professor, Division of Clinical and Administrative Pharmacy and Department of Family Medicine, College of Medicine; Elizabeth A. Chrischilles, PhD, is professor, Department of Epidemiology, College of Public Health; David Scholz, MBA, is project manager, Department of Epidemiology, College of Public Health, University of Iowa, Iowa City. Nobumasa Hayase, PhD, is associate director of pharmacy, Asahikawa Medical University Hospital, Asahikawa, Japan, and visiting research scholar, College of Pharmacy, University of Iowa, Iowa City. Nancy Bell, RPh, is vice president, clinical pharmacy services, Iowa Pharmacy Association, and coordinator, Pharmaceutical Case Management Program, Des Moines, Iowa. Correspondence: Barry L. Carter, FCCP, FAHA, PharmD, Division of Clinical and Administrative Pharmacy, College of Pharmacy, S-532, University of Iowa, Iowa City, IA, 52242. Fax: 319-353-5646. E-mail: [email protected].

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Journal of the American Pharmaceutical Association

Adverse drug events are one of the most frequent and costly consequences of medical errors.1 The number one risk factor for an adverse drug event is the number of drugs a patient is taking.2 For example, whereas 10% of older individuals may experience an adverse drug event during a 1-year period,2 this figure rises to 40% among those taking 5 or more medications.3 Some 75% of adverse drug events are considered avoidable, that is, they are a known consequence of the pharmacologic properties of the drug. However, disease state management becomes very complicated when a patient has multiple medical conditions. Pharmaceutical case management is an opportunity for physicians and pharmacists to work collaboratively to closely scrutinize the total drug regimens of their complex patients—to look across disease states and identify the best combination of drugs and doses

January/February 2003

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Pharm aceutical Case M anagem ent

for that particular patient. Strong evidence suggests that this collaboration will be an effective strategy for reducing adverse drug events and improving outcomes.3–18 The past 35 years are replete with examples of innovative practice models in community pharmacy.4 Studies have demonstrated that interventions and management by community pharmacists can improve the control of blood pressure,5–8 asthma,9 and hyperlipidemia.10 A multicenter study also demonstrated that lipid control was significantly improved when community pharmacists assisted with management of patients with hyperlipidemia.11 Pharmaceutical care training has been shown to result in increased resolution of drug-related problems (DRPs).12,13 Community pharmacists throughout the United States have been trained and certified to provide immunizations, and this service is clearly improving patient access to influenza and other vaccinations.14,15 Researchers have reported cost savings ranging from $12219 to $85617 per recommendation made by a community pharmacist and accepted by a physician. Two randomized, controlled trials of physician–pharmacist care teams are of particular relevance since the researchers found significant effects on patient outcomes.3,18 Both studies documented the effectiveness of a physician–pharmacist team in caring for complex patients attending U.S. Department of Veterans Affairs outpatient clinics. Hanlon et al.3 found that pharmacist consultation with physicians for patients taking 5 or more medications reduced the risk of adverse drug events from 40% to 30% and significantly reduced the rate of unnecessary drug use. Ellis et al.18 found that pharmacist consultation for complex patients resulted in better lipid control, even though the study was not specific to hyperlipidemia. Iowa has been the location of several research and demonstration projects focusing on advances in community pharmacy practice.12–15,20,21 These prior efforts established the foundation for the Iowa Medicaid Pharmaceutical Case Management (PCM) program by training more than 200 pharmacists in strategies to reengineer their practices to identify and resolve DRPs,21 by demonstrating the effectiveness of the training program,12,13 and by engaging a large number of Iowa pharmacists in practice-based research.20 The Iowa Medicaid PCM program is the first attempt to implement and reimburse physician–pharmacist teams for the delivery of medication management services for high-risk patients in the community setting. At the time of the study reported here, there were a total of 743 pharmacies in the state of Iowa, and nearly all were eligible to apply for the PCM program (only those that served nursing homes exclusively would not qualify). Iowa Medicaid PCM services were implemented in 117 participating pharmacies on October 1, 2000: 64 (55%) independent, 22 (19%) chain, 13 (11%) franchise, and 18 (15%) other (mostly clinic pharmacies). Approximately 30% of the participating pharmacies were located in large cities (Des Moines, Cedar Rapids, Waterloo–Cedar Falls, the Quad Cities). The remainder of the participating pharmacies were located in small cities and rural towns.

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RESEARCH

The ultimate aim of the Iowa Medicaid PCM Program is to avoid adverse drug events (or adverse effects) and the associated costs to the health care system by implementing more optimal, lower-risk medication regimens. The program is not a pilot project; rather, it was established as a state service by the Iowa legislature after being approved as a plan amendment by the Health Care Financing Administration (HCFA). Although the program is ongoing, the legislative language that directed the Iowa Department of Human Services (DHS) to implement the program also called for its evaluation. That evaluation includes an assessment of patient outcomes, which is forthcoming.

Objectives The objectives of this article are to summarize the start-up experience with patients identified as eligible during the first four quarters of the Iowa PCM program and to characterize the extent of the services provided by pharmacists in the program.

Development of the Service Advisory C om m ittee A peer review advisory committee was established in November 1999 to oversee the development of the service. The committee consisted of four pharmacists and four physicians working in the state. Staff from DHS, Iowa Medical Society, Iowa Osteopathic Medical Association, and Iowa Pharmacy Association were invited to attend and provide input. Specific responsibilities of the committee were to draft the State Plan Amendment for PCM, which established all the details of the service for approval by HCFA; establish eligibility requirements for participating providers; determine the eligibility of individual pharmacies and pharmacists; and review and approve the evaluation plan. The principal investigator (EAC) was contracted to develop the evaluation of the service provided. Training Program All participating pharmacists were required to attend a live, half-day training program on the services covered under the PCM program and the reimbursement process. Two live sessions were held in September 2000, and a training videotape was also made available. Physicians did not attend the training session but were mailed a manual of operations. A Web site provides general information about the PCM program and answers to frequently asked questions (www.public-health.uiowa.edu/pcm). Pharmacists and other health care providers may also join the PCM listserv for networking and informational purposes.


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Description of the Iowa PCM Program Provider Eligibility Physicians and pharmacists who formed care teams had to meet specific criteria to provide PCM services. Physicians had to be licensed to practice medicine. Both physicians and pharmacists had to complete an Iowa Medicaid provider agreement and have an Iowa Medicaid provider number. A copy of PCM records, including documentation of services provided, had to be maintained on file in each provider’s facility and made available for audit by DHS on request. To become eligible to provide these services (described below in Care Process), pharmacists had to present DHS with evidence of competency, including state licensure, submission of five acceptable patient care plans, and successful completion of professional training regarding DRP prevention and resolution. Acceptable professional training programs were approved by DHS, with input from the peer review advisory committee. A doctor of pharmacy degree was considered acceptable professional training. The Iowa Center for Pharmaceutical Care training program—a cooperative training initiative of the University of Iowa College of Pharmacy, Drake University College of Pharmacy and Health Sciences, and the Iowa Pharmacy Foundation—was also an approved training program. Other programs offering similar didactic coursework and supplemental practice site evaluation and reengineering could be considered for approval by DHS under advisement from the peer review advisory committee. Pharmacists also had to maintain problem-oriented patient records, provide a private patient consultation area, and submit a statement attesting that the patient care plans submitted were representative of their usual patient care plans. Patient Eligibility Patient eligibility for PCM services was determined using a two-step, computer-based algorithm under the direction of DHS. Initial patient eligibility criteria included having active prescriptions for four or more regularly scheduled nontopical medications and ambulatory care status. The patient also had to have at least one of the following disease states: congestive heart failure, ischemic heart disease, diabetes mellitus, hypertension, hyperlipidemia, asthma, depression, atrial fibrillation, osteoarthritis, gastroesophageal reflux disease, peptic ulcer disease, or chronic obstructive pulmonary disease. Each participating pharmacy received a list of newly eligible patients once per quarter. Patients included on a list from previous quarters continued to be eligible for PCM services as long as they were eligible for Medicaid. Physicians also received lists of their eligible patients receiving prescriptions from a participating pharmacy. Only the patient’s primary physician was notified of that patient’s eligibility for PCM services. The primary physician was not necessarily the same as a primary care provider but was the

26


individual who wrote the majority of the patient’s prescriptions; in many cases, this was a specialist physician.

Care Process The process of care in the PCM program consists of the following steps: determination of eligibility, initial assessment, problem follow-up assessment, new problem assessment, and preventive assessment. First, a primary pharmacist who is eligible to participate in the program and the patient’s primary physician are notified of their patient’s eligibility for the PCM program. Once the patient has been identified, the initial assessment by the pharmacist begins. Typically, pharmacists interview patients directly. In the cases of children, pharmacists typically interview the child’s parent or legal guardian for much of the information, but, whenever possible, pharmacists question the child directly about medication use (e.g., inhaler use and technique). This initial assessment includes: 1. Patient evaluation by the pharmacist, including: a. Medication history. b. Assessment of medication indications, effectiveness, safety, and adherence. c. Assessment for the presence of untreated illness. d. Identification of DRPs, such as: — Unnecessary medication therapy. — Suboptimal medication selection. — Poor adherence. — Adverse drug reactions. — Need for additional medication therapy. 2. A written report and recommendation from the pharmacist to the physician. 3. A patient care action plan developed and implemented by the PCM team with the patient’s agreement. Specific components of the action plan in step 3 of the initial assessment vary based on a patient’s needs and conditions. Components may include changes in medication regimen, focused patient or caregiver education, periodic assessment for changes in the patient’s condition, periodic monitoring of the effectiveness of medication therapy, self-management training, provision of patient-specific educational and informational materials, adherence enhancement, and reinforcement of healthy lifestyles. An action plan is completed on the basis of each initial assessment. If the physician agrees to the pharmacist’s recommendations, a problem follow-up assessment is scheduled with the pharmacist at a time agreed upon by the team. This assessment: Is based on patient need or a problem identified during the initial assessment. Is the strategy used by the care team to assess the effectiveness of the agreed-upon action plan. Takes place at an appropriate interval determined by the team. Is used to modify the previous action plan as necessary. When a new medication use issue arises between the scheduled assessments, the physician–pharmacist patient assessment cycle of


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the PCM program can be restarted and a care plan for a new problem assessment begun. A new problem assessment: Can occur in the interim between other PCM services. Is initiated when the care team identifies a new DRP. Involves the care team’s assessment of the patient and development of a new action plan. After the goals of the action plan are achieved, and if no new DRPs develop, a preventive follow-up assessment can be scheduled, which: Follows an initial assessment when no DRPs are identified. Occurs approximately 6 months following the last assessment of any kind. Involves the care team’s reassessment of the high-risk patient for newly developed DRPs. Includes a new action plan to address any new problems. An action plan is defined as a plan for patient care developed by and agreed upon by the physician and pharmacist team members. Specific activities will vary based on a patient’s needs and conditions but may include: Changes in medication regimen. Focused patient or caregiver education. Periodic assessment for changes in the patient’s condition. Periodic monitoring of the effectiveness of medication therapy. Patient self-management training. Provision of patient-specific educational and informational materials. Adherence enhancement. Reinforcement of healthy lifestyles. Standardized forms are used to facilitate communication between the pharmacist and physician (see Appendix 1).

Paym ent Process Pharmacist and physician team members are paid equally for their participation in each of the four PCM services described above. The payment structure was established after reviewing Medicaid’s physician fee schedule and payment methodologies and fees of other states and third party payers. The fee schedule and maximum number of payments for each type of assessment per patient are listed in Table 1. Written communication between the pharmacist and physician is required for them to bill for and be paid for PCM services. The peer review advisory committee developed a sample communication form (Appendix 1). Both pharmacists and physicians use the HCFA-1500 form to file claims. The individual pharmacist provider number is placed in box 24K. The following billing codes are used in place of Current Procedural Terminology (CPT) codes for PCM services: W4100—Initial Assessment–Pharmacist; W3100—Initial Assessment–Physician; W4200—Preventive Follow-up Assessment–Pharmacist; W3200— Preventive Follow-up Assessment–Physician; W4300—New Problem Assessment–Pharmacist; W3300—New Problem Assessment– Physician; W4400—Problem Follow-up Assessment–Pharmacist;

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RESEARCH

Table 1. Payment Structure for PCM Servicesa

PCM Service

Fee ($)

Maximum No. Allowed per Patient

Initial assessment

75

1

New problem assessment

40

2 in 12 months

Problem follow-up assessment

40

4 in 12 months

Preventive follow-up assessment

25

1 in 6 months

PCM= pharmaceutical case management. a Both the physician and pharmacist received these payments.

W3400—Problem Follow-up Assessment–Physician. Since claims submission and payment can be delayed significantly from the time of service, this report includes no data on these aspects of the project.

Methods The evaluation timeline includes patients who became eligible for PCM between October 1, 2000, and July 1, 2001, and who were being followed up through July 1, 2002. At the conclusion of each calendar quarter a survey (see Appendix 2) was faxed to each participating pharmacy to ascertain the status of each patient identified to the pharmacy for the first time at the beginning of that quarter. Pharmacists were asked to indicate whether they had met with the patient, worked up (evaluated) the patient’s medicationrelated information, sent a recommendation to the patient’s physician, and received a reply from the physician. When pharmacists indicated they were unable to provide the service to a patient, they were asked to give a reason. Based on the responses to these surveys, the investigators developed a PCM intensity score to represent the scope of services provided and the number of patients served. A higher intensity score indicated pharmacies that provided PCM services to more patients and/or that offered higher levels of care (e.g., provided a written set of recommendations to the physician rather than simply assessing the patient without preparing or sending recommendations). The following points were assigned to each activity: met with patient—1 point; provided a written work-up of the patient—3 points; sent recommendations to the physician—6 points; physician replied—1 point. These points were summed to obtain a total score per pharmacy (11 points possible for each patient/case). These point allocations were made based on the importance of each activity in the experience of the investigators. As this was the initial description of these services and the first use of the intensity score, future evaluations will determine the validity of the score based on patient outcomes. Also calculated for each pharmacy was percentage completed, which was the percentage of eligible patients on whose behalf the first three steps above were performed. Correlations of these two intensity measures with each other and with the total numbers of patients eligible per pharmacy were also constructed.


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RESEARCH


Results

patients (depending on quarter of enrollment) were worked up by pharmacists, and recommendations were sent to physicians for 15.7% to 23.1% of new patients in various quarters of the evaluation. Pharmacists received physician replies regarding 9.9% to 13.7% of new patients. Table 3 lists the reasons pharmacists reported for being as yet unable to provide PCM services. For the entire sample, pharmacists did not provide a reason they were unable to provide services for 575 patients (30.4%). Initially, this response was quite high (42.0%) in quarter 1, but it declined as pharmacists became familiar with the surveys and, perhaps partially, because some pharmacies (most of whom experienced start-up difficulties) requested that no additional patients be assigned to them in the subsequent quarter. Pharmacy start-up and staffing difficulties accounted for about 22% of reasons. Reasons having to do with inability to gain access to patients increased in frequency from 14.9% in quarter 1 to 44.6% in quarter 2, with an overall percentage of 23.2%. Patient outright refusal accounted for less than 10% of reasons, and physicians declining to participate accounted for less than 4%. The intensity scores for pharmacy services are displayed in Table 4. The percentage completed indicates those cases in which the pharmacist met with the patient, prepared a written assessment, and provided recommendations to the physician. In quarter 1,

There were 2,931 patients who were eligible for PCM services. The mean age was 52 years, and almost two-thirds of eligible patients were age 45 or older; 6.6% were children. Overall, 70.0% of patients were women. Of 117 eligible pharmacies, 109 had eligible patients assigned in quarter 1, 76 had more eligible patients assigned in quarter 2, 73 in quarter 3, and 81 in quarter 4. Fewer pharmacies had eligible patients assigned in later quarters primarily because these pharmacists had not yet worked up the patients from quarter 1 and did not want more patients assigned. Of the 117 eligible pharmacies, 114 had eligible patients assigned in at least one quarter. Fax surveys were returned for 2,834 out of 2,931 (96.7%) eligible assigned patients for quarters 1 through 4. Table 2 displays the numbers of patient surveys returned and the results of the quarterly fax surveys received for each patient from the pharmacies. These data represent the actions taken by pharmacists and physicians during the first quarter after a patient was identified as eligible. Within 3 months of receiving a list of newly eligible patients, pharmacists met on average with 31.7% of new patients in quarter 1, 42.2% of new patients in quarter 2, 28.3% of new patients in quarter 3, and 32.2% in quarter 4. From 25.5% to 34.6% of

Table 2. Patient Status 3 Months After Initial Eligibility for PCM Services by Quarter of Patient Initial Eligibilitya

Patient Surveys Returned by Quarter

Pharmacist Met W ith Patient No. (%)

Pharmacist W orked Up Patient No. (%)

Pharmacist Sent Recommendation to Physician No. (%)

Physician Replied No. (%)

Pharmacist Unable to Meet With Patient No. (%)

Quarter 1 (n = 1,566)

497 (31.7)

400 (25.5)

247 (15.8)

172 (11.0)

1,069 (68.3)

Quarter 2 (n = 540)

228 (42.2)

187 (34.6)

125 (23.1)

74 (13.7)

312 (57.8)

Quarter 3 (n = 424)

120 (28.3)

98 (23.1)

66 (15.6)

42 (9.9)

304 (71.7)

Quarter 4 (n = 304) Total (n = 2,834)

98 (32.2)

78 (25.7)

62 (20.4)

39 (12.8)

206 (67.8)

943 (33.3)

763 (26.9)

500 (17.6)

327 (11.5)

1,891 (66.7)

PCM= pharmaceutical case management. a The categories ª met with patientº and ª unable to meet with patientº add up to the total sample of patients fromthe returned surveys. The categories ª worked up patient,º ª sent recommendation to physician,º and ª physician repliedº were all subsequent steps that followed ª met with patient.º

Table 3. Reasons Pharmacists Were Unable to Meet With Patients

Reason Patient refusal Patient access

problem a

Scheduling issues Pharmacy staffing/start-up delay

Quarter 1 (n = 1,069) No. (%)

Quarter 2 (n = 312) No. (%)

Quarter 3 (n = 304) No. (%)

Quarter 4 (n = 206) No. (%)

Total (n = 1,891) No. (%)

98 (9.2)

27 (8.7)

28 (9.2)

26 (12.6)

179 (9.5)

159 (14.9)

139 (44.6)

95 (31.2)

45 (21.8)

438 (23.2)

44 (4.1)

20 (6.4)

9 (3.0)

0

73 (3.9)

216 (20.2)

53 (17.0)

59 (19.4)

91 (44.2)

419 (22.2)

61 (5.7)

0 (0.0)

3 (1.0)

2 (1.0)

66 (3.5)

Other patient issues

42 (3.9)

35 (11.2)

41 (13.5)

23 (11.2)

141 (7.5)

No reason specified

449 (42.0)

38 (12.2)

69 (22.7)

19 (9.2)

575 (30.4)

Physician participation issues

a Patient moved/patient changed pharmacy/deceased/nursing or

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group home patient/other patient access problem.


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RESEARCH

Table 4. Intensity Scores for Pharmacy Services by Quarter Quarter 1 (n = 109 Pharmacies) No. (%)

Quarter 2 (n = 76 Pharmacies) No. (%)



% completeda > 50 25– 49.9 1– 24.9 0

18 14 17 60

(16.5) (12.8) (15.6) (55.0)

15 7 6 48

(19.7) (9.2) (7.9) (63.2)

9 10 3 51

(12.3) (13.7) (4.1) (69.9)

8 8 4 61

(9.9) (9.9) (4.9) (75.3)

Total intensity score b > 50 25– 49.99 0.01– 24.99 0

19 20 42 28

(17.4) (18.3) (38.5) (25.7)

3 4 21 48

(3.9) (5.3) (27.6) (63.2)

1 1 20 51

(1.4) (1.4) (27.4) (69.9)

3 4 13 61

(3.7) (4.9) (16.0) (75.3)

a Percentage of patients who had the following services:

ª met with patient,º ª worked up patient,º ª sent recommendation to physician.º Intensity score was the summation of the following for each patient: met with patient = 1 point; worked up patient = 3 points; sent recommendation to physician = 6 points; physician replied = 1 point. b

16.5% of the pharmacies completed all these steps for half their eligible patients. Approximately 17% of pharmacies during quarter 1 were considered “high intensity,” indicating that pharmacists worked up and/or completed the care process for a large number of patients. However, depending on the specific quarter, only 1–3 pharmacies (out of 117) continued to be high intensity pharmacies in quarters 2–4. Table 5 shows correlations between total number of patients who received PCM services, total intensity score, and percentage completed (i.e., receiving all services), by quarter of assignment. We found little evidence of association between the number of PCM patients assigned to a pharmacy and the percentage of patients for whom a PCM service was completed (correlations –0.042, 0.147, 0.054, and 0.148 for quarter 1, 2, 3, and 4 patients, respectively). While the intensity score was designed simply to describe the level of activity in various pharmacies, we wanted to ascertain what factors weighed most heavily in determining the score. Total patients assigned and total intensity score were strongly associated as expected due to the intensity score formula (Pearson correlation coefficients 0.599, 0.819, 0.760, and 0.779 for quarters 1, 2, 3, and 4, respectively). Intensity score and percentage completed were also positively associated, but this correlation was moderate, supporting the somewhat different constructs represented by these two measures (Pearson correlation coefficients 0.516, 0.498, 0.442, and 0.535 for quarters 1, 2, 3, and 4, respectively). The correlation between percentage completed and intensity score was positive, indicating that pharmacies with a high percentage completed were also likely to have a higher intensity score. The moderate magnitude of this correlation coefficient, however, indicates that the two measures capture different aspects of intensity. For example, some pharmacies with a large volume of patients may have provided a low level of service for most patients but few complete services; thus, they obtained a high total intensity score. In contrast, some pharmacies provided complete services to some patients and no service to others, resulting in a higher intensity score but lower percentage completed.

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Table 5. Correlations Between Various Components of the Intensity Score

Measure

Quarter

Total intensity score

1 2 3 4

Total no. of patients receiving any PCM service

1 2 3 4

% completed

1 2 3 4

Total Intensity Score 1.0 1.0 1.0 1.0

Total No. of Patients Receiving Any PCM Service 0.599 0.819 0.760 0.779 1.0 1.0 1.0 1.0

% Completed a 0.516 0.498 0.442 0.535 – 0.042 0.147 0.054 0.148 1.0 1.0 1.0 1.0

PCM= pharmaceutical case management. a Pharmacist met with the patient, prepared a written work-up of the visit, and sent recommendations to the physician.

Discussion Iowa Medicaid PCM services were founded on a solid body of evidence demonstrating that medication safety is improved when pharmacists and physicians work together.3–18 In this evaluation we found a relatively high delivery of PCM services, compared with other intervention studies in community pharmacies. Pharmacists met with nearly 1,000 patients, prepared written assessments for 760 patients, and sent recommendations to 500 physicians during the 12-month evaluation period. Despite these impressive results, this program clearly suffered from many of the start-up problems experienced during other pharmaceutical care studies conducted in community pharmacies. The effort to start up this new service must be undertaken largely by the pharmacist. When a pharmacy receives its list of eligible patients, a pharmacist contacts the patients, schedules appointments, meets with them, obtains additional information from their


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RESEARCH


physician if necessary, completes their assessment, and forwards a written recommendation to the physician. Because of the time needed to complete all of these steps, finalizing an action plan for a patient may take several months, and, in fact, some pharmacists were still attempting to meet with patients or complete work-ups when they received the survey. This lag would mean that some steps may not have been completed when the survey was faxed to the pharmacy. However, because pharmacies continued to receive lists of patients newly eligible for the service at the beginning of each quarter, it is unknown when, or whether, pharmacists would catch up. In many pharmacies, catching up could require hiring additional staff. In the face of uncertainty about the longevity of the PCM program and the effect of staffing changes on pharmacy finances, managers would be understandably reluctant to make such changes during the initial year of the program. The two main obstacles to establishing PCM services were related to patient access and pharmacist issues. Pharmacists had many difficulties with patients moving, losing eligibility for Medicaid, and related problems. Pharmacists also had significant problems with pharmacist staffing, including insufficient staff to expand the service and problems scheduling patient visits. Problems with start-up are understandable for a new program. However, all of the pharmacists received PCM training and indicated their desire to participate. It is disturbing that, depending on the quarter, between 40% and 60% of the pharmacies were providing very few or no PCM services. In some cases, this may have been related to the pharmacist shortage or problems hiring qualified technicians. Interestingly, patient and physician refusal to participate was uncommon. It is possible, however, that patient or physician refusal accounted for some instances when pharmacists did not list a reason for their inability to provide the service. Clearly, however, some of the pharmacists were very effective in working with selected physicians. Several authors have described methods for training community pharmacists to implement pharmaceutical care.12,16,22–27 Currie et al.12 found that patients seen by pharmacists who had received such training were seven times more likely than a control group of patients to have problems identified (21% versus 3%). Additionally, study patients were more than eight times as likely to have an intervention performed on their behalf as patients receiving traditional pharmacy services. Rupp19 found that, of 623 prescriptions identified as problematic by pharmacists, their interventions may have avoided otherwise likely adverse consequences in 128 (21%) instances. Pharmacists’ interventions were judged to have resulted in an estimated savings of $122 per intervention. Dobie and Rascati28 reported that community pharmacists’ interventions saved $3.50 per prescription processed, but the intervention rate was only 0.78% of all prescriptions. Finally, in a study of 31 pharmacies, Knapp et al.29 reported an intervention rate of 0.7% of all prescriptions (range across pharmacies was 0 to 4%). In the Florida Therapeutic Outcomes Monitoring study, community pharmacists were trained to provide pharmaceutical care for

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patients with asthma.23 Of the 12 participating pharmacies, 7 successfully implemented the program, but only 49 patients were recruited, and only 22 remained throughout its duration. Pharmacists did not expand this service, and they stated that their main problem was the lack of time to provide and document the service.16 While our PCM program has enrolled far more patients, the main obstacles have also been problems related to the pharmacists, including startup, difficulty sustaining the program, and lack of time. Miller and Scott17 reported the results of providing drug information and pharmaceutical care training to pharmacists from five rural pharmacies. The 878 interventions made during a 2-month period were initiated by pharmacists (57%), physicians (18%), patients (17%), or other professionals (8%). The pharmacist recommended seeing a physician 21% of the time or nonprescription therapy 47% of the time. The authors estimated that these interventions saved $752,391 in costs to the health care system. The Washington State Cognitive Activities and Reimbursement Effectiveness Project evaluated 110 treatment pharmacies and 90 control (nonpaid) pharmacies.24–27 Treatment pharmacies billed Medicaid for each intervention related to a DRP. Pharmacists were paid $4 for each intervention requiring less than 6 minutes and $6 for those requiring 6 minutes or more. During a 12-month period, 3,333 interventions (average of 2.5 per pharmacy per month) led to a drug change in the paid pharmacies, compared with 2,084 (average of 1.9 per pharmacy per month) in the nonpaid pharmacies. The majority of these involved “change in drug of choice” (37%), “change dose or dosage regimen” (32%), or “do not dispense” (11%). The cost savings for each drug change averaged $13. In this study, pharmacists in medical centers or rural areas, in pharmacies with lower prescription volumes, and in pharmacies with more Medicaid patients performed and documented more interventions. The researchers also found that this payment rate did not have a dramatic effect on the frequency of interventions.27 Comparing our findings with those of the studies cited above is somewhat difficult. Most of the previous intervention programs in community pharmacy have had to do with problem prescriptions or single disease states. The Iowa Medicaid PCM program is different in that it is an opportunity for physicians and pharmacists to closely evaluate the entire patient care plan. The program is initiated by pharmacists, but physicians are closely involved as the plan is implemented and followed. In addition, the PCM program involves complex patients for whom the pharmacist looks at all diseases to find the best combination of drugs and doses. This makes the service complex and may, in part, explain some of the start-up difficulties. However, many of these programs have experienced difficulty starting and maintaining the service. We found that a small percentage of pharmacies in our sample were particularly active. The significant drop-off in intensity with time was probably related to the fact that the active pharmacies were still struggling to continue follow-up visits and physician communication with patients deemed eligible in previous quarters. Thus, they were less able to initiate the service for newly eligible patients in the later quarters of the program.


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Limitations The sensitivity and specificity of the program used to identify patients eligible for PCM services at each pharmacy, which uses the potential risk of DRPs, have not been evaluated. It is possible that adjustment of the screening rules could reduce the number of patients deemed eligible for PCM services without substantially compromising the number of DRPs detected. This article provides an initial description of the intensity score we developed. This score was not necessarily meant to have validity outside the use described here. It was intended to provide some numeric assessment so that readers can compare activity levels in various pharmacies. Since the evaluation of the PCM service and resulting patient outcomes is ongoing, we were not able to validate this intensity score with patient outcomes or quality of life. However, we believe the tool has good face validity, even if the actual point assignments are disputable. For instance, while it is important that the pharmacist meet with the patient (1 point) and perform the written work-up (3 points), these activities are of modest value if the pharmacist does not communicate his or her findings to the physician (6 points). Although the pharmacist cannot control whether a physician replies, response or nonresponse might indicate some level of their relationship, so only 1 point was given for this factor.

Conclusion In this article, we described the initial start-up experience with the Iowa Medicaid PCM program. Because of the complexity of the program, the complexity of the patient population, and physicians’ general unfamiliarity with the concept of pharmaceutical care, the large number of enrolled patients must be considered a success. In addition, the service provides both pharmacists and physicians with a relatively high reimbursement rate, compared with similar programs. Despite this, many pharmacies performed very few or no PCM services during the 12-month evaluation period, even though the pharmacists had been trained to provide the services and had agreed to implement the program. Efforts are ongoing to increase pharmacist, patient, and physician participation. Future evaluations of this program will examine whether pharmacists’ interventions influence the quality of prescribing and patients’ quality of life. The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, stock holdings, gifts, or honoraria. The authors acknowledge the assistance and support of Thomas Temple and the Iowa Pharmacy Association, Cheryl Clarke, Shari Chen-Hardee, Tae-Ryung Park, Jay Currie, Randal McDonough, William Doucette, Michael Ernst, Karen Farris, William Miller, and the Iowa pharmacists who have participated in this service. Funding for Pharmaceutical Case Management services is provided by the State of Iowa General Assembly and federal matching funds for the Medicaid program in Iowa. Funding for the evaluation of this service, reported here, was provided by the State of Iowa General Assembly, the

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Iowa Pharmacy Foundation, McKesson HBOC and the Institute for the Advancement of Community Pharmacy. The findings described in this article have not been presented at any medical or pharmacy meetings.

References 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999. 2. Chrischilles EA, Segar ET, Wallace RB. Self-reported adverse drug reactions and related resource use. A study of community-dwelling persons 65 years of age and older. Ann Intern Med. 1992;117:634–40. 3. Hanlon JT, Weinberger M, Samsa GP, et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. Am J Med. 1996;100:428–37. 4. Carter BL, Helling DK. Ambulatory care pharmacy services: has the agenda changed? Ann Pharmacother. 2000;34:772–87. 5. McKenney JM, Slining JM, Henderson HR, et al. The effect of clinical pharmacy services on patients with essential hypertension. Circulation. 1973;48:1104–11. 6. McKenney JM, Brown ED, Necsary R, Reavis HL. Effect of pharmacist drug monitoring and patient education on hypertensive patients. Contemp Pharm Pract. 1978;1:50–6. 7. Park JJ, Kelly P, Carter BL, Burgess PP. Comprehensive pharmaceutical care in the chain setting. J Am Pharm Assoc. 1996;36:443–51. 8. Carter BL, Barnette DJ, Chrischilles E, et al. Evaluation of hypertensive patients after care provided by community pharmacists in a rural setting. Pharmacotherapy. 1997;17:1274–85. 9. Rupp MT, McCallian DJ, Sheth KK. Developing and marketing a community pharmacy-based asthma management program. J Am Pharm Assoc. 1997:37:694–9. 10. Shibley MCH, Pugh CB. Implementation of pharmaceutical care services for patients with hyperlipidemias by independent community pharmacy practitioners. Ann Pharmacother. 1997;31:713–9. 11. Bluml BM, McKenney JM, Cziraky MJ, Elswick RK Jr. Interim report from Project ImPACT: Hyperlipidemia. J Am Pharm Assoc. 1998;38:529–34. 12. Currie JD, Chrischilles EA, Kuehl AK, Buser RA. Effect of a training program on community pharmacists’ detection of and intervention in drugrelated problems. J Am Pharm Assoc. 1997;37:182–91. 13. Kuehl AK, Chrischilles EA, Sorofman BA. System for exchanging information among pharmacists in different practice environments. Consult Pharm. 1998;5:564–74. 14. Ernst ME, Charlstrom CV, Currie JD, Sorofman B. Implementation of a community pharmacy-based influenza vaccination program. J Am Pharm Assoc .1997;37:570–80. 15. Ernst ME, Bergus GR, Sorofman BA. Patients’ acceptance of traditional and nontraditional immunization providers. J Am Pharm Assoc. 2001;41:53–9. 16. Hepler CD. Looking toward a market for pharmaceutical care. J Am Pharm Assoc. 1997;37:625–6. 17. Miller LG, Scott DM. Documenting indicators of pharmaceutical care in rural community pharmacies. J Managed Care Pharm. 1996;2:659–66. 18. Ellis SL, Carter BL, Malone DC, et al. Clinical and economic impact of ambulatory care clinical pharmacists in management of dyslipidemia in older adults: the IMPROVE study. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers. Pharmacotherapy. 2000:20:1508–16. 19. Rupp MT. Value of community pharmacists’ interventions to correct prescribing errors. Ann Pharmacother. 1992;26:1580–4. 20. Chrischilles E, Sorofman B, Zieglowsky MB, et al. The Iowa on-line prospective drug utilization review (OPDUR) demonstration project: study design, system design, and conceptual models. J Res Pharm Econ. 1997;8:171–91. 21. Rovers JP, Currie JD, Hagel HP, et al. A Practical Guide to Pharmaceutical Care. Washington, DC: American Pharmaceutical Association; 1998. 22. Barnette DJ, Murphy CM, Carter BL. Clinical skill development for community pharmacists. J Am Pharm Assoc. 1996;36:573–81. 23. Grainger-Rousseau TJ, Miralles MA, Hepler CD, et al. Therapeutic outcomes monitoring: application of pharmaceutical care guidelines to community pharmacy. J Am Pharm Assoc. 1997;37:647–61.


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24. Christensen DB, Holmes G, Fassett WE, et al. Influence of a financial incentive on cognitive services: CARE project design/implementation. J Am Pharm Assoc. 1999;39:629–39. 25. Christensen DB, Hansen RW. Characteristics of pharmacies and pharmacists associated with the provision of cognitive services in the community setting. J Am Pharm Assoc. 1999;39:640–9. 26. Smith DH, Fassett WE, Christensen DB. Washington State CARE project: downstream cost changes associated with the provision of cognitive services by pharmacists. J Am Pharm Assoc. 1999;39:650–7.

27. Christensen DB. Lessons learned from the Washington state CARE project. J Am Pharm Assoc. 1999;39:606–7. 28. Dobie RL, Rascati KL. Documenting the value of pharmacist interventions. Am Pharm. 1994;34:50–4. 29. Knapp KK, Katzman H, Hambright JS, Albrant DH. Community pharmacist interventions in a capitated pharmacy benefit contract. Am J Health Syst Pharm. 1998;55:1141–5.

Appendix 1. Sample Pharmacist–Physician Communication Form PHARM ACEUTICAL CASE M ANAG EM ENT ASSESSM ENT COM M U N ICATIO N FO RM (COMPLETE, SIGN, AN D FAX TO PHYSICIAN) Physician: ______________________________ Fax: ___________________________ Phone:________________________________ CONFIDENTIALITY WARNING: The information contained in this facsimile message is privileged and confidential information intended only for the review and use of the individual or entity named above. If the reader of this message is not the intended recipient, you are hereby notified that any disclosure, dissemination, distribution, or copying of this communication or the information contained herein is strictly prohibited. If you have received this communication in error, please immediately notify sender by telephone, and destroy the original documents.

Initial

Follow-up

New Problem

Preventive

Patient Name: ______________________________________ Medicaid #: ___________________________________ Birthdate: _______________________

Sex: ____________

Pharmacist: (print name) ___________________ ___________________________________________________ Date: _______________________ Subjective Findings: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ Objective Findings: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ Assessment: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ Plan: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ Recommended Pharmacist Follow-Up Assessment:

4 weeks

8 weeks

6 months

Other __________________________________________________

Signature:______________________________________________________ Pharmacist: ______________________________ Fax: ___________________________ Phone:_____________________________________________ Physician: (print name) __________________________________________________________________________ Date: _______________________ Agree W ith Plan Recommended Proposed Modified Plan_________________________________________________________________________________________________ Pharmacist Follow-Up: As Recommended Other _________________________________________________________________________ Signature:______________________________________________________

(COM PLETE, SIGN, AND FAX TO PHARM ACIST)

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Appendix 2. Patient Status Survey

Pharmacy Number____________ Pharmacy Name _____________

PCM 1st QUARTER PROGRESS REPORT

PLEASE COMPLETE AND FAX TO: ____________________ BY ____________________. THANK YOU ****PLEASE CHECK AS MANY AS APPLY******

Patient ID Number

Patient First Name

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Patient Last Name

Conducted Met W ith Patient Patient W ork-up

Sent Recommendation to Physician

Received Reply from Physician

Unable to Provide PCM to Patient

If Unable, Please Briefly State Why


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Perceptions of British Columbia residents and their willingness to pay for medication management services provided by pharmacists.

Cost of services provided by the National Breast and Cervical Cancer Early Detection Program.

Public's perception and satisfaction on the roles and services provided by pharmacists - Cross sectional survey in Sultanate of Oman.

Completeness of medication reviews provided by community pharmacists.

Medicaid personal care services for children with intellectual disabilities: what assistance is provided? When is assistance provided?

Iowa pharmacists fill allergy testing niche.

Cost, utilization, and quality of care: an evaluation of illinois' medicaid primary care case management program.

Evaluation of patient satisfaction with diabetes management provided by clinical pharmacists in the patient-centered medical home.

The extent of advertising of pharmaceutical products.

Interventions by pharmacists in out-patient pharmaceutical care.

Longitudinal changes in dental services provided by Australian dentists.

Patients' evaluations of gynecologic services provided by nurse practitioners.

The Medicaid personal care services program: implications for social work practice.

An outcome evaluation of counseling services provided by abortion clinics.

An exploratory, population-based, mixed-methods program evaluation of user satisfaction of services provided by a regional extension center (REC).

Provision of Clinical Preventive Services by Community Pharmacists.

Supplanting ecosystem services provided by scavengers raises greenhouse gas emissions.

Higher blood pressure control rate in a real life management program provided by the community health service center in China.

Costs of Public Pharmaceutical Services in Rio de Janeiro Compared to Farmácia Popular Program.

The Massachusetts dental Medicaid program 1967-1971.

Medicaid primary care physician fees and the use of preventive services among Medicaid enrollees.

An exploration of clinical interventions provided by pharmacists within a complex asthma service.

Barriers to Implementation of Pharmaceutical Care by Pharmacists in Nsukka and Enugu metropolis of Enugu State.

Preparing pharmacists to deliver a targeted service in hypertension management: evaluation of an interprofessional training program.