Pharmacy Education Article
Implementation of a Student Pharmacist-Run Targeted Medication Intervention Program
Journal of Pharmacy Practice 2017, Vol. 30(1) 109-114 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190015587697 journals.sagepub.com/home/jpp
Karleen T. Melody, PharmD, BCACP1, Chintan J. Shah, PharmD1, Jaydip Patel, PharmD1, and Vincent J. Willey, PharmD, BCACP2
Abstract Objective: To evaluate the impact of a student pharmacist-run targeted medication intervention (TMI) program. Methods: Student pharmacists in their third professional year resolved TMIs at 5 independent pharmacies under the supervision of a pharmacist. A claims report of completed TMIs from the medication therapy management (MTM) platform, which captured the category and outcome of the TMIs and the estimated cost avoidance (ECA) level, was analyzed using descriptive statistics. Time spent was calculated using an estimation based on each of the tasks required to complete the TMI. Results: Of the 156 TMIs that were billed, 42 (26.9%) were accepted, 24 (15.4%) were rejected, and 90 (57.7%) were unable to be reached. For TMIs where the prescribers or patients were reached, the acceptance rates were 20% and 71%, respectively. Student pharmacists spent a total of 25.2 hours completing TMIs, and the pharmacist spent 2 hours on administrative tasks. Total revenue generated from all TMIs was US$1058, which led to a revenue generation of US$38.90/h. Successfully completing 42 TMIs resulted in a savings to the health care system of approximately US$121 000. Conclusion: This pilot study demonstrates an innovative model for community pharmacies to complete TMIs by utilizing student pharmacists under the supervision of a pharmacist. Keywords student pharmacist, medication therapy management, targeted medication intervention, community pharmacy, reimbursement for services
Introduction The role of a community pharmacist is changing dramatically. What once was a profession focused on acquiring, preparing, and dispensing a drug product has evolved into a profession focused on providing patient-centered care. Medication therapy management (MTM) has been defined by the profession of pharmacy as a service or a group of services that optimize therapeutic outcomes for individual patients.1 MTM has been identified as one of the solutions to the ever-rising cost of health care with medication-related problems accounting for at least 177 billion dollars annually.2 Many community pharmacies have embraced this opportunity and incorporated MTM as a standard of care into their practice. Pharmacists are the optimal health care practitioners to provide MTM because they are medication experts, easily accessible, and commonly have a close connection with their patients. Online MTM platforms are commonly used to connect insurance companies with community pharmacies to facilitate the identification, resolution, and reimbursement of MTM services. MTM services include medication therapy reviews (MTRs) and targeted medication interventions (TMIs). TMIs represent a group of interventions designed to resolve specific gaps in care and increase adherence, thereby improving patient
outcomes and preventing additional costs to the health care system. These TMIs can be either generated automatically by the online MTM platform or entered manually by the individual who found a drug therapy problem that needs to be addressed. Resolving TMIs involves either contacting the patient to address adherence and to provide education and counseling or contacting the prescriber to initiate a new medication or to change a medication to a more cost-effective alternative. Accepted TMIs are ones where a positive response is received from either the patient or the prescriber. A number of studies have found positive economic and clinical outcomes as a result of pharmacists’ interventions.3,4 However, a majority of these studies were conducted in an inpatient setting and looked at the economic impact of the interventions
1 Department of Pharmacy Practice, Philadelphia College of Pharmacy at the University of the Sciences, Philadelphia, PA, USA 2 HeathCore, Wilmington, DE, USA
Corresponding Author: Karleen T. Melody, Department of Pharmacy Practice, Philadelphia College of Pharmacy at the University of the Sciences, 600 S 43rd St, Philadelphia, PA 19104, USA. Email: [email protected]
110 on the health care system versus the economics of the model itself.4 There is limited evidence in the literature evaluating the economic viability of a model to make these interventions, particularly in the community setting such as a TMI program. A study conducted by Rhodes and colleagues evaluated the economic impact of a 6-month TMI program executed by pharmacists in a regional chain in North Carolina, which showed a negative 3% return on investment (ROI).5 Although there are positive economic and clinical outcomes associated with pharmacists’ interventions as mentioned previously, literature showing a negative ROI may deter for-profit entities from implementing these types of programs. TMIs can have a positive impact on a patient’s health, however, increasing responsibilities competing for time and inadequate reimbursement can be barriers for community pharmacists to complete MTM services, including TMIs. Therefore, it is essential that other models be developed to help facilitate the completion of TMIs. This article highlights an innovative practice model to provide MTM that is economically viable by utilizing student pharmacists.
Objective The objective of this study was to determine whether the implementation of a student pharmacist-run TMI program would be practical and economically viable in an independent community pharmacy setting.
Methods Setting This study took place within a subset of 5 pharmacies in a local chain of 20 independent community pharmacies that serve many patients with a low socioeconomic status. Pharmacies included in this study are all located in an urban community. Clinical services that are provided to patients of these pharmacies include immunizations, health screenings, diabetes education, and MTM including both MTRs and TMIs. A residency-trained community practice clinical faculty member along with advanced pharmacy practice experience student pharmacists provides this array of clinical services 12 hours a week. This research was approved by the institutional review board at the University of the Sciences.
Practice Innovation Due to an increased volume of clinical responsibilities as well as new opportunities, a student pharmacist-run TMI model was created to allow the clinical pharmacist to streamline efforts and spend more time providing and expanding other clinical services previously mentioned as well as to enhance student learning. In this model, 2 student pharmacists in their third professional year resolved TMIs from August to December 2013 for 5 independent community pharmacies for patients insured by a state Medicaid insurance plan while under the supervision of a pharmacist.
Journal of Pharmacy Practice 30(1) The 2 student pharmacists completed the online training specific for the MTM platform (1 hour each) and received additional personalized training from the clinical pharmacist on how to manage and resolve TMIs (2 hours each for the clinical pharmacist and student pharmacists). Personalized training included the following: the students first observed the clinical pharmacist completing various types of TMIs associated with different disease states, then modeled this behavior under direct supervision, and ultimately completed TMIs under indirect supervision. Both students had prior didactic therapeutic knowledge on common chronic disease states, patient outreach experiences, and were concurrently taking a diabetes elective that discussed motivational interviewing. The student pharmacists were not employed by the independent pharmacies and as such did not receive payment; however, they did receive research credit as part of an independent research elective. The TMIs, completed on a bimonthly basis, were documented and submitted by the student pharmacists once the TMIs were checked by the clinical pharmacist. A flow sheet was created which outlined the protocol to follow for each of the different categories of TMIs (Figure 1). To note, all patient TMIs were conducted over the phone. For underuse TMIs, the student pharmacists would determine the cause of nonadherence and provide education to improve adherence directly with the patient. After counseling the patient, their refill history would be tracked and a second follow-up phone call would be made to enhance and reinforce adherence. Patients were also contacted for new therapy monitoring TMIs. During the initial call, they were provided education on indication, directions for use, and monitoring parameters for adverse drug events. Follow-up was made with patients at least 2 weeks later to assess the efficacy and safety of the new therapy, which was determined by addressing patient-specific goals of therapy and adverse drug events. For cost-efficacy TMIs, the patients were contacted for approval before contacting their prescriber for the cost-effective alternative. For TMIs requiring the prescriber be contacted (needed additional therapy or changes in therapy), the prescribers were contacted via fax using templates created by the clinical pharmacist. All TMIs were attempted a minimum of 3 times and documented on the online MTM platform. Attempts were made on a weekly to biweekly basis. The reimbursement per TMI was dependent on whether the intervention was accepted or rejected. Additionally, if the TMI was accepted, the rate was then determined by the category of the TMI. Accepted TMIs categorized as underuse, cost efficacy, or needs additional drug therapy were reimbursed at US$20 each. An accepted TMI categorized as new drug therapy monitoring was reimbursed at US$10 each. Reimbursement of a rejected TMI or if the patient or the prescriber was unable to be reached was US$2 each. An hourly rate of reimbursement was calculated based on the total revenue generated for the TMIs divided by the hours required to perform them by the students and be reviewed by the pharmacist. Furthermore, each accepted TMI had an estimated cost avoidance (ECA), automatically assigned by the MTM platform. The ECA is based on the severity of the outcome of the
Melody et al
111
Underuse
Check Rx ill history and contact patient Counsel on adherence Ensure adherence for 2 ills Submit Claim
New Drug Therapy Monitoring Initial contact •Discuss administration •Educate on importance of adherence •Discuss adverse drug events Follow-up 7-14 days after initial contact •Reinforce adherence •Assess eficacy and safety •Address patient concerns
Cost Eficacy
Contact patient to obtain approval to contact prescriber Contact prescriber via faxed template
Needs Additional Drug Therapy
Check Rx history Contact prescriber via fax template Submit Claim
Submit claim
Figure 1. Workflow to complete targeted medication interventions (TMIs).
intervention and corresponds to an estimated dollar value cost avoided by the health care system using average national health care utilization cost models.6 Each ECA level (1-7) is assigned to an actual dollar amount (ie, US$424 per additional prescription, US$845 per emergency department visit, and US$26 205 per hospital admission). A claims report of completed TMIs was downloaded from the MTM platform and was analyzed using descriptive statistics. This report captured the category of TMI, outcome of the TMI (accepted or rejected), and the ECA level. Time spent was calculated using an estimation based on the student pharmacists’ personal experience executing each of the various tasks that was required to complete each TMI; a baseline of 5 minutes was assigned for opening, reading, processing, and ultimately submitting the TMI; an additional 4 minutes were added if counseling occurred or if a fax was created; and 1 minute was added each time a number was dialed or a fax was sent.
Results From August to December 2013, a total of 156 TMIs were attempted, which resulted in, 42 (26.9%) accepted TMIs, 24 (15.4%) rejected TMIs, and 90 (57.7%) TMIs for which neither patients nor prescribers were able to be reached. Specifically analyzing the TMIs where the prescribers or patients were reached, the acceptance rates were 20.0% and 71.4%, respectively, with an overall acceptance rate of 63.6% (Figure 2). The majority of TMIs, 115 (73.7%), required the patient to be contacted. Of these TMIs, 40 (34.8%) were accepted (patient became adherent), 16 (13.9%) were rejected (patient continued to be nonadherent), and for 59 (51.3%) of the TMIs, the patients were unable to be contacted (Figure 2). The remaining 41 (26.3%) TMIs, required prescribers to be contacted,
Prescriber TMIs
Unable to reach, 31 (76%)
Reached, 10 (24%)
Refused, 8 (80%)
Accepted, 2 (20%)
Total: 41 TMIs
Patient TMIs
Unable to reach, 59 (51%)
Reached, 56 (49%)
Accepted, 40 (71%)
Refused, 16 (29%)
Total: 115 TMIs Figure 2. Acceptance rates of targeted medication interventions (TMIs).
which resulted in 2 (4.9%) accepted TMIs, 8 (19.5%) rejected TMIs, and 31 (75.6%) TMIs where the prescribers could not be contacted (Figure 2). The TMIs broken down by category and result (accepted, rejected, or unable to be reached) showed that
112
Journal of Pharmacy Practice 30(1)
100
39
Accepted
14
Rejected
80 60
0
2
40
4
6
20
1
31
1 0
Unable to Reach 57
1
Cost Efficacy (n=5) Type of TMI
Number of TMIs
120
$10
New Drug Therapy Initiation (n=39)
$15
New Drug Therapy Monitoring (n=2)
$38
0 Cost-Eficacy
Needs Additional Drug Therapy
New Drug Therapy Monitoring
Underuse
Underuse (n=110) $0
Type of TMI
Figure 3. Breakdown of targeted medication interventions (TMIs) by result.
14.0 Time (minutes)
12.0
12.0
$57
9.5
$20 $30 $40 $50 $60 Revenue per Hour ($/hour)
$70
Figure 5. Revenue generated per hour per targeted medication intervention (TMI).
avoided an emergency department visit and 4 prevented a hospital admission. In total, the 42 accepted TMIs resulted in a savings to the health care system of approximately US$121 000.
12.0
10.0
$10
8.8
8.0 6.0
Discussion
4.0 2.0 0.0 Needs Additional Drug Therapy (n=39)
Cost Efficacy (n=5)
New Drug Therapy Monitoring (n=2) Type of TMI
Underuse (n=110)
Figure 4. Time spent per targeted medication intervention (TMI).
cost efficacy had the lowest acceptance rate whereas underuse had the highest, which is in line with the number of each TMI performed (Figure 3). Total revenue from all TMIs was US$1058, with US$830 (78.4%) of the total revenue generated from only 42 (26.9%) of the TMIs. The breakdown of the revenue by each category of TMIs was as follows: US$922 from underuse (n ¼ 110), US$114 from needs additional therapy (n ¼ 39), US$12 from new therapy monitoring (n ¼ 2), US$10 from cost-effective alternative (n ¼ 5), and US$0 from administration/technique education (n ¼ 0). The student pharmacists spent a total of 25.2 hours completing all of the TMIs, and the pharmacist spent a total of 2 hours answering questions related to resolving TMIs and reviewing them before submission. Therefore, the total time to execute this model was 27.2 hours. The average time it took to complete a TMI was 10.5 minutes, although it did vary by category of TMI (Figure 4). Ultimately, this student pharmacist-run model led to a reimbursement rate of US$38.90/h. Underuse TMIs generated the most revenue per hour, while new therapy monitoring and cost efficacy generated the least (Figure 5). Thirty-six (85.7%) of accepted TMIs corresponded to an ECA level of 4, meaning they prevented an additional prescription order to control the disease state. Additionally, 1 TMI
This study explored the viability of a student pharmacist-run TMI program in an independent community pharmacy. Within this practice setting, workflow, and patient population, a revenue of US$38.90/h was able to be generated. Although certainly not economically feasible for a pharmacist to provide these services based on a national average hourly wage of US$56.96, this level of reimbursement does lead to the opportunity to further explore this model with student pharmacists.6 Rhodes and colleagues also found that pharmacists providing TMIs at the current reimbursement levels and wages were not economically viable, as they demonstrated a negative 3% ROI.5 Training time was not included in our hourly revenue calculation because this study sought to evaluate the revenue that could be generated using a student pharmacist supervised by a pharmacist when actually performing the service. Furthermore, training time may vary substantially based on the individual student pharmacist, as prior experiences including introductory pharmacy practice experiences (IPPEs) or work experiences as well as the student pharmacists’ baseline knowledge will play a key role in determining how much training is required. The time commitment for training in combination with differences in salaries of student pharmacists and pharmacists’ will need to be considered when determining expectations for and calculating profit margins. Our findings showed that a majority of the TMIs were for underuse, which is a noteworthy concern, as nonadherence can lead to considerable morbidity, mortality, and avoidable health care costs.7 Evidence has shown that patients on chronic medications are adherent to only 50% to 60% of medications and that resolving nonadherence can result in significantly improved patient outcomes.7-9 Needs additional therapy, the second most common category of TMIs, identifies gaps in care
Melody et al based on clinical guidelines. These TMIs ensure that patients are receiving safe and appropriate treatment. For example, in most patients over the age of 40 with diabetes, a statin should be initiated, an angiotensin-converting enzyme inhibitor is preferred for hypertensive diabetics, and a short-acting betaagonist should be available to patients with asthma in case of an asthma attack, as it is shown to be the most effective medication for relieving acute bronchoconstriction.10-12 Additionally, pharmacists can have a significantly positive impact on insurance plans’ quality measures and ultimately improve their Medicare Star Ratings by resolving these TMIs.13,14 An overall acceptance rate of 63.6% for TMIs where the patient or physician was reached is consistent with other published literature acceptance rates for student completed medication interventions, which range from 32% to 75%.5,15,16 A large limitation that may be contributing to the poor overall acceptance rate of 26.9% is that many physicians and patients were not able to be reached. This limitation represents many missed opportunities to improve patient outcomes and generate revenue. This point was emphasized by how a majority of the revenue came from a minority of the TMIs, indicating that improvement in reaching patients and physicians can have a significant impact on revenue, which we believe will also have a beneficial impact on patient clinical outcomes and health care costs. Inaccurate fax numbers on file, offices not accepting faxes, or just no response even after multiple fax and phone attempts significantly contributed to the poor response rate with physicians. A possible solution could be educating local doctors about the program and the intention of working alongside the physician to make sure the patient’s medication regimens are adequately managed. In addition, it would be advantageous to obtain a more accurate contact list for these physicians, possibly from the insurance plan, as a majority of contact information from the national provider identification (NPI) database was inaccurate. Patients were similarly difficult to contact, which was largely attributed to the patient population. A large number of patients did not have active phone numbers on file through the MTM platform or the pharmacy dispensing system because they commonly change addresses and phone numbers without updating their records with the state. Educating patients on the importance of consistently updating their contact information, and verifying this information regularly at pickup in addition to having change of address forms available at the pharmacy may serve as possible solutions to this problem. Our study showed that it took the students 10.5 minutes on average to complete each TMI, whereas the Rhodes et al study showed an average time of 22.6 minutes.5 The time difference between the 2 studies may be due to the methods used in assessing time. The Rhodes et al study obtained average time by sending out a questionnaire to the pharmacists completing TMIs.5 This has the potential for selection and recall bias, as their response was voluntary and the time reported would be from memory. The current study estimated time based on each of the tasks necessary to complete each TMI, which was
113 previously discussed. Although this method was used to help standardize the process, it may also not be the most accurate because time to complete tasks could vary based on the person doing the task or other unforeseen situations. If actual time was used, the hourly reimbursement rate might have been different. Completing what seemed like minor interventions resulted in a significant ECA to the health care system, with potential avoidances of clinically significant negative health outcomes. From only 42 accepted TMIs, 36 additional prescription orders, 1 emergency department visit, and 4 hospital admissions were potentially prevented. Although this seems to demonstrate positive economical results and speaks to the importance of completing the TMIs, this is only theoretical cost savings. Another limitation of this study was the sample size. Since TMIs were only completed for 5 independent pharmacies, the total number of TMIs as well as the individual type of TMIs (ie, new therapy monitoring and administration/technique) was limited. Additionally, since all of the patients included were from a Medicaid population it limits its applicability to other third-party payers. However, these populations traditionally have suboptimal access to health care and have a significant potential to benefit from these types of services.
Future Directions Future goals include determining whether this model is sustainable, scalable, and replicable. As this was a pilot study, the student pharmacists were not employed by the pharmacy and instead received research credit through their university. To determine whether the model is sustainable, a student pharmacist will be hired as an intern at the pharmacy, and the ROI will be evaluated in future research. This model will also be expanded to include the remaining stores in the local independent community pharmacy chain to increase the number of TMIs that can be attempted and to evaluate its scalability. Some of the additional pharmacies to be included in future research have a predominantly Spanish-speaking population. When considering research into additional markets, it will be important to take into account the language barriers and to include a bilingual student pharmacist to help with completing TMIs. The ability for this model to be replicated in other pharmacy settings and with other third-party payers is also a future goal.
Conclusion This study describes an innovative practice model to provide MTM services in an independent pharmacy setting. This program demonstrated that student pharmacists under the supervision of a pharmacist can play an important role in developing a revenue-generating program to complete TMIs. Further research needs to be conducted to evaluate whether this model is sustainable, scalable, and replicable.
114 Authors’ Note The results of this article were previously presented at the 2014 Pennsylvania Pharmacist Association Mid-year meeting in Bedford, Pennsylvania and at 2014 American Pharmacists Association Annual meeting in Orlando, Florida.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Bluml BM. Definition of medication therapy management: development of profession wide consensus. J Am Pharm Assoc. 2005; 45(5):566-572. 2. Institute of Medicine. Report brief: preventing medication errors. http://www.iom.edu/*/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf. Accessed June 3, 2014. 3. Schumock GT, Butler MG, Meek PD, et al. Evidence of the economic benefit of clinical pharmacy services: 1996-2000. Pharmacotherapy. 2003;23(1):113-132. 4. Perez A, Doloresco F, Hoffman JM, et al. Economic evaluations of clinical pharmacy services: 2001-2005. Pharmacotherapy. 2009;29(1):128. 5. Rhodes SA, Reynolds AE, Marcininak MW, et al. Evaluating the economic impact of a targeted medication intervention program. J Pharm Pract. 2013;26(6):562-573. 6. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Employment Statistics. http://www.bls.gov/oes/current/ oes291051.htm. Accessed April 1, 2015
Journal of Pharmacy Practice 30(1) 7. Johnson JA, Bootman JL. Drug-related morbidity and mortality. A cost-of-illness model. Arch Intern Med. 1995;155(18): 1949-1956. 8. Bosworth HB, Granger BB, Mendys P, et al. Medication adherence: a call for action. Am Heart J. 2011;162(3):412-424. 9. Vegter S, Oosterhof P, van Boven JF, et al. Improving adherence to lipid-lowering therapy in a community pharmacy intervention program: a cost-effectiveness analysis. J Manag Care Pharm. 2014;20(7):722-732. 10. Stewart K, George J, McNamara KP, et al. A multifaceted pharmacist intervention to improve antihypertensive adherence: a cluster randomized trial (HAPPy trial). J Clin Pharm Ther. 2014;39(5):527-534. 11. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;63(25 Pt B): 2889-2934. 12. National Asthma Education and Prevention Program. Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol. 2007;120(5 Suppl): S94-S138. 13. American Diabetes Association. Standards of medical care in diabetes–2014. Diabetes Care. 2014;37 (Suppl 1): S14-S80. 14. Owen J. Medicare star ratings: Stakeholder proceedings on community pharmacy and managed care partnerships in quality. J Am Pharm Assoc. 2014;54(3):228-240. 15. Hata M, Klotz R, Sylvies R, et al. Medication therapy management services provided by student pharmacists. Am J Pharm Educ. 2012;76(3):1-6. 16. McCollom M, Nuffer W, Ellis S, et al. Physician acceptance of pharmacotherapy recommendations made by pharmacy students in a rural pharmacy-based diabetes care and education clinic. Am J Pharm Edu. 2009;73(2):1-4.
Implementation of a Student Pharmacist-Run Targeted Medication Intervention Program
Journal of Pharmacy Practice 2017, Vol. 30(1) 109-114 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190015587697 journals.sagepub.com/home/jpp
Karleen T. Melody, PharmD, BCACP1, Chintan J. Shah, PharmD1, Jaydip Patel, PharmD1, and Vincent J. Willey, PharmD, BCACP2
Abstract Objective: To evaluate the impact of a student pharmacist-run targeted medication intervention (TMI) program. Methods: Student pharmacists in their third professional year resolved TMIs at 5 independent pharmacies under the supervision of a pharmacist. A claims report of completed TMIs from the medication therapy management (MTM) platform, which captured the category and outcome of the TMIs and the estimated cost avoidance (ECA) level, was analyzed using descriptive statistics. Time spent was calculated using an estimation based on each of the tasks required to complete the TMI. Results: Of the 156 TMIs that were billed, 42 (26.9%) were accepted, 24 (15.4%) were rejected, and 90 (57.7%) were unable to be reached. For TMIs where the prescribers or patients were reached, the acceptance rates were 20% and 71%, respectively. Student pharmacists spent a total of 25.2 hours completing TMIs, and the pharmacist spent 2 hours on administrative tasks. Total revenue generated from all TMIs was US$1058, which led to a revenue generation of US$38.90/h. Successfully completing 42 TMIs resulted in a savings to the health care system of approximately US$121 000. Conclusion: This pilot study demonstrates an innovative model for community pharmacies to complete TMIs by utilizing student pharmacists under the supervision of a pharmacist. Keywords student pharmacist, medication therapy management, targeted medication intervention, community pharmacy, reimbursement for services
Introduction The role of a community pharmacist is changing dramatically. What once was a profession focused on acquiring, preparing, and dispensing a drug product has evolved into a profession focused on providing patient-centered care. Medication therapy management (MTM) has been defined by the profession of pharmacy as a service or a group of services that optimize therapeutic outcomes for individual patients.1 MTM has been identified as one of the solutions to the ever-rising cost of health care with medication-related problems accounting for at least 177 billion dollars annually.2 Many community pharmacies have embraced this opportunity and incorporated MTM as a standard of care into their practice. Pharmacists are the optimal health care practitioners to provide MTM because they are medication experts, easily accessible, and commonly have a close connection with their patients. Online MTM platforms are commonly used to connect insurance companies with community pharmacies to facilitate the identification, resolution, and reimbursement of MTM services. MTM services include medication therapy reviews (MTRs) and targeted medication interventions (TMIs). TMIs represent a group of interventions designed to resolve specific gaps in care and increase adherence, thereby improving patient
outcomes and preventing additional costs to the health care system. These TMIs can be either generated automatically by the online MTM platform or entered manually by the individual who found a drug therapy problem that needs to be addressed. Resolving TMIs involves either contacting the patient to address adherence and to provide education and counseling or contacting the prescriber to initiate a new medication or to change a medication to a more cost-effective alternative. Accepted TMIs are ones where a positive response is received from either the patient or the prescriber. A number of studies have found positive economic and clinical outcomes as a result of pharmacists’ interventions.3,4 However, a majority of these studies were conducted in an inpatient setting and looked at the economic impact of the interventions
1 Department of Pharmacy Practice, Philadelphia College of Pharmacy at the University of the Sciences, Philadelphia, PA, USA 2 HeathCore, Wilmington, DE, USA
Corresponding Author: Karleen T. Melody, Department of Pharmacy Practice, Philadelphia College of Pharmacy at the University of the Sciences, 600 S 43rd St, Philadelphia, PA 19104, USA. Email: [email protected]
110 on the health care system versus the economics of the model itself.4 There is limited evidence in the literature evaluating the economic viability of a model to make these interventions, particularly in the community setting such as a TMI program. A study conducted by Rhodes and colleagues evaluated the economic impact of a 6-month TMI program executed by pharmacists in a regional chain in North Carolina, which showed a negative 3% return on investment (ROI).5 Although there are positive economic and clinical outcomes associated with pharmacists’ interventions as mentioned previously, literature showing a negative ROI may deter for-profit entities from implementing these types of programs. TMIs can have a positive impact on a patient’s health, however, increasing responsibilities competing for time and inadequate reimbursement can be barriers for community pharmacists to complete MTM services, including TMIs. Therefore, it is essential that other models be developed to help facilitate the completion of TMIs. This article highlights an innovative practice model to provide MTM that is economically viable by utilizing student pharmacists.
Objective The objective of this study was to determine whether the implementation of a student pharmacist-run TMI program would be practical and economically viable in an independent community pharmacy setting.
Methods Setting This study took place within a subset of 5 pharmacies in a local chain of 20 independent community pharmacies that serve many patients with a low socioeconomic status. Pharmacies included in this study are all located in an urban community. Clinical services that are provided to patients of these pharmacies include immunizations, health screenings, diabetes education, and MTM including both MTRs and TMIs. A residency-trained community practice clinical faculty member along with advanced pharmacy practice experience student pharmacists provides this array of clinical services 12 hours a week. This research was approved by the institutional review board at the University of the Sciences.
Practice Innovation Due to an increased volume of clinical responsibilities as well as new opportunities, a student pharmacist-run TMI model was created to allow the clinical pharmacist to streamline efforts and spend more time providing and expanding other clinical services previously mentioned as well as to enhance student learning. In this model, 2 student pharmacists in their third professional year resolved TMIs from August to December 2013 for 5 independent community pharmacies for patients insured by a state Medicaid insurance plan while under the supervision of a pharmacist.
Journal of Pharmacy Practice 30(1) The 2 student pharmacists completed the online training specific for the MTM platform (1 hour each) and received additional personalized training from the clinical pharmacist on how to manage and resolve TMIs (2 hours each for the clinical pharmacist and student pharmacists). Personalized training included the following: the students first observed the clinical pharmacist completing various types of TMIs associated with different disease states, then modeled this behavior under direct supervision, and ultimately completed TMIs under indirect supervision. Both students had prior didactic therapeutic knowledge on common chronic disease states, patient outreach experiences, and were concurrently taking a diabetes elective that discussed motivational interviewing. The student pharmacists were not employed by the independent pharmacies and as such did not receive payment; however, they did receive research credit as part of an independent research elective. The TMIs, completed on a bimonthly basis, were documented and submitted by the student pharmacists once the TMIs were checked by the clinical pharmacist. A flow sheet was created which outlined the protocol to follow for each of the different categories of TMIs (Figure 1). To note, all patient TMIs were conducted over the phone. For underuse TMIs, the student pharmacists would determine the cause of nonadherence and provide education to improve adherence directly with the patient. After counseling the patient, their refill history would be tracked and a second follow-up phone call would be made to enhance and reinforce adherence. Patients were also contacted for new therapy monitoring TMIs. During the initial call, they were provided education on indication, directions for use, and monitoring parameters for adverse drug events. Follow-up was made with patients at least 2 weeks later to assess the efficacy and safety of the new therapy, which was determined by addressing patient-specific goals of therapy and adverse drug events. For cost-efficacy TMIs, the patients were contacted for approval before contacting their prescriber for the cost-effective alternative. For TMIs requiring the prescriber be contacted (needed additional therapy or changes in therapy), the prescribers were contacted via fax using templates created by the clinical pharmacist. All TMIs were attempted a minimum of 3 times and documented on the online MTM platform. Attempts were made on a weekly to biweekly basis. The reimbursement per TMI was dependent on whether the intervention was accepted or rejected. Additionally, if the TMI was accepted, the rate was then determined by the category of the TMI. Accepted TMIs categorized as underuse, cost efficacy, or needs additional drug therapy were reimbursed at US$20 each. An accepted TMI categorized as new drug therapy monitoring was reimbursed at US$10 each. Reimbursement of a rejected TMI or if the patient or the prescriber was unable to be reached was US$2 each. An hourly rate of reimbursement was calculated based on the total revenue generated for the TMIs divided by the hours required to perform them by the students and be reviewed by the pharmacist. Furthermore, each accepted TMI had an estimated cost avoidance (ECA), automatically assigned by the MTM platform. The ECA is based on the severity of the outcome of the
Melody et al
111
Underuse
Check Rx ill history and contact patient Counsel on adherence Ensure adherence for 2 ills Submit Claim
New Drug Therapy Monitoring Initial contact •Discuss administration •Educate on importance of adherence •Discuss adverse drug events Follow-up 7-14 days after initial contact •Reinforce adherence •Assess eficacy and safety •Address patient concerns
Cost Eficacy
Contact patient to obtain approval to contact prescriber Contact prescriber via faxed template
Needs Additional Drug Therapy
Check Rx history Contact prescriber via fax template Submit Claim
Submit claim
Figure 1. Workflow to complete targeted medication interventions (TMIs).
intervention and corresponds to an estimated dollar value cost avoided by the health care system using average national health care utilization cost models.6 Each ECA level (1-7) is assigned to an actual dollar amount (ie, US$424 per additional prescription, US$845 per emergency department visit, and US$26 205 per hospital admission). A claims report of completed TMIs was downloaded from the MTM platform and was analyzed using descriptive statistics. This report captured the category of TMI, outcome of the TMI (accepted or rejected), and the ECA level. Time spent was calculated using an estimation based on the student pharmacists’ personal experience executing each of the various tasks that was required to complete each TMI; a baseline of 5 minutes was assigned for opening, reading, processing, and ultimately submitting the TMI; an additional 4 minutes were added if counseling occurred or if a fax was created; and 1 minute was added each time a number was dialed or a fax was sent.
Results From August to December 2013, a total of 156 TMIs were attempted, which resulted in, 42 (26.9%) accepted TMIs, 24 (15.4%) rejected TMIs, and 90 (57.7%) TMIs for which neither patients nor prescribers were able to be reached. Specifically analyzing the TMIs where the prescribers or patients were reached, the acceptance rates were 20.0% and 71.4%, respectively, with an overall acceptance rate of 63.6% (Figure 2). The majority of TMIs, 115 (73.7%), required the patient to be contacted. Of these TMIs, 40 (34.8%) were accepted (patient became adherent), 16 (13.9%) were rejected (patient continued to be nonadherent), and for 59 (51.3%) of the TMIs, the patients were unable to be contacted (Figure 2). The remaining 41 (26.3%) TMIs, required prescribers to be contacted,
Prescriber TMIs
Unable to reach, 31 (76%)
Reached, 10 (24%)
Refused, 8 (80%)
Accepted, 2 (20%)
Total: 41 TMIs
Patient TMIs
Unable to reach, 59 (51%)
Reached, 56 (49%)
Accepted, 40 (71%)
Refused, 16 (29%)
Total: 115 TMIs Figure 2. Acceptance rates of targeted medication interventions (TMIs).
which resulted in 2 (4.9%) accepted TMIs, 8 (19.5%) rejected TMIs, and 31 (75.6%) TMIs where the prescribers could not be contacted (Figure 2). The TMIs broken down by category and result (accepted, rejected, or unable to be reached) showed that
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Journal of Pharmacy Practice 30(1)
100
39
Accepted
14
Rejected
80 60
0
2
40
4
6
20
1
31
1 0
Unable to Reach 57
1
Cost Efficacy (n=5) Type of TMI
Number of TMIs
120
$10
New Drug Therapy Initiation (n=39)
$15
New Drug Therapy Monitoring (n=2)
$38
0 Cost-Eficacy
Needs Additional Drug Therapy
New Drug Therapy Monitoring
Underuse
Underuse (n=110) $0
Type of TMI
Figure 3. Breakdown of targeted medication interventions (TMIs) by result.
14.0 Time (minutes)
12.0
12.0
$57
9.5
$20 $30 $40 $50 $60 Revenue per Hour ($/hour)
$70
Figure 5. Revenue generated per hour per targeted medication intervention (TMI).
avoided an emergency department visit and 4 prevented a hospital admission. In total, the 42 accepted TMIs resulted in a savings to the health care system of approximately US$121 000.
12.0
10.0
$10
8.8
8.0 6.0
Discussion
4.0 2.0 0.0 Needs Additional Drug Therapy (n=39)
Cost Efficacy (n=5)
New Drug Therapy Monitoring (n=2) Type of TMI
Underuse (n=110)
Figure 4. Time spent per targeted medication intervention (TMI).
cost efficacy had the lowest acceptance rate whereas underuse had the highest, which is in line with the number of each TMI performed (Figure 3). Total revenue from all TMIs was US$1058, with US$830 (78.4%) of the total revenue generated from only 42 (26.9%) of the TMIs. The breakdown of the revenue by each category of TMIs was as follows: US$922 from underuse (n ¼ 110), US$114 from needs additional therapy (n ¼ 39), US$12 from new therapy monitoring (n ¼ 2), US$10 from cost-effective alternative (n ¼ 5), and US$0 from administration/technique education (n ¼ 0). The student pharmacists spent a total of 25.2 hours completing all of the TMIs, and the pharmacist spent a total of 2 hours answering questions related to resolving TMIs and reviewing them before submission. Therefore, the total time to execute this model was 27.2 hours. The average time it took to complete a TMI was 10.5 minutes, although it did vary by category of TMI (Figure 4). Ultimately, this student pharmacist-run model led to a reimbursement rate of US$38.90/h. Underuse TMIs generated the most revenue per hour, while new therapy monitoring and cost efficacy generated the least (Figure 5). Thirty-six (85.7%) of accepted TMIs corresponded to an ECA level of 4, meaning they prevented an additional prescription order to control the disease state. Additionally, 1 TMI
This study explored the viability of a student pharmacist-run TMI program in an independent community pharmacy. Within this practice setting, workflow, and patient population, a revenue of US$38.90/h was able to be generated. Although certainly not economically feasible for a pharmacist to provide these services based on a national average hourly wage of US$56.96, this level of reimbursement does lead to the opportunity to further explore this model with student pharmacists.6 Rhodes and colleagues also found that pharmacists providing TMIs at the current reimbursement levels and wages were not economically viable, as they demonstrated a negative 3% ROI.5 Training time was not included in our hourly revenue calculation because this study sought to evaluate the revenue that could be generated using a student pharmacist supervised by a pharmacist when actually performing the service. Furthermore, training time may vary substantially based on the individual student pharmacist, as prior experiences including introductory pharmacy practice experiences (IPPEs) or work experiences as well as the student pharmacists’ baseline knowledge will play a key role in determining how much training is required. The time commitment for training in combination with differences in salaries of student pharmacists and pharmacists’ will need to be considered when determining expectations for and calculating profit margins. Our findings showed that a majority of the TMIs were for underuse, which is a noteworthy concern, as nonadherence can lead to considerable morbidity, mortality, and avoidable health care costs.7 Evidence has shown that patients on chronic medications are adherent to only 50% to 60% of medications and that resolving nonadherence can result in significantly improved patient outcomes.7-9 Needs additional therapy, the second most common category of TMIs, identifies gaps in care
Melody et al based on clinical guidelines. These TMIs ensure that patients are receiving safe and appropriate treatment. For example, in most patients over the age of 40 with diabetes, a statin should be initiated, an angiotensin-converting enzyme inhibitor is preferred for hypertensive diabetics, and a short-acting betaagonist should be available to patients with asthma in case of an asthma attack, as it is shown to be the most effective medication for relieving acute bronchoconstriction.10-12 Additionally, pharmacists can have a significantly positive impact on insurance plans’ quality measures and ultimately improve their Medicare Star Ratings by resolving these TMIs.13,14 An overall acceptance rate of 63.6% for TMIs where the patient or physician was reached is consistent with other published literature acceptance rates for student completed medication interventions, which range from 32% to 75%.5,15,16 A large limitation that may be contributing to the poor overall acceptance rate of 26.9% is that many physicians and patients were not able to be reached. This limitation represents many missed opportunities to improve patient outcomes and generate revenue. This point was emphasized by how a majority of the revenue came from a minority of the TMIs, indicating that improvement in reaching patients and physicians can have a significant impact on revenue, which we believe will also have a beneficial impact on patient clinical outcomes and health care costs. Inaccurate fax numbers on file, offices not accepting faxes, or just no response even after multiple fax and phone attempts significantly contributed to the poor response rate with physicians. A possible solution could be educating local doctors about the program and the intention of working alongside the physician to make sure the patient’s medication regimens are adequately managed. In addition, it would be advantageous to obtain a more accurate contact list for these physicians, possibly from the insurance plan, as a majority of contact information from the national provider identification (NPI) database was inaccurate. Patients were similarly difficult to contact, which was largely attributed to the patient population. A large number of patients did not have active phone numbers on file through the MTM platform or the pharmacy dispensing system because they commonly change addresses and phone numbers without updating their records with the state. Educating patients on the importance of consistently updating their contact information, and verifying this information regularly at pickup in addition to having change of address forms available at the pharmacy may serve as possible solutions to this problem. Our study showed that it took the students 10.5 minutes on average to complete each TMI, whereas the Rhodes et al study showed an average time of 22.6 minutes.5 The time difference between the 2 studies may be due to the methods used in assessing time. The Rhodes et al study obtained average time by sending out a questionnaire to the pharmacists completing TMIs.5 This has the potential for selection and recall bias, as their response was voluntary and the time reported would be from memory. The current study estimated time based on each of the tasks necessary to complete each TMI, which was
113 previously discussed. Although this method was used to help standardize the process, it may also not be the most accurate because time to complete tasks could vary based on the person doing the task or other unforeseen situations. If actual time was used, the hourly reimbursement rate might have been different. Completing what seemed like minor interventions resulted in a significant ECA to the health care system, with potential avoidances of clinically significant negative health outcomes. From only 42 accepted TMIs, 36 additional prescription orders, 1 emergency department visit, and 4 hospital admissions were potentially prevented. Although this seems to demonstrate positive economical results and speaks to the importance of completing the TMIs, this is only theoretical cost savings. Another limitation of this study was the sample size. Since TMIs were only completed for 5 independent pharmacies, the total number of TMIs as well as the individual type of TMIs (ie, new therapy monitoring and administration/technique) was limited. Additionally, since all of the patients included were from a Medicaid population it limits its applicability to other third-party payers. However, these populations traditionally have suboptimal access to health care and have a significant potential to benefit from these types of services.
Future Directions Future goals include determining whether this model is sustainable, scalable, and replicable. As this was a pilot study, the student pharmacists were not employed by the pharmacy and instead received research credit through their university. To determine whether the model is sustainable, a student pharmacist will be hired as an intern at the pharmacy, and the ROI will be evaluated in future research. This model will also be expanded to include the remaining stores in the local independent community pharmacy chain to increase the number of TMIs that can be attempted and to evaluate its scalability. Some of the additional pharmacies to be included in future research have a predominantly Spanish-speaking population. When considering research into additional markets, it will be important to take into account the language barriers and to include a bilingual student pharmacist to help with completing TMIs. The ability for this model to be replicated in other pharmacy settings and with other third-party payers is also a future goal.
Conclusion This study describes an innovative practice model to provide MTM services in an independent pharmacy setting. This program demonstrated that student pharmacists under the supervision of a pharmacist can play an important role in developing a revenue-generating program to complete TMIs. Further research needs to be conducted to evaluate whether this model is sustainable, scalable, and replicable.
114 Authors’ Note The results of this article were previously presented at the 2014 Pennsylvania Pharmacist Association Mid-year meeting in Bedford, Pennsylvania and at 2014 American Pharmacists Association Annual meeting in Orlando, Florida.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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