Based on a presentation by Marissa Schlaifer, RPh; Linda Baggett, RPh, CGP; and Kimberly Vernachio, PharmD, at the Academy of Managed Care Pharmacy Annual Meeting, April 17, 2008, San Francisco, CA.
Marisa Schlaifer, RPh, Director of Pharmacy Affairs at the Academy of Managed Care Pharmacy (AMCP) described a new medication therapy management (MTM) program that was developed by the AMCP to serve as a guide for MTM programs for those designing and those purchasing an MTM program.
There are differences between MTM programs and MTM services, Dr Schlaifer explains. MTM programs are developed by health plans or other healthcare groups and focus on optimizing therapeutic outcomes, whereas MTM services describe the components of MTM programs delivered by healthcare professionals. MTM programs that implement effective MTM services enhance patient care and lead to better health, while decreasing healthcare system costs.
Drug therapy management programs are designed to ensure that medications provided to eligible beneficiaries are used appropriately, thus reducing adverse events and optimizing therapeutic outcomes through improved medication use.
The MTM Validation Project
This new MTM initiative was intended to guide all purchases of MTM programs, whether they are under Medicare Part D, commercial, or other settings. The National Committee for Quality Assurance (NCQA) was contracted to conduct the validation study. The NCQA surveyed 20 representative Medicare Part D and non–Medicare Part D programs and conducted indepth site visits with 5 of the programs. Phase 1 consisted of telephone surveys with purchasers, pharmacies, physicians, and consumer advocacy organizations and regulators.
The NCQA found great variety among the programs. Technology played a great role in all aspects of the MTM programs. In addition to regular mail and personal communications and interventions, they used fax, the Internet, and e-mail. The features and operational aspects were confirmed as realistic and valuable as a general direction for MTM programs. Among the 20 programs surveyed, pharmacists were identified as the primary deliverers and managers.
All the information gathered was then presented to the AMCP Advisory Panel, which reviewed it and made recommendations on how to modify the original document. The MTM consensus document was pulled together by a broad array of stakeholders, including representatives from the American Association of Retired Persons, AMCP, American Academy of Family Physicians, American Geriatric Society, American Pharmacists Association, Veterans Administration, and National Business Coalition on Health, and representatives from health plans, pharmacy benefit managers, integrated health systems, and stand-alone MTM programs. Many of the details of the program are contained in a January 2008 AMCP supplement.
Features of a Successful MTM Program
Linda Baggett, RPh, CGP, and Kimberly Vernachio, PharmD, Pharmacotherapy Specialists at Aetna, described the qualities of a Medicare MTM program at Aetna that can serve as a model for implementing successful MTM programs. They began by noting that a significant proportion of medical errors are related to adverse events, and hospitalizations are significantly attributed to adverse events. The Institute of Medicine reported that as of January 2000, 44,000 to 98,000 deaths occurred annually as a result of medical errors. Of these, approximately 7000 deaths annually are related to adverse drug reactions.1 Statistics point to adverse drug reactions as a serious problem, occurring in 1 of 5 patient injuries or death per year.2
Drug-related issues are responsible for 33% of hospital admissions in older patients, including misuse (eg, nonadherence, wrong indication, and contraindication) and adverse drug reactions (eg, electrolyte imbalances from changes in cardiovascular medications).3
Aetna's MTM program has been a work in progress since 2006. Aetna has identified the following 7 key features that characterize a successful MTM program. Such a program should:
- Be patient-centered
- Use an interdisciplinary approach and be teambased
- Have effective communication among team members
- Clearly define the perspective on each issue regarding population-based or individual perspective
- Be flexible in design
- Use an evidence-based medical approach
- Promote its services; a good program does no good unless others know about it.
From the start, Aetna assumed that the number of drugs a patient was taking would provide a strategy for intervention. This approach led to the development of a screening algorithm. The number of prescriptions quantitated the number of drug-related opportunities for intervention. Members taking 14 or more drugs were considered the most complex members; however, polypharmacy turned out not to be the first issue requiring attention. The number of drugs was not necessarily supportive of meaningful opportunities for intervention.
Identifying Risk Groups
Program coordinators eventually differentiated clinical risk groups based on medication (eg, anticoagulant use, diabetes mellitus, congestive heart failure, dementia, asthma and chronic obstructive pulmonary disease, end-stage renal disease, and rheumatoid arthritis).
The highest risk group was patients older than age 80, the frail elderly. These patients were at highest risk and received direct care from pharmacists. The vast majority of their members were between ages 71 and 80 years. Aetna expected to find most of their drug-related issues in this group. They also expected that the frail elderly would have more medical issues, which did not turn out to be the case. Instead they found that drug-related issues in patients younger than age 60 years were just as great as those in patients older than age 80. The proportions were identical across the ages.
Another finding was that most of their patients had 3 physicians. They then reached out to all these physicians, who needed to be a part of their effort in coordinating care.
Postintervention follow-up by letters to patients (low touch) and letters plus critical calls (high touch) served to reduce events and, therefore, costs. Cost avoidance occurred whether the intervention was low touch ($476 per member annually) or high touch ($2506 per member annually). Getting to the most optimal outcome in a cost-effective manner was the next problem to solve. It was once again brought home that any intervention would reduce events and thus costs.
Focus for the Future?
A pharmacy-based intervention program is critical to the success of future program expansions. The focus should remain on opportunities to expand clinical and safety issues in medication therapy, as well as meeting the educational needs of physicians about drug-related issues and coordinating this information with members.
The focus should be on pill burden (ie, the number of medications a patient takes each day). Therapy must be streamlined to facilitate successful patient implementation. Aetna is currently looking at alternative strategies for compliance and persistence. The data are beginning to suggest that there is a finite longevity to any intervention, which may very well vary by the type of intervention.
- Committee on Quality of Health Care in America: Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
- Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-384.
- Cooper JW Jr, Burfield AH. Medication therapy management strategies for geriatric patient interventions: Medicare Part D implementation. Ann Long Term Care. 2007;15:33-38.
Ms Schlaifer is Director of Pharmacy Affairs at the Academy of Managed Care Pharmacy; Ms Baggett and Dr Vernachio are Medicare Pharmacotherapy Specialists at Aetna, Inc.