Ethics Toolbox – Medication Therapy Management: Challenge and Opportunity

January 1, 2006 ‐ Leslie Proctor

January / February 2006

Ethics Toolbox

Medication Therapy Management: Challenge and Opportunity

By Joel V. Brill, MD; Dennis A. Robbins, PhD, MPH

As of January, under provisions in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, pharmacists are authorized to provide medication therapy management (MTM) services to Medicare patients. The challenge and opportunity inherent in that significant change raise the question whether the profession of pharmacy can vault itself from allied health into primary care and prevention. How the profession chooses to capitalize on this opportunity will depend on its vision and sense of creating a profession of the future.

Several have questioned whether pharmacy will limit itself to assessing a patient’s health status before dispensing a medication, or whether the profession will supersede the constraints of the status quo and take the lead in improving the interface between health literacy and medication adherence. MTM provides a unique opportunity for pharmacists to assume stewardship by taking the lead in enhancing care for the patient and coordinating care among other primary care providers.

Health literacy, which refers to a patient’s ability to understand common communications relating to healthcare, has become a critical driver of healthcare costs. Health literacy involves significant analytic and decision-making skills as well as the ability to appropriately apply those skills. Those who are health-literacy challenged are among the most vulnerable and least well-equipped to understand and deal with the system. Patients with low levels of health literacy will likely incur medical expenses that are up to 4 times greater than patients with adequate literacy skills. Anybody taking several medications can be confused; literacy challenges exacerbate confusion through an inability to articulate their condition or understand a treatment regimen.

Col, Fanale, & Kronholm (1990) showed that 28% of hospital admissions for elderly patients were drug-related, where 12% were due to non-compliance and 16% to adverse drug reactions. In 1995, the GAO estimated that medication related problems among the elderly, including improper diagnoses and adverse reactions, may account for as many as 17% of hospitalizations of older Americans and may cost $20 billion a year in hospital stays (Merck Institute of Aging & Health). The National Academy on an Aging Society estimated that additional healthcare costs due to low health literacy were approximately $73 billion in 1998.

According to the Institute of Medicine report (2004) on health literacy, 90 million people from all ages, races, and income and education levels have difficulty understanding, using, and acting on health information. The problem is exacerbated by the fact that most patients hide their confusion from their doctors because they are too ashamed and intimidated to ask for help. This presents an opportunity for pharmacists to take the lead in managing patients with complex pharmaceutical care needs, for these patients require thoughtful, well-meaning, and knowledgeable guides.

How, when, and if pharmacists choose to maximize the opportunity will be a crucial distinguishing factor for the profession. We applaud those pharmacists who have chosen to push the envelope and insist on becoming valued members of the healthcare team. Models for pharmacists as an integral component of the healthcare team already exist in a number of settings including the Indian Health Service, academic institutions, and private practice. With the advent of Medicare Part D, the Centers for Medicare and Medicaid Services (CMS) has recognized the value that pharmacists bring to the system. As friends of pharmacy, it is our hope that the profession embraces MTM as an opportunity for increased professional recognition through keeping the quality bar high. We are appalled, however, to learn that a number of the Part D Prescription Drug Plans aim to fulfill the MTM mandate through the use of impersonal communication methods such as faxes to patients. Pharmacists should take the lead in defining what MTM should be, rather than kowtow to more minimalist approaches.

In the new reality of value-based purchasing, teams of health professionals will work together to optimize patient care and outcomes. Even before the Part D Medicare benefit became law, progressive state governments in North Carolina, New Mexico, Minnesota, and Mississippi saw the benefit of pharmacists as active participants with their healthcare delivery systems.

With the advent of disease management programs, pharmacy has a unique opportunity to improve the nation’s healthcare system: to craft consumer-centric care models to better accommodate, integrate, and engage the consumer. Engagement involves significant opportunities to work closely with patients and other health professionals. But making the patient a prime decision-maker is a bolder step. The relationship between the patient and pharmacist can become the fulcrum of the healing relationship. Coming from a physician and an ethicist, that model of the patient-centered approach may raise questions, eyebrows, and expectations. It should not, especially if the pharmacist is to be a valued member of the healthcare delivery team.

Embracing a consumer model mandates that the consumer be an integral and actively engaged member of the team. The consumer is no longer someone with whom to meet and interact so as to obtain passive concurrence. From the get-go, the patient must be an integral part of the care planning process. In the not-too-distant future, we may recognize that the concept of the physician as captain of the ship has sailed away, in favor of the team approach to healthcare. As that evolves, the pharmacist may become a coordination point for medical management.

The complexity of healthcare in the 21st century cannot be overstated, nor can the importance of coming up with viable solutions. All healthcare professionals have the chance to help patients become less vulnerable. Pharmacists have a unique opportunity to help patients better navigate our somewhat incomprehensible, overwhelming, and opaque healthcare system. Taking an active role by embracing MTM helps make the process and the goals transparent for patients. Rather than creating barriers or obstacles, we can identify and forge solutions. Newly established collaborative relationships can guide and fuel this process. Health professionals can keep patients centered and help them seek the best path to improve their care. Health service providers must be aware and responsive to the health literacy of patients. The importance of meeting this unmet need cannot be underestimated, for we have an affirmative duty to help promote a health-literate America.

Medication Therapy Management Services Definition and Program Criteria

Performing or obtaining necessary assessments of the patient’s health status;
Formulating a medication treatment plan;
Selecting, initiating, modifying, or administering medication therapy;
Monitoring and evaluating the patient’s response to therapy, including safety and
Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events;
Documenting the care delivered and communicating essential information to the patient’s other primary care providers;
Providing verbal education and training designed to enhance patient understanding and appropriate use of his/her medications;
Providing information, support services, and resources designed to enhance patient adherence with his/her therapeutic regimens;
Coordinating and integrating medication therapy management services within the broader healthcare-management services being provided to the patient.

Patient-specific and individualized services or sets of services provided directly by a pharmacist to the patient*. These services are distinct from formulary development and use, generalized patient education and information activities, and other population-focused quality assurance measures for medication use.
Face-to-face interaction between the patient* and the pharmacist as the preferred method of delivery. When patient-specific barriers to face-to-face communication exist, patients shall have equal access to appropriate alternative delivery methods. Medication Therapy Management programs shall include structures supporting the establishment and maintenance of the patient*-pharmacist relationship.
Opportunities for pharmacists and other qualified healthcare providers to identify patients who should receive medication therapy management services.
Payment for Medication Therapy Management Services consistent with contemporary provider payment rates that are based on the time, clinical intensity, and resources required to provide services (e.g., Medicare Part A and/or Part B for CPT & RBRVS).
Processes to improve continuity of care, outcomes, and outcome measures.

Joel V. Brill (Joel.Brill@verizon.net) is chief medical officer of Predictive Health, LLC. Board certified in internal medicine and gastroenterology, he is nationally recognized for his expertise in coding and reimbursement methodologies, technology assessment, pharmacy, and therapeutics. In 2005, Brill co-chaired the Part D medication measures Technical Expert Panel for CMS. He is the American Gastroenterological Association’s advisor on practice management and reimbursement issues, a representative to the American Medical Association (AMA) RBRVS Update Committee (RUC), the CPT Editorial Panel, the Practice Expense Review Committee (PERC), and the AMA Physician Consortium for Performance Improvement, and serves on the Board of Directors of ABQAURP.

Dennis Robbins (DennisRobbins@cox.net) is a nationally prominent healthcare innovator, author, and thought leader. He is president of Integrated Decisions, Ethics, Alternatives, and Solutions (IDEAS). He has served as an advisor on ethics and related issues for major national organizations, associations, law firms, hospital systems, private industry, and government. Robbins holds a PhD in philosophy from Boston College and a postdoctoral master’s degree in public health from Harvard. He is a member of the Editorial Advisory Board for Patient Safety and Quality Healthcareand member of several technical and scientific advisory boards. Robbins has more than three decades of academic and consulting experience. He is an adjunct professor at the W.P. Carey School of Business at Arizona State University where he teaches graduate courses in ethics and health law.

References

Col, N., Fanale. J. E., & Kronholm, P. (1990). The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Archives of Internal Medicine,150, 841-845.

Institute of Medicine. (2004, April 8). Health literacy: A prescription to end confusion. Accessed December 5, 2005, at www.iom.edu/report.asp?id=19723

Merck Institute of Aging & Health, & The National Academy on an Aging Society. (n.d.). The state of aging and health in America. Accessed December 20, 2005, at www.agingsociety.org/agingsociety/pdf/state_of_aging_report.pdf

National Academy on an Aging Society. (n.d.). Accessed December 1, 2005, at www.agingsociety.org/healthlit.htm

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