Durham pharmacists pushing patient counseling model

Medication therapy management (MTM) is mandated in the new Medicare drug benefit. And Gina Upchurch, R.Ph., MPH, hopes that will bring attention to the kind of comprehensive service provided by the MTM program she directs and supported by the local pharmacists in Durham, N.C.

A nonprofit organization that grew out of concern for the needy by the Durham County Hospital Corp., Senior PHARMAssist has helped low-income elders afford medications for more than 10 years, serving about 800 people last year. But just as important, its services include having one of its two staff pharmacists do a one-on-one, in-person review and counseling session with each participant every six months, on all medications, including over-the-counter and herbal.

The program computerizes each participant's medications list, with dosages and what the drugs are taken for. The staff gives a printout to patients, who are encouraged to show it to any provider or caregiver they deal with.

The results are interesting. An early evaluation looked at participants with incomes at 150% of poverty or less. Thirty-one percent fewer participants had emergency room visits during their first year enrolled in Senior PHARMAssist, and 29% fewer had an overnight hospital stay.

A more recent evaluation, currently submitted for publication, looks at results through 2001 and finds even more improvement after a two-year enrollment.

In the meantime, in 2001 Upchurch received a $100,000 Robert Wood Johnson Foundation award for creation of the model, one of several awards that have highlighted the program. But, according to Upchurch, it is still one of only a few similar programs she knows of in the country. And, she noted, local pharmacists' cooperation is a big part of making it feasible.

Senior PHARMAssist is supported by a combination of funds from the state and county, local foundations, businesses, and individuals. But one key to the program's success is the agreement by all community pharmacists in Durham-about 40 in all-to charge the program rates that are lower than those for Medicaid or for cash-paying customers. The beneficiaries pay an $8 co-pay per prescription and Senior PHARMAssist pays the rest.

In addition, pharmacists, along with other professionals, serve on its board and on the committee that develops its formulary, which, according to the program, helps it avoid "paying for expensive medications that have limited therapeutic benefits."

Beyond that, said Upchurch, the program coordinates with and depends on community pharmacists to deal with problems between the six-month visits. They help participants understand the formulary, and they deal with PHARMAssist's drug interaction alerts. And PHARMAssist sends the pharmacists copies of recommendations made to prescribers about specific patients.

Upchurch said, "We see them as partners in getting this all done. We want them to advocate with prescribers, seniors, and caregivers for rational use of drugs."

The need for the system is obvious to staff, said Upchurch. From inhalers held upside down to hazardous medication combinations and confusion about medications' purposes, many people come into the program with problems, including some serious enough to send them to the hospital.

So, with the savings in hospitalization that Senior PHARMAssist claims to have generated, are payers beating a path to the program's door to find out how it works? Not really, lamented Upchurch, who speculated that health plans look for savings that show up more quickly. But she also conceded there is still work to do to illustrate the model's financial effectiveness, as well as whether it could be duplicated. For now, the evaluation of her program does not have a control group.

As for the immediate financial impact, Upchurch said, it's probably a wash: Some participants stop some medications, but others get on the medications they need. But that's partly due to the fact the program enables clients to buy drugs they could not previously afford. MTM might be able to help the higher-income seniors save money on drugs, she said, perhaps helping them avoid the "donut hole" of noncoverage under Part D.