MTM opens door to direct patient care

With the move toward coordinated care systems, a "brave new future" will be shifting pharmacists' roles from dispensing to direct clinical practice, says Terry McInnis, MD, MPH, co-leader of the Medication Management Taskforce for the Patient-Centered Primary Care Collaborative. PCPCC is a nonpartisan advocacy group that promotes the Joint Principles of the Patient-Centered Medical Home, a Washington, D.C.-based initiative sponsored by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association.

Medication therapy management (MTM) will be key in new systems such as accountable care organizations and patient-centered medical homes, where the goals are to pay attention to the patient, coordinate care, and ensure that the system is helping to control their diseases, she said.

According to McInnis, with payment reform, quality rather than volume will be emphasized. Lower hospitalization rates will be encouraged; unneeded procedures and duplicative diagnostics will not.

More than drug review

McInnis, who is president of Blue Thorn, Inc., a healthcare consulting services company, spoke during a recent webinar sponsored by URAC, a nonprofit organization that promotes healthcare quality through accreditation, education, and measurement programs.

She warned that if pharmacists are only reviewing the drug list and are not aware of patients' clinical conditions, it will be impossible to determine any untreated indications or subtherapeutic dosages, saying, "Some of these other issues are large in terms of drug-related problems in an ambulatory setting."

Sixty-five percent of pharmacists are currently in dispensing roles, she said, but developments such as robotics and the expanding role of pharmacy technicians could free up a "whole new workforce of community pharmacists" to work in direct patient care. At the same time, McInnis noted, dispensing fees are decreasing.

The steps to MTM include finding the actual patterns of use, ascertaining where patients are clinically and where they need to be, and then assessing each medication, in that order.

This requires direct interaction with each patient, she pointed out. Whether a physician or a pharmacist interacts with the patient, an individualized care plan must be developed to achieve treatment goals, she said. "Think about clinical goals of therapy first and then think about the medications needed."

The model also ensures that the patient "understands, agrees with, and actively participates in the treatment regimens," she said.

MTM requires follow-up with patients, during which, said McInnis, the practitioner makes sure that changes actually were made. "Just as a physician will require follow-up, the pharmacist has to see the patient again."

The future is now

McInnis cited a trial, published in the Journal of the American Pharmacists Association in 2008, in which Blue Cross/Blue Shield health plan members with hypertension or hyperlipidemia were able to achieve significant clinical improvement and economic outcomes in 2001–2002 with the implementation of MTM. Healthcare Effectiveness Data and Information Set (HEDIS) measures improved in the intervention groups for hypertension (71% vs. 59%) and hyperlipidemia (52% vs. 30%)compared with the control groups.

Total healthcare costs in 186 patients who received MTM from pharmacists were only $8,197 per member per year compared with $11,965 in the control group. She warned, however, that drug costs may actually increase with MTM.

McInnis told pharmacists, "You are the medication experts, and I think you are so desperately needed to get this right ... Really, the future is now."

Asked what it will take for the Centers for Medicare and Medicaid Services to pay pharmacists for this work, McInnis replied, "Pharmacists, as a profession, are going to have to really define what they're doing, what outcomes can be expected, and then, what are the appropriate pay levels for what you're doing. And then, I think, they're going to get the attention of payers and other providers."

To a great extent, she said, physicians will be paid to help patients reach their clinical goals and reduce expenses, such as hospitalizations and ER visits. If pharmacists can help patients reach such goals, she asserted, "there are not many physicians who won't buy into that."

"The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes" is a useful resource guide available on the PCPCC website at http://www.pcpcc.net/files/medmanagement.pdf.

Kathryn Foxhall is a healthcare journalist based in the Washington, D.C. area.