Medication Therapy Management as a tool for reduced cost of care and fewer readmissions

A colleague asked me if I had any information on the use of Medication Therapy Management (MTM) as a way to reduce healthcare cost and prevent, or decrease, readmissions.

I’m kind of a digital packrat and I knew that I had some stuff sitting in Evernote, so I spent the better part of a day rummaging through the information I had. The deeper I dug the more I realized that MTM is a no-brainer. There’s enough information out there to convince even the staunchest opposition.

Some thoughts I had as I read through my Evernote notes:

1. I find it interesting that we’ve coined the phrase Medication Therapy Management (MTM) for something that pharmacists have been doing for decades. I remember interning for a community pharmacy back in the late 90’s. Speaking to the patient about their medication, adherence, compliance, adverse effects, etc was simply part of the job. Have we forgotten about that?
2. MTM comes in many forms. Positive intervention can be achieved over the phone, via Telepharmacy, face-to-face with a pharmacist or technician, and so on. It is not a one size fits all approach.
3. Even the simplest interaction between provider and patient can create a positive impact.
4. MTM should start when a patient is admitted for any condition, continue throughout their hospital stay, and follow the patient out the door to their homes. In other words it should be continuous.
5. Not everyone will need pharmacist intervention once they leave the hospital. Healthcare systems should first target patients with chronic conditions, problems with cognition, poor history of compliance, or a heavy medication burdens. Like everything else in the world around us, some people will do better with more help while others will prefer less.
6. mHealth and sensors should be part of MTM. Continuous glucose monitoring, heart monitors, blood pressure sensors, smart bottles, devices to monitor and record inhaler use – classic area for pharmacist intervention, wireless digital scales for weight – think heart failure, and so on . This information should be fed directly into the patients MTM record for review by the pharmacist, physician and nurse.

Below is a summary of the MTM information I sent my colleague.

Avoidable Readmissions

Medication misadventures have been shown to play a significant role in readmissions. Issues include unfilled prescriptions, poor patient knowledge, lack of medication reconciliation, and adverse events.

Evidence shows that pharmacy can play a key role in helping to reduce readmissions in specific ways:

Reconciling medications.

Before discharge, a pharmacist verifies a patient’s medication history, clarifies that prescribed medications and doses are appropriate, and reconciles discrepancies. Medication reconciliation can prevent up to 70% of potential errors and 15% of adverse drug events.

A Health Research and Education Trust presentation showed that poor patient knowledge and nondisclosure of current drug therapy, and/or inadequate medication reconciliation, can yield drug therapy duplication or interaction [1]

Ensuring that prescriptions are filled

Study of over 75,000 insured patients found that 30% failed to fill a new prescription, and new prescriptions for chronic conditions such as high blood pressure, diabetes, and high cholesterol were not filled 20%-22% of the time [2]

It is estimated that nearly a third of patients fail to fill first-time prescriptions [3]

Discharged patients often fail to get necessary post-discharge prescriptions filled. One reason for this is that important information about a patient’s post-discharge plans and medications is often not accurately entered by physicians and other clinicians into a patient’s discharge reports and is not clearly communicated to patients [4]

According to a study by Osterberg and Blaschke published in the NEJM, the aggregate cost of hospital admissions related to poor medication adherence has been estimated at roughly $100 billion per year [5]

Educating patients about their drugs. Having a pharmacists spend time with patients before discharge, at which point they provide education to patients about their medications, use, potential side effects, and so on, i.e. perform MTM.

3.8 billion prescriptions written for every year [6], but over 50% taken incorrectly or not at all [5]

75% of 1000 surveyed patients admitted to not always taking their medications correctly [7]

A Dartmouth Atlas publication stated that “patients may be confused about what medicines they take and when they should take then, and they may not take the right medication at the right time”. [4]

Too little information is offered to patients. Average time a physician spends discussing all aspects of a newly prescribed medication is approximately 49 seconds. [8] Surveys show that no medication instructions are given by physicians in 19%-39% of prescriptions; in observational studies, 17%-25% of prescriptions are not accompanied by instructions from the doctor.[9] For a new prescription, doctors discuss dosing directions in fewer than 60% of cases, and they review potential adverse events — a major reason why patients quit taking their drugs — only 33% of the time.[9]

Following up post discharge. Pharmacists may perform phone-based follow-up to ensure medication compliance and reduce adverse events. Targeting high-risk patients, Massachusetts General Hospital found medication-related problems in more than 50% of the calls completed by the pharmacy. The post discharge intervention helped decrease readmission rates by 50% among this population.

Poor compliance accounts for 33%-69% of drug-related adverse events that result in hospital admissions [5]

Poor compliance with medication regimens is associated with up to 40% of nursing home admissions [10]

Compared with patients who follow instructions, patients who don’t take their medications as intended have a risk for hospitalization, re-hospitalization, and premature death that is 5.4 times higher if they have hypertension, 2.8 times higher if they have dyslipidemia, and 1.5 times higher if they have heart disease [11]

Adverse events

19% of Medicare discharges are followed by an adverse event within 30 days; 2/3 of these are drug events, which are often preventable [1]

One-third of adverse drug events resulting in a hospital admission were related to non-adherence [12]

—————————————————–

Reducing Readmissions: Case Studies

RARE (Reducing Avoidable Readmissions Effectively).

82 hospitals and 6 health systems in Minnesota set goals to reduce 30-day readmissions, improve Hospital Consumer Assessment of Healthcare Providers and Systems scores, and decrease health care costs. Pharmacists use the teach-back method to engage patients prior to discharge regarding their medications, conduct medication reconciliation at transitions of care, and schedule follow-up appointments. Since 2011, 3603 readmissions have been prevented.

Novant Health (North Carolina).

A pharmacist-led team at Novant Health uses pharmacists to provide post discharge medication follow-up. Through this program, 30-day readmissions for adverse drug events were decreased by 1.4% and overall readmissions by 6.1%.

Hennepin County Medical Center (Minnesota).

During a pilot program started in 2010, discharged patients who had received high levels of inpatient service were identified. Within 3 to 5 days post discharge, they were engaged in MTM visits. The pilot program reduced admissions by 42%, emergency department visits by 37%, and the cost of care by approximately $2500 per member per year.

J Am Pharm Assoc (2003)

A study published in the January/February 2013 Journal of the American Pharmacists Association assessed the impact of clinical pharmacist medication therapy assessment and reconciliation for patients post discharge in terms of hospital readmission rates, financial savings, and medication discrepancies. The investigators reported that patients who received medication therapy assessment and reconciliation had decreased readmission rates at 7, 14, and 30 days postdischarge. Financial savings for Group Health per 100 patients who received medication reconciliation were an estimated $35,000, translating to more than $1,500,000 in savings annually. [13]

REACH (Reconciliation, Education, Access, Counseling, Healthy Patient at Home)

Launched in the fall of 2010 through a grant from the Albert Einstein Society, Einstein’s internal foundation, Medication REACH targeted patients at high risk for readmission to the hospital – those with congestive heart failure, heart attack or hypertension. The efforts resulted in more than a 42 percent reduction in 30-day inpatient readmission rate for the patients who received the Medication REACH intervention compared to the control group.

Purdue University

Study of 895 participants Medicare patients, 232 (26%) considered high risk (risk level 1) for readmission. MTM showed reduced hospital readmissions by 86% for the risk level 1 patients. Based on CMS estimates that readmission costs average between $10,000 – $13,000 per Medicare patient, the 26% of Medicare patients that receive MTM experience an 86% reduction in hospital readmissions, equating to a net savings of $2.7 billion annually for Medicare.

P T. Feb 2011; 36(2): 63.

Brian A. Gallagher, RPh, JD, Senior Vice President of Government Affairs for the American Pharmacists Association (APhA), says that MTM programs that are part of The Asheville Project and Diabetes Ten City Challenge have demonstrated the potential to save $1,079 per patient ($23 billion per year) for diabetes alone. The Asheville Project showed that MTM interventions, if applied nationwide to the appropriate management of cardiovascular disease, could save $5 billion per year, whereas MTM services could save $1.6 billion for patients with asthma.

Circulation: Heart Failure

In the American Heart Association journal, researchers describe a collaborative model between pharmacists and physicians for ensuring heart failure patients take their medicines properly. The rate of hospitalization was cut by 45 percent in the first year of being part of a collaborative medicines review service.

Researchers followed 273 heart failure patients over age 65 who underwent collaborative medicine review and compared them to 5,444 controls who didn’t have their medicines reviewed. After adjusting for a range of possible confounders, the researchers found that only 5.5 percent of the patients in the collaborative review group were hospitalized within a year, compared to 12 percent of the control group. The collaborative review group recieved in-home MTM from a pharmacist.[15]

 

References

1. Reducing Avoidable Hospital Readmissions.” Health Research and Educational Trust presentation at the June 4, 2010 Florida Hospital Association Meeting; presentation posted on AHRQ website at http://www.ahrq.gov/professionals/systems/hospital/red/readmissions/readslide1.html
2. Fischer MA, Stedman MR, Lii J, et al. Primary medication non-adherence: analysis of 195,930 electronic prescriptions. J Gen Intern Med. 2010;25:284-290. Abstract
3. Tamblyn, Robyn, Tewodros Eguale, Allen Huang, Nancy Winslade, and Pamela Doran. “The Incidence and Determinants of Primary Nonadherence With Prescribed Medication in Primary Care.” Annals of Internal Medicine 160.7 (2014): 441.
4. “Medicare Hospital Readmissions: Issues, Policy Options and PPACA.” Congressional Research Service Report for Congress. September 21, 2010. http://assets.opencrs.com/rpts/R40972_20100921.pdf
5. Osterberg L, Blaschke T. “Adherence to Medication.” New England Journal of Medicine 353.5 (2005): 487-97.
6. Cutler DM, Everett W. Thinking outside the pillbox – medication adherence as a priority for health care reform. N Engl J Med. 2010,362:1553-1555.
7. Enhancing prescription medication adherence: a national action plan. National Council on Patient Information and Education. August 2007.http://www.talkaboutrx.org/documents/enhancing%5Fprescription%5Fmedicine%5Fadherence.pdf Accessed June 17, 2014.
8. Tarn DM, Paterniti DA, Kravitz RL, et al. How much time does it take to prescribe a new medication. Patient Educ Couns. 2008;72:311-319. Abstract
9. Tarn DM,. Heritage J, Paterniti DA, et al. Physician communication when prescribing new medications. Arch Intern Med. 2006;25:1855-1862.
10. Pan F, Chernew M, Fendrick AM. Impact of fixed-dose combination drugs on adherence to prescription medications. J Gen Intern Med. 2008;25:611-614.
11. Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2012;23:1296-1310.
12. McDonnell PJ, Jacobs MR. Hospital admissions resulting from preventable adverse drug reactions. Ann Pharmacother. 2002 Sep;36(9):1331-6. PubMed PMID: 12196047
13. Kilcup M, Schultz D, Carlson J, Wilson B. “Postdischarge Pharmacist Medication Reconciliation: Impact on Readmission Rates and Financial Savings.” Journal of the American Pharmacists Association 53.1 (2013): 78.
14. Barlas S. “Pharmacists want to become part of accountable care groups: medicare to define which professionals can join in 2012. P T. 2011; 36(2):63
15. American Heart Association. (2009, August 19). Doctor-pharmacist Partnership Reduces Hospitalization For Heart Failure. ScienceDaily. Retrieved June 17, 2014 from www.sciencedaily.com/releases/2009/08/090818182006.htm