Milbank pharmacy piloting Medicare cost-control program

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Editor’s note: October marks National Pharmacy Month and provides an opportunity to shine the light on innovative practice that increases the involvement of pharmacists with their customers.

BROOKINGS – Medication spending in the United States in 2016 was a staggering $323 billion, tops in the world at $1,100 per capita. Ranking second, third and fourth for per capita spending were Canada ($787), Japan ($783) and Germany ($741), according to Statista, an internet-based statistics company.

In the clamor that has erupted to tame these costs, a culprit seeing few headlines is medication nonadherence, or not taking medications as prescribed. A 2013 study by QuintilesIMS found that nonadherence resulted in more than $200 billion in avoidable health-care costs, which include avoidable hospital admissions, outpatient treatments, emergency room visits and prescriptions.

A review in the Annals of Internal Medicine estimates that a lack of adherence causes nearly 125,000 deaths and 10 percent of hospitalizations. It also said 20 to 30 percent of medication prescriptions are never filled and 50 percent of medications for chronic disease are not taken as prescribed.

“Our country spends billions on medications but very little is spent on how to use them properly,” Jessica Strobl, a South Dakota State University graduate and a pharmacist at Lewis Drug in Milbank, said.

But in January 2017 the Centers for Medicare and Medicaid Services Innovation Center began a five-year test of a model called Enhanced Medication Therapy Management. The aim is to bring down Medicare spending on medications and other health care as well as optimize medication use through improvements in coordination of care.

South Dakota is one of 11 states where this model is being tested and there are still relatively few locations in the state taking full advantage of the program.

The program is “enhanced” because it expands the existing Medication Therapy Management program that allows eligible patients to have a no-cost annual consultation with their community pharmacist.

The existing program is for Medicare patients taking eight-or-more prescription medications with three or more chronic health conditions who spend at least $4,000 per year on medications, according to Alex Middendorf, an assistant professor of pharmacy practice at SDSU.

A proactive approach

Enhanced Medication Therapy Management allows the pharmacist to identify patients who would benefit from additional pharmacist-provided care and work with insurance companies who offer Medicare plans and their partners to be reimbursed for providing these services.

“By spending a little more on how to use medications properly, we can save money in the long run,” said Strobl, a 2004 SDSU alumnus who right after graduation went to work in Milbank at what was then Liebe Drug. “Now the pharmacist can be proactive – identify the patient, go in and initiate the service and document what they did.”

Citing a recent example of pharmacist intervention, Strobl noted a doctor called in a prescription but the pharmacist noticed the patient was allergic to the medication.

“So we called the doctor and they substituted a different medication for the original prescription. We can now go in and document to be paid for the action of helping that patient. I think it’s just a matter of Medicare realizing how much can be saved by having pharmacy at the table with other health-care providers … We can save money on the back end by preventing unnecessary future hospitalizations,” Strobl said.

Getting to know the patient

Manuela “Mary” Martel, a 63-year-old Milbank resident, is another beneficiary of pharmacist-provided care.

Her conditions include diabetes, asthma, arthritis and, until recently, cataracts.

The cataracts made it difficult for her to see her medication directions so she had difficulty taking the medications correctly, including insulin injections. Her primary care physician was not comfortable signing off on her cataract surgery until her diabetes was under better control.

Martel added, “I’m one that don’t like to take medicines at all. I like to know what they are and what they do. If I don’t know what it does, I won’t take it.”

“After visiting with Mary, I contacted her provider and suggested some ways to simplify her medication therapies,” Strobl said. Courtney Feist, the community pharmacy resident at Lewis-Milbank, and Strobl then made Martel some handouts that showed a large picture of her medication and the directions for using them in very large print.

“I hand-delivered the medications to Mary and visited with her in her home to help her come up with a plan for remembering to take her medications and use them correctly.

“I then called Mary frequently to make sure she was using the medications and not having any troubles. She has now been able to have her eye surgery and still continues to be able to take the right medications with her simplified regimen. I still call her frequently to check in on her to be sure she isn’t having any trouble with her medications,” Strobl said.

Martel said, “They were all real helpful to me and they treated me with respect. They took time to listen to me. I understood they would make a diagram and that’s the way I am learning.”

She said she has been a customer of Strobl since moving to Milbank about four years ago and has had a “wonderful” relationship with the staff at Lewis-Milbank.

“I just love them to death … Jessica comes to the phone when I need her for something,” Martel said.

Ready access to pharmacist

The “no appointment necessary” accessibility of community pharmacists to patients makes them unique in health care and is one more reason pharmacists are included in the patient’s health-care team, Middendorf said.

Martel would already be eligible for the traditional Medication Therapy Management program, but Strobl said the pharmacy was able to use the Enhanced Medication Therapy Management program to document and submit claims for some of the extra necessary services provided.

In addition to providing financial incentive for pharmacy involvement, Strobl said Enhanced Medication Therapy Management “can save people money as we are able to optimize their therapy. There may be two drugs that do the same thing or we change a very expensive medication to one with a lesser cost that works just as well.”

She also stressed the value of patient education.

“With the internet, patients don’t know what’s reliable. Patients have been happy to learn how to take their medications properly to get the most benefit out of them. Sometimes people are on a lot of medications and they don’t even know why they’re taking it.

“Another potential advantage is it opens the line of communication between the pharmacy and physician’s office. The physician’s office and the pharmacy may have different information in their files. Something is mistyped or information is not updated electronically. The pharmacy can help the physician’s office get their files updated.

“It gives us more information back-and-forth as we work as a collaborative health-care team,” Strobl said.

Targeting discharged hospital patients

Another part of the Enhanced Medication Therapy Management program is post-hospital discharge medication reconciliation provided by the community pharmacist.  Medication reconciliation involves making sure that any medication changes after the hospitalization are updated in the pharmacy records so the patient continues to receive the right medications, which will help keep them out of the hospital.

“Now, if somebody is discharged from the hospital, we can be proactive. Those visits might take up to an hour. They’re really beneficial for the patient and the pharmacy. When someone is discharged from the hospital, they might get new orders. The consultation improves communication between the hospital, the patient and the pharmacy.

“It’s a proactive approach to knowing what is happening to the patient,” she said.

 A drawback to the spread of the Enhanced Medication Therapy Management program is the time involved. A face-to-face consultation may take up to an hour.

Because Lewis-Milbank is staffed with a community pharmacy resident, a licensed pharmacist continuing their education after receiving their Pharm.D. degree, the pharmacy has more staff flexibility. Also by serving in a small community (Milbank’s population is 3,200), “we know our patients” and they share news about other patients.

“Sometimes a patient will be in visiting and say ‘I went to see so-and-so in the hospital.’ We might not have even known they were in the hospital,” Strobl said.

Upon learning, the pharmacy can schedule a post-hospital discharge medication reconciliation.

Strobl expects that as Enhanced Medication Therapy Management proves to provide long-term cost savings for Medicare, commercial policies will begin covering the services as well. That already is the case in traditional Medication Therapy Management.

“The goal is not to just reduce the drug spend, we’re trying to keep patients healthy and out of the hospital to decrease the medical spend,” Middendorf said.

Photo from SDSU Marketing & Communications