Medication Management Systems, Inc.

As the Assurance System™ training program director at Medication Management Systems, I have the unique opportunity to follow new practitioners as they develop into extremely capable pharmaceutical care providers.  We’ve seen this not in just one practice setting, but in several –the classroom, clinics, telephonically, even virtually.  As we continue to provide care to more and more patients, it is important to reflect upon what we’ve learned.  We believe reflection is vital for growth and improvement; in fact, we teach all of our new practitioners the importance of reflection in practice.   Over the next few months, I will be reflecting upon some of the lessons we’ve learned along the way:  understanding the rational taxonomy of drug therapy problems, the importance of documentation in practice, the benefits of collaborative practice agreements, and the unique contribution pharmacists provide in patient care.

The first thing that became obvious in practice is that “common things are common,” which I had heard for years from Dr. Bob Cipolle.  When I first heard this phrase, I thought how obvious it seemed.  When I reflected on what it meant, I realized that this could be very helpful as I was learning to practice.  Our practitioners - across the globe, in all different types of service venues - are seeing patients with the same conditions, over and over again.   Diabetes, hypertension, hyperlipidemia, depression, pain; these were consistently the medical conditions (with their accompanying medications) that needed to be managed.  As a result, common drug therapy problems were occurring over and over again.  In fact, over half of our patients’ conditions are represented by the same ten conditions.  This is great news for practitioners learning to practice.  Learn as much as you can about these medications and conditions.  In doing so, you will be prepared to identify, resolve, and prevent the majority of drug therapy problems encountered each day.  Every practitioner will encounter these common situations because, well, they’re common.  So prepare yourself, and you’ll be more confident to manage these conditions as well as having time to learn to manage those conditions which are less common.

The most recent “talk” in health care circles is focused on transitions of care, medication reconciliation programs and the prevention of hospital readmissions through medication remediation.  The medical community is now recognizing the problems associated with medication use.  It is hard to imagine a better atmosphere for medication management services to be out front and pharmacists to be the focus of this discussion.  However, this does not seem to be the case. 

A recent article (1) and editorial (2) in the Journal of the American Medical Association failed to mention pharmacists in their discussion of solutions to the problems quantified in the articles.  According to Bell et.al.(1), patients prescribed medications for chronic diseases were at risk for unintentional discontinuation after hospital admission, and those admitted to the ICU had an even higher risk of medication discontinuation during the hospital stay.  Both the manuscript and the editorial emphasize the threats posed by moving patients across care sites within the health care system.  Medications are a common source of problems in all care settings and the movement of patients between settings puts patients at even greater risk. 

Perhaps it is time to re-think the role of “clinical” pharmacists.  Pharmacists will become an important part of the solution when they assume direct patient care responsibilities within our institutions.  Perhaps it is time to discontinue the clinical services designation and begin to assume direct patient care responsibilities on a day-to-day basis.  If pharmacists were placed on admitting teams and managed like all other patient care providers in institutions, pharmacists would be assigned to a patient and able to do an admission assessment, follow the patient through treatment and assume responsibility for discharge management through the care transition.  This could solve most of the issues being discussed today.  Where are the pharmacists who are best able to address these concerns?  Let’s move into the 21^st century and take responsibility on a patient specific basis and become known as the solution to not only medication adherence and medication reconciliation but medication quality in general. 

References

(1)          Bell CM, Brener, SS, Gunraj N, HuoC, Bierman AS, Scales DC, Bajcar J, Zwarenstein M, Urbach DR.  Association of ICU or Hospital Admission with Unintentional Discontinuation of Medications for              Chronic Diseases.  JAMA.  2011;306(8):840-847.

(2)          Kahn JM, Angus DC.  Going Home on the Right Medications:  Prescription Errors and Transitions of Care.  JAMA. 2011;306(8):878-879.

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Minneapolis, MN, (April 28, 2011) Molina Healthcare is a multi-state managed care organization that arranges for the delivery of healthcare services to persons eligible for Medicaid, Medicare and other government-sponsored programs for low-income families and individuals.  The Company conducts its business primarily through licensed health plans in the states of California, Florida, Michigan, Missouri, New Mexico, Ohio, Texas, Utah and Washington.

Medication Management Systems will work with Molina Healthcare to define quality medication management services for its Part D members.  Qualified pharmacists will provide services to beneficiaries using the Assurance System as the documentation platform.  This electronic therapeutic record allows for effective communication with patients and prescribers and provides Molina with comprehensive reporting as well as efficient and accurate data validation.  Molina Healthcare will benefit from workload efficiencies, service satisfaction and quality outcomes – all the result of a comprehensive, cost-effective medication management system.

Minneapolis, MN. (April 21, 2011) Gateway Health Plan^® is a top-ranked managed care organization that provides service to more than 263,000 members eligible for Medical Assistance.  Established in 1992 as an alternative to Pennsylvania’s Department of Public Welfare’s Medical Assistance Program, Gateway Health Plan operates in select counties throughout Pennsylvania.  Gateway Health Plan Medicare Assured^® HMO SNP, a Special Needs Plan for those eligible for both Medicare and Medical Assistance, is one of the nation’s largest Medicare programs for the dual-eligible population with more than 26,000 members in 27 Pennsylvania counties.  Gateway’s mission is to provide accessible, quality healthcare services to its members.

Now, Gateway Health Plan has chosen Medication Management Systems to support the operations of their Part D Medication Therapy Management program that will meet the needs of their beneficiaries.  MMS’ Assurance System™ will coordinate services that include data integration, patient recruitment, quality service delivery, timely CMS MTMP reporting and accurate data validation – all using the same Assurance System™ platform.  The service will be provided by qualified pharmacists who will work with beneficiaries to achieve maximum benefits for the patient, providers and the plan.  

I read with interest the column by Michael Millenson in Kaiser Health News entitled- “No Outrage, No Story In Dead Patients”. He was referring to the November release of the HHS- Office of the Inspector General report on adverse events in hospitalized Medicare patients with preventable serious adverse events (including death) occurring in up to 60,000 people a month. His surmise was that little has changed since the IOM Institute of Medicine (IOM) Report of 1999 “To Err is Human," so therefore the news related to the current report brought scant media attention. He also talked about the efforts made around hospital infections, health information technology, and a few other quality areas, but how overall little improvement has occurred.  

The main point of his discussion was the lack of outrage by the public (with scant media attention) and some of his “blame” for this “lack of outrage” was leveled at the “lack of an outcry” by patient advocates. But what really hit me was the fact that the report clearly pointed to medication errors as the major preventable cause of these adverse events. So, where is the “outcry” from medicine, nursing, pharmacy, health care administrators about this?  If we really want to prevent errors and improve outcomes, then we have to do something different than we have been doing for the past decade, and yet, we keep asking for the same simple solution of increasing adherence.  

A solution that is repeatedly shown to work is the integration of comprehensive medication management into everyday care of patients both inside and outside of the hospital. This service is known to get the medications right! So what is the hesitation, what is the delay, what is the problem? Why aren’t medication management services being implemented on a broad scale, quickly?   

There is plenty of convincing evidence that this is a better approach. Let me share some of our recent findings from Medication Management Systems. In 2010, a Medicare group (average age 70) of 706 patients received comprehensive medication management reviews by clinical pharmacists. This group of patients had an average of 18 medications and 11 medical conditions. Approximately 28% of these patients were found to have 10 or more drug therapy problems when systematically assessed! As these problems were identified and resolved, we saw significant improvements in cholesterol and blood pressure control (as an example) with an average cost savings/avoidance of over $1750 per participant. Approximately 97% of the savings were related to non-pharmacy costs such as reductions or cost avoidance in hospital, long-term care, and provider visits (~$2.2M total with only ~$43,000 related to drug cost savings- a major goal of MTM in part D). This means patients are healthier, costs are lower, and we have clear evidence that medication errors and adverse events can be prevented! 

These data help support an earlier argument presented in a blog where we spoke about the need to move medication management services and the payment for these services from Part D to Part B in Medicare. The data presented in this blog describe the positive results that occur when more comprehensive services, beyond Part D, are provided. These patients were eligible to receive part D MTM services, but were actually offered comprehensive medication management services as described in the PCPCC Resource document on Integrating Comprehensive Medication Management to Optimize Clinical Outcomes (.pdf).   

If medication management services were moved to Part B, redefined to be more comprehensive in nature, and funded as such, the result would be similar to the ones presented here. We can’t rely on health plans to “go beyond” the still vague definition of MTM requirements for Part D.

The data presented here reflect a service where drug therapy problems for all medications were systematically identified by clinical pharmacists directly with the patients, while focusing on the resolution of these problems to reach clinical goals of therapy, in collaboration with providers. Follow-up visits document the progression toward clinical goals and resolution of the drug therapy problems as patients actively engage in their self-care and are educated on the role of each medication.  

As seen previously in commercial and Medicaid populations, comprehensive medication management services bend the curve in improving quality and reducing cost more than any other single intervention!  So, Mr. Millenson, maybe next time you could write about “Getting the Medications Right Can Save Lives,” although it may not get as much attention as “No Outrage, No Story In Dead Patients”!

Posted by Terry McInnis

After developing pharmaceutical care practice, teaching it and establishing practices to provide the service throughout the past 25 years, I have made a number of observations. Following is this list of items I consider to be “truisms” because of the extensive evidence available to support the observations. I hope the list is helpful as you develop your own practice.

What I have learned about the practice/profession

• There will be only one universal professional patient care practice for pharmacy.
• The closer the pharmacist works to the physician, the more successful the practice.
• The dispensing (technical) functions must be completely separate from the patient care function.
• All practitioners are judged by the number of patients cared for and the clinical outcomes achieved. 
• Patient care is delivered and evaluated only based on practice standards.

What I have learned from patients

• Patients love this practice – they consistently rate the practice favorably, 98% of the time.
• Patients are not the primary cause of non-adherence.
• A majority of non-adherent behavior is valid.
• Patients have to “learn” how to engage in a new practice like pharmaceutical care. 

What I have learned about pharmacists

• Pharmacists must be explicitly taught the practice of pharmaceutical care – complete with the philosophy of practice, the patient care process, and the practice management, it is not intuitive nor do pharmacists “already know it”.
• The “rules” of patient care are written by physicians, they are non-negotiable and pharmacists have to play by them to participate. Pharmacists are not familiar with the “rules” of patient care. 
• The key to training is learning the practice of pharmaceutical care first, therapeutics second.
• Pharmacists cannot become great practitioners alone; collaboration on a continuous basis is mandatory.
• Pharmacists who learn to treat the 10 most common medical conditions are able to care for over 50% of the drug therapy problems seen in patients. 
• Preparing pharmacists is the rate limiting step to pharmaceutical care being practiced on a large scale.
• Pharmacists taught to provide pharmaceutical care don’t go back. 
• Pharmacists do not understand pharmacology enough to manage drug therapy well.
• The busiest practitioners are the best practitioners.

What I have learned from physicians

• Physicians recognize and endorse the comprehensive practice. They want to know who delivers it and how they gain access to the service for their patients.
• Physicians agree with the recommendations made by pharmacists who provide pharmaceutical care 97% of the time.
• What I have learned from payers:
• When pharmacists deliver a service that looks like patient care, sounds like patient care, and actually qualifies as patient care, payers will recognize and pay pharmacists for patient care.
• The pharmacist must add unique value (measurable) to the care of the patient.
• Drug therapy problems are the currency of the future.
• Documentation in practice is the key to almost everything.
• Pharmaceutical care practice saves or avoids 4 to 5 times more than it costs to deliver the service. 

In general, I have observed that the practice of pharmaceutical care will survive; however, the profession of pharmacy may not since dispensing as a professional function has been lost.

The Department of Health and Human Services, Centers for Medicare & Medicaid Services recently issued for comment the Standardized Format for the Comprehensive Medication Review Action Plan and Summary. 

These format requirements will have a significant impact on those providing medication management services. It is worth the time to look at the proposed requirements and to review our comments below which reflect how the staff at Medication Management Systems responded to the requirements. We hope they are instructive. If you have comments for us, please contact us at www.medsmanagement.com.  

Comments on the Proposed Required Formats follow:

1. We understand that CMS is obligated to develop a standardized format for the comprehensive medication review action plan and summary. However, we strongly disagree with the premise that standardizing the format rather than the content of communications would result in the achievement of the desired goals of the Medicare Part D MTMP. 
2. Our experience and expertise leads us to suggest that CMS create a descriptive standard that specifies the content that is required and not adopt a prescriptive format. There are many pragmatic, economic and professional practice reasons for this suggestion.
3. Our comments are based on the assumption that there are two major goals for pursuing a standardized communication approach:
   • to improve the quality and consistency of the MTMP service, and
   • to hold MTM practitioners and plan sponsors accountable for the quality of service delivered. 

The general comments below reflect our perspective on the best way to achieve each goal.  MMS hopes the following comments are both constructive and informative in your efforts to produce the best Medication Therapy Management Programs.

General Comments:

1. To improve the quality and consistency of the MTMP service delivered
   • The most direct way to improve the quality and consistency of a health care service is through standards of practice, not through required documentation and communication formats. Standards of practice for medication therapy management services have been developed and should be the basis for a standardized approach to the service. These standards have been published, are based on professional practice, and qualify as true standards of care. Fostering adherence to standards of practice is the only way that we know to improve a service to beneficiaries.
   • Medication therapy management is a patient care service that requires a professional philosophy of practice, a prescribed beneficiary care process, a sophisticated body of knowledge and an effective practice management system. It is not a list of activities that can be effectively executed and dictated by those who have not provided patient care. Therefore, one prescribed format cannot sufficiently serve the beneficiary, the provider, the health care system, or CMS sufficiently. 
2. To hold practitioners and program sponsorts accountable for the quality of service delivered

• We believe that standardization of the content, not the format, of the Medication Action Plan and Patient Medication List would result in greater accountability for the level of service delivered by the MTMP. A prescribed format for the delivery of information subsequent to a beneficiary’s comprehensive medication review, on the other hand, would not meet the need for beneficiary-centered communication nor would it enforce a consistent level of service to be delivered to all beneficiaries. 
• Communication must occur between MTMP and beneficiary, as well as between the MTMP and the beneficiary’s other health care providers. Both the information communicated and the manner in which the information is communicated is different for each of these. It is not clear that this point is acknowledged and it is certainly not dealt with in the proposed standard formats. 

We are suggesting several specific considerations for the Beneficiary Cover Letter, Medication Action Plan, and Personal Medication List based on the above goals. 

Beneficiary Cover Letter

1. The purpose of the beneficiary cover letter is to introduce a summary of what occurred during the comprehensive medication review.  It should explain how the MTM practitioner will work to address the beneficiary’s needs and how the beneficiary can contact the MTMP with further questions or concerns. 
2. The recommended required content should be:
   • a statement of the purpose of the letter and a short, general description of the MTMP
   • a description of the specific service provided and a date of the service
   • a description of the materials contained in the letter (the Medication Action Plan and Personal Medication List)
   • practitioner contact information for the beneficiary should questions arise

Medication Action Plan

1. The need for a separate Medication Action Plan and Personal Medication List is not clear to us. Our experience is that the two documents can easily and effectively be combined. 
2. The proposed Medication Action Plan formatting implies that the impetus for the resolutions of all medication related problems is with the beneficiary. It is important to note that the beneficiary is part of the care team, but not solely responsible for resolving medication related problems. Finally, a format that will facilitate communication with other members of the beneficiaries care team is essential for the success of the MTMP. 
3. We would also discourage CMS from the use of the word “concern” in the medication action plan. This can have negative connotations and many of the medication related problems identified in a medication review are not beneficiary concerns, but rather therapeutic issues.
4. The terms ‘action steps’ and ‘result’ do not have a consistent meaning in this context.
5. Our recommendations for the required content are:
   • a short description of the purpose of the medication action plan
   • a description of the action items that resulted from the medication review process
   • a clear description of the goals for each of the action items and the beneficiary’s responsibilities in the action plan
   • a clear description of the practitioner’s responsibilities in the action plan

Personal Medication List

1. The most appropriate manner with which to communicate with a beneficiary is best determined by the beneficiary and the MTM practitioner.  Whether it is a bulleted medication list, table of medications, medication diary, or other known format is best decided in practice, not by a government agency removed from knowledge of the beneficiary’s needs.  For example, a beneficiary may have limited reading proficiency and require an image based medication list.  Or the beneficiary’s caregiver may need help organizing the beneficiary’s medication box and would benefit from a medication administration diary. 
2. Chronic medications do not have a stop date and in many cases beneficiaries do not know the specific start date of the medication.  The purpose of providing the start date and stop date for ALL medications is also unclear.   
3. Goals of therapy are established by doctors, nurses, and pharmacists for the medical indication.  The medications used to manage these conditions are simply the tools to help achieve these goals.  To list goals of therapy with each medication would result in having the same goals listed across multiple medications, has the potential to confuse beneficiaries, and would conflict with the standards of practice that exist in medicine and nursing.  Additionally, this would result in an extraordinary number of pages of the PML, provided the large number of medications taken by this population, and this would decrease its utility as a document that a beneficiary could keep with them at all times. 
4. Our  recommendations for required content include:
   • a medication list organized based on the indication/medical condition for the medications (e.g. all medications for hypertension should be grouped together)
   • the name, as known by the beneficiary, of the medication, directions as the beneficiary reports taking the medication, and prescriber and prescriber’s contact information if known 
   • images and additional medication information as appropriate for the beneficiary
   • date of preparation
   • MTMP contact information

Implementation Time and Cost Estimates

1. In reviewing the current proposed standardization format, MMS estimates that the cost to plan sponsors of meeting these standards would be approximately $2-3 per MTM eligible beneficiary.
   These costs include:
   • system and program changes
   • report printing and mailing
   • more reporting time
   • Increased time to complete patient encounters

We are referring CMS to two references on MTMP standards. First, the documentation requirements generated for the medication therapy management service recognized and reimbursed by the Minnesota Medicaid Medication Therapy Management Care Program. These standards have been used since 2006 and can provide guidance for content requirements for documentation and communication. These requirements are; based on a professional practice, evidence based, comprehensive, and have been shown to result in positive clinical and economic outcomes in MTMPs. MMS encourages CMS to not establish yet a new set of requirements which will only work to confuse health care providers and beneficiaries. 

Second, we are suggesting reviewing the textbook, Pharmaceutical Care: The Clinician’s Guide (Cipolle, Strand, Morley, 2004, McGraw Hill) which describes all the components and vocabulary of medication therapy management services. Rather than using CMS resources in establishing a common format, CMS may be better served by focusing on establishing explicit MTMP practice standards. Doing so would result in the consistent delivery of the same service across differing Medicare Part D program which, in turn, would result in consistent clinical and economic impact of the MTMP.

Making medication therapy management services a part of the Medicare Part D benefit seemed like a logical thing to do at the time. Obviously, Part D provides for drug coverage for Medicare recipients and since this service is related to drug therapy, it should be there. This was certainly a logical first step, but I would suggest that it is time to make coverage changes to this important benefit.  

CMS–the Center for Medicare and Medicaid Services, of the federal government–decided that PDPs (Prescription Drug Plans) and MA-PDs (Medicare Advantage–Prescription Drug) would be responsible, and therefore cover the costs for the delivery of the service. Without passing judgment on the ability of these organizations to deliver a patient specific service, the decision by CMS precluding  individual practitioners from being paid for delivering the service (except in a couple of plan specific instances). This is now becoming a rate limiting step to expanding the reach and benefit of comprehensive medication management services. Therefore, it is time to move coverage and payment of medication management services from Part D of Medicare to Part B, the ambulatory medical service side of Medicare.  

There are several reasons why this is becoming a necessary step. First, when comprehensive medication management services are provided, the payer benefits accrue to the medical cost side of the equation and not the drug-spend side. In fact, there is overwhelming evidence that while medication management services result in more appropriate, more effective and safer drug therapy, it also results in more dollars being spent on drug products. This results in a direct conflict for the provision of the service by the PDP, as they incur all the costs of the program and the drug spend and realize none of the benefit. This structure has created a negative incentive, the less patient engagement they have, the better the return to their bottom line. So, if the benefits are realized on the medical side, service delivery and service reimbursement should also occur on the medical side. 

Another reason to move the service is that all other patient care services are delivered and reimbursed from Part A or Part B of Medicare. It is time for medication management services to become a legitimate service in the medical care of patients. It is also important that pharmacists become recognized as patient care practitioners with their own provider numbers so that this service can lead to financially viable practices and medication management services can be delivered to all patients in need of the services. 

There is no doubt that this change will involve engagement with the political process. This may be a long, slow process, but now is the perfect time to get this process moving. The status quo is simply no longer an acceptable option.   

This change will require all providers to step up, take some risk and to come prepared with tools and resources, like patient care standards, documentation systems, and billing methods all of which are necessary to succeed.

PRESS RELEASE—Medication Management Systems, Inc. (MMS), a leader in medication therapy management (MTM), today announced a new partnership that makes available, for the first time, an integrated software documentation solution to more effectively manage drug therapies and positively impact the quality of life of millions of seniors in the community and long-term care.

The American Society of Consultant Pharmacists (ASCP) Foundation has selected MMS to create a business collaboration that brings together two state-of-the-art software systems:

• The Assurance System™ from MMS provides electronic clinical decision support tools, including up-to-date best practices guides in medication use, robust data analysis and reporting, a therapeutic medication record for each patient, and claims submissions.
• The ASCP Foundation’s Monitor-Rx™ identifies medications that may cause or contribute to common geriatric problems and provides medication-monitoring recommendations to assess and preemptively address potential medication-related problems.

Now a single, fully integrated system, Assurance System Plus Monitor-Rx™ provides pharmacists with the only comprehensive pharmacy practice management system for senior care and consultant pharmacy practice, combining a set of tools to identify potential medication-related problems, track patient encounters and outcomes, maintain compliance with current regulatory requirements, substantiate and manage claims for payment for pharmacist services, and allow for outcome and economic analysis. 

“Assurance System Plus Monitor-Rx™ offers an affordable, hosted software and data management solution that consultant and senior care pharmacists can use to expand the broad range of services they already provide to our most vulnerable citizens,” said Nathan Schultz, Pharm.D., President and COO of MMS. “In addition, this new  clinical practice management tool will enable pharmacists to deliver the quality medication management services that our elderly patients need while also providing the documentation necessary to support both provider communication and  financial reimbursement.” 

Monitor-Rx is a unique clinical tool developed specifically for geriatric patients that fosters patient-centered medication therapy management by correlating medication effects with a patient’s physical, functional and cognitive status. “By identifying and avoiding preventable adverse medication effects that contribute to excess disability,” explained Lisa Gables, Executive Director of the ASCP Foundation, “pharmacists can help their patients live independently and avoid hospitalization and nursing home placement. That is why we are so pleased that ASCP’s 7,000+ practitioner and student members will now have access to this powerful new integrated system, Assurance Plus Monitor-Rx™.” 

About Assurance Plus Monitor-Rx™
Assurance Plus Monitor-Rx™ provides 24/7 access and easy-to-use web-based functionality for senior care pharmacists in any practice site. Features that support nursing facility-specific medication regimen review, regulatory requirements and reporting have been incorporated into Assurance Plus Monitor Rx™; senior care pharmacy practice tools are being developed by the ASCP Foundation.

About Medication Management Systems, Inc. (MMS)
A leader in designing, delivering and implementing successful, standards-driven medication therapy management (MTM) programs, MMS employs a proven patient-centered pharmaceutical care approach supported by the Assurance System™ to improve medication efficacy, safety, and adherence for patients with complex drug therapies.  

About American Society of Consultant Pharmacists (ASCP) Foundation
The ASCP Foundation–the research and education affiliate of the American Society of Consultant Pharmacists–has a history of leadership, innovation, and expertise in medicines and aging and a proven track record of developing practical interventions for improving medication use in the senior population. ASCP is the international professional association that provides leadership, education, advocacy and resources to advance the practice of senior care pharmacy. ASCP’s members manage and optimize drug therapy and improve the quality of life of older adults and other individuals residing in a variety of environments, including nursing facilities, subacute care and assisted living facilities, psychiatric hospitals, hospice programs, and home and community-based care. 

About Monitor-Rx
Monitor-Rx is a joint venture of the ASCP Foundation and The Interactive Aging Network. These two non-profit organizations have partnered to fulfill a social mission, earn income to support research in appropriate, effective and safe medication use in older persons and to implement innovative technology to address the growing “age wave.”

Media Contacts:
Tom Albers, R.Ph., MMS: 952-746-8185; talbers1@medsmanagement.com
Lisa Gables, ASCP Foundation: 703-739-1316, ext. 107; lgables@ascp.com