Connecticut MTM pilot wins Pinnacle

Connecticut collaboration received Pinnacle Award for MTM demonstration project

Pinnacle Award recipients Michael P. Starkowski, Margherita R. Giuliano, and Marie Smith are joined by Evelyn Dudley, Connecticut Department of Social Services Pharmacy Manager at APhA headquarters before the awards ceremony.

Imagine a unique collaboration among a payer, university pharmacy faculty researchers, and a state pharmacists association to deliver pharmacist-provided medication therapy management (MTM) in a patient-centered medical home setting. Imagine a network of specially trained pharmacists who work on a contract basis and have those crucial face-to-face conversations with the patient in the primary care physician’s office between physician visits. Now imagine results that include resolving nearly 80% of drug therapy problems and estimated annual savings that are on trend to more than pay for the contracted pharmacist services.

That’s what happened in Connecticut with a demonstration project from July 2009 to May 2010 for which findings were published in the April 2011 Health Affairs. The collaboration among the Connecticut Department of Social Services (DSS), the University of Connecticut (UCONN) School of Pharmacy, and the Connecticut Pharmacists Association (CPA) was recognized with a 2012 Pinnacle Award in the Government Agency–Nonprofit Organization–Association category from the APhA Foundation at a ceremony on June 25. (See sidebar for information on the two other Pinnacle Award winners.)

Crystal eagles were presented to the three coauthors of the Health Affairs article: Marie Smith, PharmD, Henry A. Palmer Endowed Professor in Community Pharmacy Practice and Assistant Dean for Practice and Public Policy Partnerships at the UCONN School of Pharmacy; Margherita R. Giuliano, BSPharm, CAE, CPA Executive Vice President; and Michael P. Starkowski, former DSS Commissioner.

Accepting the award for the group at the elegant evening ceremony at APhA headquarters in Washington, DC, Giuliano said, “Connecticut may be a small state, but we have larger-than-life expectations.” She attributed the collaboration to relationships developed over the years.

Preparation meets opportunity

Planning process: Smith meets with Lisa Bragaw, PharmD, PhamNetEx pharmacist.

DSS, which administers Medicaid and other state and federal health care programs in Connecticut, applied in October 2006 for a Medicaid Transformation Grant under the Deficit Reduction Act. DSS requested $5 million; the state committed $500,000 even though there wasn’t a required match, Starkowski told Pharmacy Today. “We felt that federal officials would view our application in a more positive light if the state was actually putting some skin in the game,” he recalled.

CMS awarded the grant to DSS in February 2007. The total budget for the whole project was $5.5 million. Originally, the project was conceived as a health information exchange that included e-prescribing, pretty new concepts back then, Starkowski said. But as the project participants started moving through the process, DSS realized that they would have money left over.

“So we went back to the federal government,” Starkowski said. “This is not uncommon. And it was well before they asked for any of the money back. We asked for authorization to use the unspent funds for an MTM program.”

The idea for an MTM program grew out of the good relationships that DSS had formed with both the UCONN School of Pharmacy and CPA. At the beginning of Medicare Part D, CPA proposed that a network of pharmacists be paid a stipend to match patients on complex medication regimens with an appropriate plan. DSS expanded that innovative initiative with UCONN; with oversight from the school of pharmacy, third- and fourth-year student pharmacists also were paid a stipend to help patients with less complex regimens. By the time the federal grant opportunity arose, “we had a longstanding relationship, and we kept fostering that relationship,” Starkowski continued.

The state association also had worked with DSS on a preferred drug list, a difficult process to put through with the state legislature that didn’t want a strict formulary. CPA also had met with Starkowski and his staff “to talk about moving much more into a clinical and a management role, a coordination role, than thinking of the pharmacist as you would traditionally think of a pharmacist behind the counter,” he said. “So the MTM concept was in the back of our minds, and it kept coming up to the surface.”

Now that an e-prescribing system and a health information exchange were in the works, moving into an MTM program became much easier, Starkowski explained. The fledgling collaboration put together a demonstration project with a budget of about $780,000, and CMS approved the alternative use of the money. The funding came through DSS to the UCONN School of Pharmacy, which subcontracted to CPA.

Assembling the ingredients


PharmNetEx pharmacists and University of Connecticut pharmacy faculty participate in the demonstration project: Thomas E. Buckley, BSPharm, MPH; Jose Scarpa, BSPharm.

Smith, working with a few faculty members, was a co–principal investigator. Following the MTM core elements model published in March 2008 as a joint initiative of APhA and the National Association of Chain Drug Stores Foundation, the UCONN pharmacy faculty researchers used a standardized four-step approach for pharmacists to implement the MTM services. The four steps were a comprehensive med review; a systematic assessment of potential drug-therapy problems; a personal medication action plan; and documentation and communication of the care plan to all the patients’ health professionals.

“We believe that following that systematic approach, and using the core elements as your guide for that, does help to standardize the way that we work with patients, communicate with other health care professionals, and have more care coordination in a systematic and standardized way,” Smith told Today. “I think that these are things that pharmacists can do.” Some aspects of the model may not be as easy for pharmacists in a community setting to replicate, such as having access to the electronic health record, she said.

Meanwhile, CPA had first established a network of pharmacists when the federal government was implementing Part D, according to Giuliano, the other co–principal investigator. When the Medicaid Transformation Grant came along, CPA formally formed another company in 2008 that houses its network of pharmacists, named PharmNetEx and defined as an independent practice association of credentialed pharmacists who provide medication management and coordination services. They’re selected and contracted solely for their clinical expertise and patient care experiences. They can come from any practice area. “Right now, we do not have any pharmacists that are working full-time for us,” Giuliano told Today. “But the nice thing is this provides a conflict-free environment” because they’re not attached to a practice site.

The nine pharmacists in the existing network who participated in the demonstration project were reimbursed directly as independent contractors, and their network contract fees were $2–$3 per minute on average for medication management services, according to the Health Affairs article. Citing the Lewin Group’s MTM report from 2005, Giuliano explained, “Our philosophy is that the services that we were providing were a medical service and they really should be at the same level that other midlevel practitioners might be reimbursed for their services. So we thought the $2 to $3 range was appropriate.”

Bringing it all back home


University of Connecticut faculty member Devra Dang, PharmD, BCPS, CDE educates patients about their medications and teaches student pharmacists in class.

During an 11-month period, these nine pharmacists provided MTM for 88 Medicaid patients at four federally qualified health centers and one private practice in five different cities spread out across the central and eastern parts of Connecticut. By that time, each primary care site had been using electronic health record systems with e-prescribing capabilities for at least 12 months, according to the Health Affairs article. The practice model was the patient-centered medical home (PCMH) in a primary care setting. Everybody defines the PCMH a little bit differently, Smith said, but “the model of practice that we’re looking for [is] more team-based, collaborative care [that] promotes better care coordination.”

The 88 Medicaid patients received primary care at these sites, had at least one chronic condition, and were taking three or more prescription medications for chronic conditions including pain, lipid disorders, hypertension, asthma, chronic obstructive pulmonary disease, diabetes, and depression, Smith and colleagues wrote. The pharmacists had three sources of medical and medication information for each patient: the electronic health record, pharmacy claims, and face-to-face conversations during pharmacist appointments. The pharmacists met with the Medicaid patients in the offices of their primary care providers between physician visits. The initial pharmacist appointment was 60 to 75 minutes, with five follow-up appointments of 20 to 40 minutes at monthly intervals.

Over the course of the demonstration project, the pharmacists identified 917 drug therapy problems, resolving almost 80% of them after four appointments, according to Smith and colleagues. Their work resulted in estimated annual savings of $1,123 per patient on medication claims and $472 per patient on medical, hospital, and emergency department expenses—approximately 2.5 times the cost of the pharmacists’ contract fees and network administration.

Surveys of the Medicaid patients and prescribers were overwhelmingly positive. A survey of the pharmacists noted that a key to success was meeting face-to-face with patients. “It took a few visits for that relationship to really become solid,” Giuliano told Today. “At the first visit, the patient is on their best behavior and they want to be the perfect patient. They want you to think they’re doing everything right. But by the second or third visit, they feel more comfortable in sharing certain behaviors that they might not have felt comfortable sharing before.” She added, “They started referring to the pharmacist as ‘my pharmacist.’”

Making a stronger case for pharmacist-provided MTM, Smith said, are factors including patients who may have multiple chronic conditions (medical as well as behavioral health conditions), fragmented care with multiple medications from multiple prescribers that sometimes are filled in multiple pharmacies, and a lack of team-based care and care coordination among their health care providers. “Going forward, I think it’s important that we think about who is the best candidate, the best patient, for this type of service,” she added. “These patients were very complex, so that’s got a lot to do with why we saw the results we did. … They tend to be the people we probably need to, in limited resources, work with them first.”

The future

The results of the demonstration project influenced DSS to include pharmacists in a pending CMS Center for Medicare and Medicaid Innovation application related to dual eligibles, Smith said. In the new proposal, pharmacists are included as members of the interdisciplinary health care team; and MTM services are included in an accountable care organization–like health neighborhood delivery model, an innovative care delivery and payment reform model, for a broader population.

“We are going to be very aggressive to make this a sustainable model of care,” Giuliano said. “I think we’ve garnered the credibility that we need, and there’s certainly a good relationship there [with DSS] to help create some policy changes for pharmacists.” Policy changes could include building on the 1997 Connecticut law that recognizes pharmacists as health care providers at the state level. “If we could integrate into some of the state-funded programs,” she added, “we could bill as a provider.”

“I loved the project,” Starkowski said, laughing happily. “I thought it was one of the best initiatives we did at DSS. I was just curious to see how much we could save and how much we could enhance the quality of life for patients. By the end of the project, I was definitely a believer that this is a new direction.”

Two more winners of the Pinnacle Award

The APhA Foundation’s 2012 Pinnacle Awards in three categories were presented at APhA headquarters on June 25. Each year, the Foundation’s Pinnacle Awards program recognizes contributions to health care quality through the medication use process. This year marked the 15th celebration of the awards program, created in 1998. Premier support for the celebration was provided by Merck and support was also provided by an educational donation by Amgen.

The 2012 winner of the Individual Award for Career Achievement is Jeff Jellin, PharmD, President, Therapeutic Research Center (TRC) in Stockton, CA, and editor-in-chief of TRC’s health care and evidence-based newsletters, which are designed to improve the use of medications and drug therapy outcomes. Jellin’s nominator wrote, “Jellin has built a company that is trusted around the world and has significantly influenced the safe and cost-effective use of medicines. ... Under his leadership, TRC has had significant influence on therapeutic decision-making and patient care.”

The 2012 winner of the Group Practice–Health System–Corporation Award is Walgreen Company Immunization Services. Walgreens has more than 26,000 immunization delivery–trained pharmacists who support the company’s all day, every day, every store immunization offering. Suzanne Hansen, BSPharm, Group Vice President of Pharmacy Operations, Walgreens, accepted the award. “We all know the importance of the pharmacist–patient relationship,” Hansen said in her remarks. “Immunizations to date have been the biggest driver of the transformation [of the profession] we’ve seen.”