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White paper demonstrates the value of Comprehensive Medication Management
Interview with Marilyn Stebbins, PharmD
By Andrew Schwartz / Mon Jul 11, 2016
A growing body of evidence is showing that comprehensive medication management (CMM) can be an important component in reaching the so-called triple aim of health care reform:
- Improving the experience of care
- Improving the health of populations
- Reducing per capita costs
In December 2015, the California Department of Public Health (CDPH) issued a white paper that examined six CMM pilot programs in southern California and found each showed improvements in clinical, fiscal, and quality measures. Co-authored by physicians and pharmacists, and bearing a stamp of approval from the CDPH, the paper’s publication represents a significant step forward for CMM’s growth and acceptance both in California and nationwide.
What is CMM?
Titled Comprehensive Medication Management Programs: Description, Impacts and Status in Southern California, 2015, the white paper notes that CMM was first defined in 2010 by the Patient-Centered Primary Care Collaborative as a practice intended for high-risk, chronically ill patients in which pharmacists assess each patient’s medications (whether they are prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) to determine that each medication is:
- Appropriate for the patient
- Effective for the medical condition
- Safe, given the comorbidities [concurrent medical conditions] and other medications being taken
- Able to be taken by the patient as intended
These assessments are part of an individualized care plan that includes appropriate follow-up to determine actual patient outcomes. The paper adds that CMM’s “whole patient” focus is different from other medication therapy management (MTM) services such as managing medications for a particular disease state or drug-only interventions.
“CMM is always a collaboration among physician, pharmacist, and patient; the pharmacist is never acting alone.” — Marilyn Stebbins, PharmD
To better understand CMM, its path to widespread implementation, and its implications for patient care, we spoke with one of the paper’s authors, UCSF School of Pharmacy faculty member Marilyn Stebbins, PharmD. She is Vice Chair of Clinical Innovation in the School’s Department of Clinical Pharmacy.
Terms in this article marked with an asterisk (*) are defined here.
Accountable Care Organization (ACO): where groups of doctors, hospitals, and other health care providers come together to provide coordinated care to patients
Affordable Care Act: health insurance reform legislation (also known as Obamacare) that provides a mandate for and access to health care coverage
Capitated model: a set payment to a physician or medical group for each enrolled person assigned to them, per period of time
Patient-centered medical home: where a primary care physician coordinates treatment to ensure patients receive the necessary care when and where they need it
PRICE Clinic (Pharmacist Review to Increase Cost Effectiveness): A collaborative, pharmacist-directed model designed to help low-income elderly patients afford and have access to clinically appropriate and cost-effective drug regimens
Q & A with Marilyn Stebbins, PharmD
Why is CMM important in the context of the changes occurring in health care, such as patient-centered medical homes* and accountable care organizations*?
We’re now in the midst of a perfect storm: a primary care clinician shortage; insurance reform [the Affordable Care Act*], where we have a new population that is eligible for and has access to health care; and baby boomers hitting Medicare age, which means more chronic disease and more medications. All of this raises the question: How do we care for all these people in the most economic, efficient, and value-based manner?
Things like patient-centered medical homes and accountable care organizations (ACOs) are an attempt to answer that question. The idea is to create groups of providers with everyone working at the top of their license [practicing to the full extent of their education and training, instead of spending time doing something that could be effectively done by someone else], so we can see more patients and provide them with the most appropriate care at the most appropriate time. This is where CMM fits.
What does CMM look like in the real world?
Well, first, because pharmacists may be adding, subtracting, or titrating medications, CMM is always a collaboration among physician, pharmacist, and patient; the pharmacist is never acting alone. CMM requires a collaborative practice agreement that spells out roles and responsibilities. Some of those agreements are quite narrow and some are much broader, depending on both state regulations and the preference of the provider groups.
Let me give you one example. A physician in a primary care practice might have a lot of patients with complex chronic conditions like diabetes and hypertension, which are very medication-intensive and which often overlap. As part of a collaborative agreement between a pharmacy and a medical practice, the physician diagnoses, sets the goals of care with the patients, and gets them on a medication regimen before handing them off to a pharmacist. In turn, the pharmacist manages patients’ medications across all their disease states—and with an understanding of the patients’ individual biology and social circumstances—while keeping all other providers up-to-date on both physical and medication changes. This frees primary care providers to focus on the things that they are uniquely qualified to do, such as diagnosis and the creation of appropriate treatment plans. The ultimate outcome is a value-based proposition: better care at a lower cost.
Is that how CMM worked when you practiced it for 15 years in the PRICE Clinic* in Sacramento, California? [Pharmacist Review to Increase Cost Effectiveness]
Well, it can look very different from setting to setting. In my own practice, the trigger used to refer patients to PRICE was when patients who were not adhering to their regimens would admit that they were struggling to afford the medications. Because, generally, physicians don’t know the prices for certain drugs or what drugs are covered in what formulary [and pharmacists usually do]. The physician would send patients to us, explaining that the pharmacist would help the patient find ways to access more affordable treatment.
It was an effective hook because patients care about costs, but they also don't usually understand the pharmacists’ role and training. So there has to be this warm handoff from physician to pharmacist, with the physician making sure patients understand that we’re working as a team and that the pharmacist has the physician’s trust. Once patients came to the pharmacist, medications were addressed holistically. Our job was to figure out everything from whether they were eligible for a copay assistance program to whether their medications needed to be adjusted to optimize their clinical effect. And that included all of their medications—not just the medications that were unaffordable.
The case studies in your white paper demonstrated that CMM had quality and cost benefits. What more do you need to do to see more widespread implementation?
One key is proving value: proving that we can reduce overall cost, improve efficiency, and achieve quality outcomes compared to usual care. Of course, proving causality—that it’s the CMM that achieved those results—that’s the never-ending question. But it is incumbent on us to develop models that show value—not just cost reductions, but also better clinical outcomes like blood pressure control, better blood sugar control for diabetics, and so on—and look to replicate and disseminate these results.
That’s why we’re waiting for Steve Chen’s papers to be published. [Steven Chen, PharmD, a white paper co-author, is chair of the Department of Clinical Pharmacy at USC School of Pharmacy and is co-leading a study for the Center for Medicare and Medicaid Innovation, designed to prove the value of CMM.] He is the guru on this and is getting ready to publish data on how a triad team of pharmacist, pharmacy resident, and pharmacy technician can create more value by using the most appropriately trained team member to perform patient care and follow up. Because his is a large, well-designed study and, until now, there have been few CMM studies in the peer-reviewed literature, this publication will be extremely important.
“… We believe a pharmacist doing CMM can make a physician more efficient.”
The other important component is getting buy-in from physicians—and that will not happen if this is only the work of pharmacists. Our white paper was a close collaboration between pharmacists and physicians, led by a physician, Jessica Núñez de Ybarra, from the California Department of Public Health and supported by physician Terry McInnis, one of the early pioneers in the development of CMM.
As physicians understand that CMM is true team-based care that will enable them to be more cost-effective while providing better quality care for their patients, I think they will come on board. Even in today’s perverse payment world, we believe a pharmacist doing CMM can make a physician more efficient. [Currently, clinicians typically receive a “fee-for-service,” rather than for efficiently delivering care that improves patient outcomes, which is called “value-based payment.”]
Are there other challenges to more widespread implementation?
The white paper mentioned getting the proper reimbursement mechanisms in place, improving electronic health information exchange, and raising awareness among patients and providers. On the last, establishing the necessary collaborative practice agreements with physician groups is 1,000 percent about relationships and trust. If physicians don't trust you with their patients, they won't collaborate.
“The climate in health care is definitely changing for the better, toward collaboration…. Primary care physicians are open to ways to improve their patients’ medication management.”
I learned this when I moved from practicing within the VA, where I was an equal team member with my own patient panels, to a private physician group, where physicians were not as familiar with the role of the pharmacist in medication management. I spent two years building relationships and, ultimately, the same physicians who initially thought I had five heads were referring their patients to my PRICE Clinic and asking for medication consults in the hallways.
The climate in health care is definitely changing for the better, toward collaboration in order to provide improved patient-centered care. Primary care physicians are open to ways to improve their patients’ medication management. Keeping everyone on the team informed when collaborations occur—including patients, physicians, and pharmacists—is the key. Adding pharmacists to the team as medication managers enables physicians to practice at the top of their license, lets them see more of the patients that need to be seen in our expanding health care system, and provides a financial win–win if the value proposition is met.
Have you been able to show that CMM is, indeed, a financial win-win?
This white paper didn't address payment models. That would be its own paper, and we were focused on first describing comprehensive medication management and showing its effect on efficiency, overall costs, and quality outcomes. If and when we truly get to value-based payments, I think the payment piece will be easier to look at. But there needs to be a transitional phase where pharmacy is engaged as part of this continuum of care, so physicians and patients can begin to understand why CMM can be so valuable.
Are there California examples of CMM happening outside of the Southern California pilots in your white paper? For example, will CMM be part of the UCSF Accountable Care Organizations?
CMM by pharmacists has occurred in the VA for years, as well as in many Kaiser pharmacy practices. In these systems the payment model is a capitated model* and billing is not an issue. Our colleagues at UC Davis have pharmacist-provided CMM and the billing is very complex and depends largely on the type of encounter and the type of clinic. Getting paid for services remains a challenge.
The California Pharmacists Association has sponsored a bill that’s been introduced in the California legislature—AB 2084—that would provide CMM as a covered benefit under Medi-Cal and that would really give it a boost. [The bill did not make it out of committee during this spring’s legislative session.]
And, yes, we are getting ready to bring more pharmacists into the primary care arena to do CMM here at UCSF Medical Center. We are hiring a pharmacist for one of our ACOs focused on a population of high-risk patients.
And we have an absolute commitment to studying this. If we don't study it, publish it, and get it out there, we've failed. It needs to be in the medical literature and we're committed to making that happen.
Are pharmacists emerging from school prepared to play this role? And how would wider implementation of CMM change the practice of pharmacy in California?
The answer to the first is a resounding “yes” here at UCSF. Pharmacy schools understand that health care is evolving and pharmacy education must evolve as well. As an example, when hospital systems assumed responsibility for what happened after patients left the hospital [recent Medicare regulations mandate that there is no reimbursement for inappropriate hospital readmissions], pharmacists began to integrate into coordinated and transitional care programs. Therefore, treating people across the continuum of care—not just from hospital to home, but from hospital to nursing home, from ICU to inpatient floor and so on—became a huge focus in pharmacy education and practice.
On the second question, if CMM became more widely implemented and had a payment model, many of our insured and newly insured patients would have access to medication management. And many of our primary care providers would have a resource on their team or in the community to help co-manage patients. This, in turn, could provide increased access to primary care providers, who are in demand due to the primary care provider shortage. It would be a win for patients, physicians, and insurers, as well as for pharmacists.
About the School: The UCSF School of Pharmacy is a premier graduate-level academic organization dedicated to improving health through precise therapeutics. It succeeds through innovative research, by educating PharmD health professional and PhD science students, and by caring for the therapeutics needs of patients while exploring innovative new models of patient care. The School was founded in 1872 as the first pharmacy school in the American West. It is an integral part of UC San Francisco, a leading university dedicated to promoting health worldwide.