pharmacy practice initiatives - wellmark demonstration article

8/13/2019 Pharmacy Practice Initiatives - Wellmark Demonstration Article

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IMPACT OF PHARMACEUTICAL CARE DELIVERED IN THECOMMUNITY PHARMACY SETTING:

Results of a Two Year Demonstration Project

Executive SummarWellmark Blue Cross and Blue Shield of Iowa, the Iowa Pharmacy ssociation, and the

!utcomes Pharmaceutical "ealth Care #formerly PC$Iowa% network of &harmacieswere &artners in a demonstration &roject to e'amine the im&act of &harmaceuticalcare deli(ery in the community &harmacy settin)* Patients who had asthma,hy&ertension, dia+etes, or ischemic heart disease were identified and enrolled +y&harmacists to &artici&ate in the &roject* Patients recei(ed ser(ices that were+ased on their o(erall needs and not limited to the enrollment disease states*

Pharmacists were reuired to meet s&ecific criteria to &artici&ate in the &roject* These

criteria included com&letion of Iowa Center for Pharmaceutical Care trainin),mem+ershi& in the !utcomes network, and com&letion of disease$s&ecificcontinuin) education modules* In addition, the &harmacies were encoura)ed toutili-e the "ealth !utcomes .ana)ement documentation system*

Pharmacists were reim+ursed for &atient care ser(ices +ased on a resource$+ased

relati(e (alue scale calculation* /uarterly monitorin) (isits were reim+ursed at aminimum le(el of 012* dditional reim+ursement was allowed if dru) thera&y&ro+lems were identified and resol(ed* De&endin) on the com&le'ity of the &atient3smedical needs, the num+er of current medications, and the num+er of dru) thera&y&ro+lems identified and resol(ed, uarterly &ayments ran)ed from 012 $ 0145*

nalysis +y Wellmark of o(erall medical claims e'&enditures com&ared inter(ention&atients to a control )rou& matched +y a)e, )ender, and disease state* Total medicalclaims e'&enditures for the inter(ention )rou& were 01,674,444 com&ared to08,597,444 for the control )rou&, resultin) in a difference of 07:7,444* Totaladministrati(e costs for the deli(ery of &harmaceutical care ser(ices for the inter(ention)rou& were 0944,444, of which &harmacy &ro(ider &ayments accounted for 0188,745*

fter deductin) the administrati(e costs of the &ro)ram, the unadjusted cost &er &atientof the inter(ention )rou& was 09,7:5 com&ared to 09,;4: &er &atient in the control)rou&, or 0898 lower &er &atient in the inter(ention )rou&*

The


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METHODSPatient EnrollmentTo +e eli)i+le for the &roject, &atients were reuired to ha(e at least one of the eli)i+le

disease states and +e less than 75 years of a)e* The eli)i+le disease states

included asthma, hy&ertension, dia+etes, and ischemic heart disease* Patients wereidentified and enrolled +y the &harmacist +ased on the &harmacist3s knowled)e ofthe &atient3s health conditions, while also confirmin) the &atient was enrolled in aWellmark health &lan* Wellmark did not identify eli)i+le &atients throu)h claimsdata* Patients &artici&ated on a (oluntary +asis*

Pharmacy ParticipationPharmacies and &harmacists meetin) s&ecific reuirements were eli)i+le to &artici&atein the &roject* Partici&atin) &harmacies were reuired to +e a mem+er in )ood standin)of the PC$Iowa network* Pharmacists &ro(idin) &harmaceutical care ser(ices werereuired to com&lete of the Iowa Center for Pharmaceutical Care #ICPC% trainin)

&ro)ram* ICPC trainin), a colla+orati(e effort of the ni(ersity of Iowa Colle)e ofPharmacy, the Drake ni(ersity Colle)e of Pharmacy and "ealth Sciences, and theIowa Pharmacy >oundation, consists of two se&arate two$day trainin) sessions, whichare conducted o(er a 17$week &eriod* Trainin) includes site re$en)ineerin), detectionand resolution of dru) thera&y &ro+lems, and documentation strate)ies* >aculty fromthe colle)es of &harmacy &ro(ides su&&ort to the &harmacists throu)h routine site (isits,which hel&s ensure the &atient care &rocesses are incor&orated into daily &ractice*

In addition, &harmacists were reuired to attend educational &ro)rams s&ecific to theeli)i+le disease states* These educational &ro)rams were de(elo&ed +y the IowaPharmacy >oundation and were a&&ro(ed for continuin) education credit +y the

merican Council on Pharmacy @ducation* Pharmacists could attend the &ro)rams in&erson or on the Iowa Communication Aetwork #ICA%* >or those una+le to attend theli(e &ro)ram, (ideos of the &ro)rams were made a(aila+le* Pharmacists electin) homestudy were reuired to &ass a learnin) assessment* @ach &ro)ram (aried in len)th, withthe ischemic heart disease &ro)ram +ein) the lon)est at ; hours* The hy&ertension&ro)ram lasted 7 hours while the dia+etes and asthma &ro)rams were each 2 hours inlen)th*

The final reuirement for &artici&ation &ertained to documentation standards*Pharmacists were encoura)ed to utili-e the "ealth !utcomes .ana)ement system fordocumentation of their &atient care encounters and su+mission of &harmaceutical care

claims* The "ealth !utcomes .ana)ement network system was utili-ed +y PAI to&rocess claims as well as descri+e the &harmaceutical care ser(ices &ro(ided to&atients durin) this &roject* >or some &harmacies, leasin) this documentation system&resented a +arrier to &artici&ation* To alle(iate this +arrier, &harmacies were )i(en theo&tion of manually su+mittin) their claims to PAI who would then enter the claims in the"ealth !utcomes .ana)ement system* If &harmacies elected the manual method, theya(oided the &otential cost +arrier associated with leasin) the documentation system*


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"owe(er, reim+ursement for &harmaceutical care ser(ices &aid throu)h the manualsystem was reduced +y 54?*

ReimbursementThe demonstration &roject was intended to +e a two$year e(aluation of 1,544 enrolled&atients* lthou)h &atient enrollment +e)an in 1;;5, +arriers to im&lementation delayedreim+ursement until !CS@D

1 medical p!o"lem

@PAD@D PR!B@.>!CS@D

1-2 medical p!o"lems

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2-3 medical

p!o"lems

@PAD@DD@TI@D

3 medical p!o"lems

C!.PR@"@ASIE@

4 medical p!o"lems

DecisionMaking

STRI="T>!RWRD

1-2 d! t%e!apy p!o"lems

STRI="T>!RWRD

1-2 d! t%e!apy p!o"lems

!WC!.P@ITY

2-3 d! t%e!apy

p!o"lems

.!D@RT@C!.P@ITY

2-3 d! t%e!apy

p!o"lems

"I=" C!.P@ITY

4 d! t%e!apy p!o"lems


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>or e'am&le, consider a &atient takin) four acti(e medications and ha(in) threeconcurrent medical &ro+lems* ssume durin) the +illin) cycle the &harmacist3s careser(ices resulted in the resolution of one dru) thera&y &ro+lem* This inter(ention wouldualify for le(el 8 reim+ursement* lthou)h the history com&onent was le(el 9 and thee'am com&onent could +e either le(el 9 or 2, the decision$makin) com&onent was no)reater than le(el 8* e(el 8 reim+ursement resulted in a &ayment of 095* If, o(er theuarter, the &harmacist resol(ed three dru) thera&y &ro+lems for this &atient, e(el 9reim+ursement would +e warranted, or a 079 &ayment*

sin) the "ealth !utcomes .ana)ement network system, PAI &aid &harmaceuticalcare claims on a uarterly +asis* The software &erformed systematic checks to ensure&harmacies were codin) ser(ices for reim+ursement at the a&&ro&riate le(el* The"ealth !utcomes .ana)ement system also &ro(ided a detailed descri&tion of the ty&esof ser(ices &ro(ided, the ty&es of dru) thera&y &ro+lems resol(ed, and thedemo)ra&hics of the &atient &o&ulation*

Project Administrationdministration of the &roject was the res&onsi+ility of PAI* PAI &ro(ided (arious formsof feed+ack to the &harmacies as well as &ayment for the ser(ices* !ne &harmacist atPAI was res&onsi+le for the daily administration of the &ro)ram includin) routinecommunication with &artici&atin) &harmacies* To&ics of these communications in(ol(edissues such as num+er of &atients enrolled, documentation needs, reim+ursementissues, and assistance in usin) the documentation system* PAI also em&loyed&harmacy students to assist in the entry of claims data from &harmacies su+mittin)manual claims*

Pharmacists em&loyed +y PAI with e'&ertise in uality assurance &ro(ided additional

feed+ack to the &artici&atin) &harmacists* Disease$s&ecific &rotocols for &atientmonitorin) were de(elo&ed and disseminated to the &harmacists to &romoteconsistency amon) the &artici&atin) &harmacies* >eed+ack was also &ro(idedre)ardin) the com&leteness of documentation and the uality of assessments throu)hthe re(iew of at least si' &atient care &lans written +y each &harmacist in the &roject*The "ealth !utcomes .ana)ement software selected the care &lans re(iewed +y PAI*This &rocess was com&leted e(ery si' months* Common areas for im&ro(ement were&resented at meetin)s of the &artici&atin) &harmacists* Re&orts were disseminated toeach &harmacist &ro(idin) feed+ack re)ardin) the care &lans they had com&leted*

Patient enrollment and su+seuent data collection +e)an as early as 1;;5* "owe(er,

continuity of the &roject was not esta+lished until late 1;;7 when PAI +e)anadministration of the &roject* This transition resulted in consistency in data collectiondurin) the two$year &eriod of calendar years 1;;: and 1;;6* Data collection ended onDecem+er 91, 1;;6*


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RESULTSTwo sources of information are utili-ed to descri+e the results of this &rojectF themedical claims data at Wellmark and the &harmaceutical care claims data at PAI* TheWellmark data &ro(ides a )lo+al &ers&ecti(e of the &roject while the PAI data allows thedescri&tion of the care &ro(ided +y the &harmacists*

Wellmark DataOverall Medical Claims ExpendituresThe Wellmark data e'amines the total costs of medical claims for the &atients enrolledin the &roject in com&arison to the costs for a control )rou& matched +y a)e, )ender,and disease to the inter(ention )rou&* Durin) the &roject, the inter(ention )rou&e'&erienced medical claims totalin) 01,674,444* In addition, the inter(ention )rou&incurred an additional 0944,444 for the &ayment of the &harmaceutical care claims andthe administration of the &harmaceutical care &roject, resultin) in a total cost of ser(icesfor the inter(ention )rou& of 08,174,444* The control )rou& e'&erienced medical claimsof 08,597,444, resultin) in an unadjusted difference of 07:7,444 less medical claims inthe inter(ention )rou&* fter deductin) the administrati(e costs of the &roject and costsof &harmaceutical care ser(ices, the inter(ention )rou& e'&erienced 09:7,444 less inmedical claims than the control )rou&* !n a &er &atient +asis, the unadjusted cost forthe inter(ention )rou& was 09,7:5, while the cost for the control )rou& was 09,;4:, or alower unadjusted cost in the inter(ention )rou& +y 0898 &er &atient*

The m+ulatory Care =rou&s #C=% case mi' system de(elo&ed at


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The majority of &atients were enrolled +ased on the dia)nosis of hy&ertension*Pharmacist inter(entions in the treatment of hy&ertension, such as increasedcom&liance, may +e unlikely to modify outcomes durin) the relati(ely short durationof this &roject*

>urther, this &roject did not e(aluate for the &resence of a sentinel effect from the

&ro(ision of &harmaceutical care ser(ices* There is a &otential for im&ro(in)outcomes in &atients not enrolled in the &roject +ut who also recei(ed care from&harmacists &ro(idin) these ser(ices*

Disease-Specific AnalysisThe most &re(alent disease resultin) in enrollment in the &roject was hy&ertension,accountin) for 78? of the &atients* sthma and dia+etes accounted for similar &ortionsof the &o&ulations, at 16? and 17? res&ecti(ely* small num+er of &atients #2?% wereenrolled +ased u&on a dia)nosis of ischemic heart disease* Patients were enrolledunder a &rimary disease state as su+mitted +y the &harmacist* Disease$s&ecificanalysis does not address &atients who may ha(e had concomitant disease states*

"owe(er, this factor was e'amined in the o(erall analysis throu)h the C= se(erityadjustment*

In all disease states, the unadjusted costs of medical ser(ices for the inter(ention )rou&were less than the unadjusted costs of medical ser(ices for the control )rou&* Aodisease$s&ecific analysis was se(erity adjusted +y the C= software* Therefore, theraw data has limited (alue in the direct com&arison of the inter(ention and control)rou&s* Disease$s&ecific analysis com&ared the inter(ention )rou& to the control )rou&durin) the time &eriod of 1;;: and 1;;6 and is summari-ed in Ta+le 8*

Ta+le 8FDisease State Number

ofPatients

Intervention

Group: ClaimsCost*

Intervention

Group:Administrative

Cost

Intervention

Group:Total Cost*

Control

Group:Total Cost*

Difference:

(Control -Intervention*

Hypertension 715 $1,413,000* $184,437 $1,597,437* $1,7,000* $78,53*!st"ma #1# $ 35,500* $ 54,8 $ 90,18* $ 111,400* $#1,#14*Diaetes 190 $ 181,300* $ 49,01# $ #30,31#* $ #41,400* $11,088*%sc"emicHeart Disease

4 $ 180,900* $ 11,85 $ 191,85* $ #7,#00* $74,435*

* &"ese 'ig(res represent ra) ata an are not se+erity a(ste-

The disease state of hy&ertension resulted in the enrollment of :15 &atients in the&roject* In the years 1;;: and 1;;6, the inter(ention &atients enrolled under the

dia)nosis of hy&ertension e'&erienced 01,219,444 in medical claims in addition to the&ro&ortional administrati(e and direct costs of &harmaceutical care ser(ices ofa&&ro'imately 0162,29:, resultin) in a total unadjusted cost in the inter(ention )rou& of01,5;:*29:* The control )rou&3s medical claims totaled 01,7:7,444, resultin) in 0:6,579less s&ent in the hy&ertension inter(ention )rou&* This cost analysis is not se(erityadjusted*


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sthma accounted for the enrollment of 818 &atients in the &roject* In the years 1;;:and 1;;6, the cost of the inter(ention )rou& included 095,544 in medical claims and052,767 in &ro&ortional administrati(e and direct costs of &harmaceutical care ser(ices,for a total unadjusted cost in the asthma inter(ention )rou& of 0;4,167* The cost ofmedical claims in the asthma control )rou& was 0111, 244* This com&arison, resultin)

in 081,812 less s&ent on the asthma inter(ention )rou&, is not se(erity adjusted*@nrollment of 1;4 &atients was due to the dia)nosis of dia+etes* In the years 1;;: and1;;6, there was 074,144 less s&ent on the unadjusted costs of the inter(ention )rou,944% com&ared to the control )rou& #0821,244%* This difference does not includethe &ro&ortional cost of &ro(idin) these ser(ices of a&&ro'imately 02;,418, resultin) in anet unadjusted difference of 011,466*

The effects of &ro(idin) &harmaceutical care to &atients with ischemic heart diseasewere studied in a small )rou& of 27 &atients* In the years 1;;: and 1;;6, medicalclaims cost of the inter(ention )rou& totaled 0164,;44 while the medical claims cost ofthe control )rou& totaled 087:,844* This difference of 067,944 is not se(erity adjusted*

fter deductin) the &ro&ortional cost of &ro(idin) these ser(ices of 011,675, theinter(ention )rou& e'&erienced 0:2,295 less medical claims cost than the control )rou&*

The same limitations descri+ed &ertainin) to the e(aluation of o(erall Wellmark claimsdata, such as hi)h administrati(e costs, also a&&ly to the e(aluation of the disease$s&ecific data* In addition, the disease$s&ecific data are not adjusted +y the C=software* Small sam&le si-e is also a limitin) factor in all enrollment disease statesother than hy&ertension* final limitation is the ina+ility to identify &atients withconcomitant disease states*

PNI Data

PAI data was collected usin) the "ealth !utcomes .ana)ement software, either at the&artici&atin) &harmacy or entered +y PAI* The PAI data allows a )reater descri&tion ofthe &ro(ision of &harmaceutical care +y the &artici&atin) &harmacists* This descri&tionincludes the ty&es of dru) thera&y &ro+lems resol(ed, the methods used in dru) thera&y&ro+lem resolution, and the num+er of &atient encounters reuired to resol(e certainty&es of dru) thera&y &ro+lems* PAI data e'amines data su+mitted for &harmaceuticalcare ser(ices durin) the calendar years of 1;;: and 1;;6*

Enrollment total of 28 &harmacies met the eli)i+ility reuirements to &artici&ate in the &roject, and92 &harmacies enrolled &atients in the &roject* !f these, 91 &harmacies su+mitted

&harmaceutical care claims for the &roject, of which 8; &harmacies recei(ed &aymentfor ser(ices* Se(en of the 91 &harmacies su+mittin) claims utili-ed a manual system,while 88 &harmacies utili-ed the "ealth !utcomes .ana)ement system*

!ri)inal &roject e'&ectations called for the enrollment of 1,544 &atients* llowin) for&atient withdrawal and for disenrollment, it was e'&ected that +etween 1,444 and 1,144&atients would +e acti(e cases for e(aluation* ccordin) to the PAI data, 1,228 &atientswere enrolled in the &roject, of which 1,1:1 &atients recei(ed &harmaceutical care


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ser(ices* These ser(ices were &ro(ided throu)h ;,51: documented &atient careencounters, an a(era)e of 2*1 encounters &er &atient &er year* This le(el of acti(ityindicated that on a(era)e, the )oal of uarterly &atient monitorin) was met*

Patient enrollment &arameters influenced the demo)ra&hics of the &atient &o&ulation*s the enrollment disease states skew the &o&ulation to a more a)ed &o&ulation, it isnot sur&risin) that o(er one$half of the &o&ulation was +etween the a)es of 54 and 72*@nrollment of &atients o(er a)e 75 was not allowed due to lack of access to .edicareclaims* Concomitant diseases were common as each enrolled &atient had an a(era)eof 9*85 different medical conditions* Sli)htly more females than males were enrolled inthe &roject*

Drug Therapy ProlemsIdentification of dru) thera&y &ro+lems alone did not result in reim+ursement*Reim+ursement +eyond the minimal monitorin) fee was allowed only when dru)thera&y &ro+lems were resol(ed* Pharmacists resol(ed 1,251 dru) thera&y &ro+lemsdurin) the study &eriod* !(er half #58?% of the &atients recei(in) &harmaceutical care

ser(ices, or 719 &atients, had one or more dru) thera&y &ro+lems resol(ed*

The most common ty&e of dru) thera&y &ro+lem resol(ed +y the &harmacists wasina&&ro&riate adherence to medication thera&y* This &ro+lem accounted for 86? of thedru) thera&y &ro+lem resolutions* The ne't most common ty&es of dru) thera&y&ro+lems resol(ed were ad(erse dru) reactions and the need for additional dru)thera&y, at 81? and 84? res&ecti(ely* !ther ty&es of dru) thera&y &ro+lems resol(edwere dosa)e too low #18?%, wron) dru) #14?%, unnecessary dru) thera&y #5?%, anddosa)e too hi)h #2?%* This analysis is outlined in Ta+le 9*

The num+er of &atients who +enefited from the resolution of dru) thera&y &ro+lems is

nota+le* !(er one$half of the &atients recei(in) ser(ices had at least one dru) thera&y&ro+lem resol(ed* Correctin) ina&&ro&riate adherence to thera&y +enefited 876&atients, and eliminatin) ad(erse dru) reactions +enefited 884 &atients* dditional dru)thera&y was initiated in 812 &atients* Doses were adjusted in almost 844 &atients* Thedose was su+thera&eutic for 129 &atients while the dose was e'cessi(e in 52 &atients*The use of an ina&&ro&riate medication was corrected in 115 &atients throu)h&harmaceutical care ser(ices* nnecessary dru) thera&y was eliminated in 7: &atients*

Ta+le 9F

T!pes of Dru" T#erap!

Problems $esolved

Number of

$esolutions

Number of Patients

%nappropriate !"erence 413 .#8/ #8!+erse Dr(g eaction #98 .#1/ ##0!itiona2 Dr(g &"erapy #93 .#0/ #14Dosage &oo o) 171 .1#/ 143rong Dr(g 140 .10/ 115nnecessary Dr(g &"erapy 78 .5/ 7Dosage &oo Hig" 58 .4/ 54


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Some dru) thera&y &ro+lems reuired more &atient care encounters on a(era)e toresol(e the &ro+lem* Ina&&ro&riate adherence a&&eared to reuire the most freuentencounters, at 1*52 encounters &er resolution* d(erse dru) reactions and need foradditional dru) thera&y followed with a&&ro'imately 1*97 encounters &er resolution*Pro+lems related to e'cessi(e doses of medication were )enerally sol(ed in one &atient

care encounter*

The most freuent disease states addressed durin) the &atient care encounters werethe enrollment disease states* Dru) thera&y &ro+lems related to the four enrollmentdisease states accounted for 5:? of resol(ed &ro+lems* "owe(er, nearly 154 diseasestates were addressed in &atient encounters* The most freuently encountered diseasestates are listed in Ta+le 9*

Ta+le 9Most Frequent Disease States

Encountered by

Pharmacists

HypertensionDiaetes!st"maHyper2ipiemia!22ergic "initis!rt"ritis6steoporosiseptic 2cer DiseaseDepressionHeaac"e or MigraineMenopa(seHypot"yroiism

The methods +y which the &harmacists resol(ed dru) thera&y &ro+lems are of interest*In the majority of cases #::?%, the &harmacist contacted the &atient to resol(e the&ro+lem* Durin) this contact, &atients may ha(e +een instructed to contact their&hysician if a&&ro&riate* Pharmacists directly contacted &hysicians to facilitate 84? ofthe dru) thera&y &ro+lem resolutions, while third &arty &ayers were contacted in a small&ercenta)e #2?% of cases* When the &hysician was contacted, the action mostfreuently occurrin) was the initiation of new medication thera&y #8:?%* Chan)in) thedose and chan)in) the medication each occurred in 16? of the &hysician contacts,while discontinuin) thera&y accounted for 12? of the &hysician contacts*

lthou)h the actions taken when consultin) a &hysician were relati(ely limited, actionstaken when contactin) &atients (aried )reatly* The most common action was theinitiation of an o(er$the$counter medication #17?%* !ther actions resulted in small&ercenta)es of the total num+er of contacts*

!eimursementThe majority #71?% of +illin)s for &harmaceutical care ser(ices was su+mitted forreim+ursement e(el 1* Reim+ursement e(el 8 was +illed in 91? of the&harmaceutical care claims* Reim+ursement e(el 9 was su+mitted for 7? of the


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demonstrates that this is a system$wide &ro+lem reuirin) systemic solutions* !n themicrosco&ic le(el, o(er 744 &atients3 uality of health care was im&ro(ed throu)h theresolution of dru) thera&y &ro+lems* This &roject demonstrated that dru) thera&y&ro+lems are common in this &o&ulation and that &harmacists &lay a si)nificant role inresol(in) these &ro+lems and im&ro(in) &atients3 uality of care*

This &roject demonstrates, as did the Washin)ton CR@ study, that reim+ursement for&harmaceutical care ser(ices yields fiscal results that are at least +ud)et neutral* &ositi(e +ud)etary im&act would ha(e resulted from a reduction in administrati(e costs*=i(en the nature of a demonstration &roject, it is reasona+le to assume future initiati(eswould reuire less administrati(e costs*

Detectin) the im&act of care &ro(ision throu)h the measurement of )lo+al utili-ationdata is difficult* .any factors contri+ute to o(erall utili-ation and may +e outside theinfluence of the care +ein) &ro(ided* It is not known whether catastro&hic illnessunrelated to medication use or e'ternal risk factors, such as automo+ile accidents, mayha(e contri+uted to utili-ation &atterns* In addition, the two year time &eriod studied may

not ha(e +een sufficient to e(aluate the +enefits of &ro(idin) ser(ices to im&act chronicdisease states*

C'(c#u&i'(This demonstration &roject &ro(ides further e(idence that reim+ursement to &harmacistsfor &atient care ser(ices to identify and resol(e dru) thera&y &ro+lems can im&ro(e&atient care, while remainin) at least +ud)et neutral* &ositi(e +ud)etary im&act would+e feasi+le if the hi)her administrati(e costs associated with this demonstration &rojectwere reduced* In addition, this demonstration &roject confirms that dru) thera&y&ro+lems are common in this &o&ulation and that &harmacists in community &ractice

settin)s can si)nificantly contri+ute to the resolution of these &ro+lems*

pharmacy practice initiatives - wellmark demonstration article

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