Improving Medication Adherence in an ACO Primary Care Office With a Pharmacist-Led Clinic: A Report From the ACORN SEED

Bridging the continuity: Practice-enhancing publications about the ambulatory care medication-use process in 2021

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the ambulatory care medication-use process (ACMUP) from calendar year 2021 that can impact ambulatory pharmacy practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment and was reimagined to focus on new innovations and advancements in ambulatory pharmacy practice. The ACMUP is defined in this article as having the following components: transitions of care, prescribing and collaborative practice, accessing care, adherence, and monitoring and quality. Articles evaluating at least one step of the ACMUP were assessed for their usefulness toward practice improvement.

SUMMARY

A PubMed search was conducted in January 2022 for the year 2021 using targeted Medical Subject Headings keywords and the tables of contents of selected pharmacy journals were also searched, providing a total of 6,026 articles. A thorough review identified 86 potentially practice-enhancing articles: 10 for transitions of care, 9 for prescribing and collaborative practice, 20 for adherence, 17 for accessing care, 18 for monitoring and quality, and 12 for monitoring and medication therapy management. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest ranked articles are briefly summarized, with a mention of why each article is important. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article continues a series of articles defining and evaluating the currently published literature around the ACMUP. As healthcare continues to advance and care shifts to ambulatory settings, the ACMUP will continue to be a crucial process to evaluate.

Pharmacist-supported electronic outreach to address medication nonadherence for Medicare Advantage enrollees

BACKGROUND

Improved medication adherence, represented as an increase in the proportion of days covered (PDC), to chronic medications is associated with better patient outcomes, yet effective strategies to improve adherence are often resource intensive. OBJECTIVE: To quantify the impact of a pharmacist-supported electronic outreach initiative on medication adherence measures and to qualitatively evaluate patient engagement with and response to electronic messaging.

METHODS

This retrospective cohort evaluation used mixed methods to assess the impact of a population health quality improvement program to address medication adherence for Medicare Advantage enrollees. The intervention was performed between January 1, 2023, and December 31, 2023, by population health teams supporting the University of Colorado Primary Care practices. The teams reviewed insurer-provided lists to identify patients late to refill a medication and sent an electronic health message, a mailed letter, or a phone call conveying concern for adherence. Patient responses requiring clinical intervention or education were triaged to clinical pharmacists for management per their clinical discretion. The proportion of Medicare Advantage enrollees classified as adherent, defined as PDC value of 0.8 or higher, was compared before (2022) and after implementation of the population-based outreach intervention for the 2023 plan year. Qualitative methods were used to evaluate patient response to electronic messages. The text of all patient replies to electronic messages was thematically analyzed and categorized.

RESULTS

The proportion of patients classified as adherent to diabetes medications was higher in the postintervention group (87.5%) compared with the preintervention group (83.4%, P = 0.021), whereas the adherence rates in the post- vs prehypertension (89.3% vs 88.7%, P = 0.517) and cholesterol (89.4% vs 89.2%, P = 0.721) groups were not significantly different. The population health teams sent 1,593 electronic health record messages, 1,185 (74.4%) of which were opened, and patients responded to 516 (32.4%). The most common patient response was patients self-reporting being adherent (306, 59.3%); fewer patients admitted to some degree of nonadherence (111, 21.5%). An equal number of patients reported appreciation for (111, 21.5%) and confusion about or irritation with the outreach (111, 21.5%).

CONCLUSIONS

The University of Colorado Medicine's population health initiative provided mixed results on medication adherence metrics. Electronic health record messaging provided insight into ways to improve the intervention to better engage and assist patients.

Estimating the economic impact of blister-packaging on medication adherence and health care costs for a Medicare Advantage health plan

BACKGROUND

Medication nonadherence is a persistent challenge in the United States, leading to increased health care resource utilization (HCRU) and health care costs and worsened health outcomes. Medicare Star Ratings is a program developed by the Centers for Medicare and Medicaid Services (CMS) to evaluate Medicare health plan quality and performance. Three of the Medicare Part D Star Ratings quality measures assess medication adherence, showing the importance CMS places on improving medication adherence in older adults. Although a variety of medication adherence-enhancing interventions are available to help promote adherence among patients, one intervention that has shown success historically is blister-packaging.

OBJECTIVE

To model the potential impact of blister-packaging chronic medications on HCRU and health care costs in the Medicare population.

METHODS

An economic model was developed to assess the potential impact of blister-packaging the 3 Medicare Star Ratings adherence measure medication classes: renin-angiotensin system antagonists (RASAs), statins, and noninsulin antidiabetics. The model perspective was that of a hypothetical Medicare Advantage health plan with a plan size of 100,000 members. A 12-month time horizon was used in the model. The dichotomous adherence threshold in the model was set at 80% or greater of the proportion of days covered (PDC). Literature-based references were used to inform both the impact of blister-packaging on the number of patients who become adherent as well as the impact of medication adherence on HCRU and health care costs for each of the medication classes. One-way sensitivity analyses and several scenario analyses were conducted to assess model uncertainty.

RESULTS

Owing to increased adherence from the blister-packaging intervention, the hypothetical health plan in the analysis saw 776 additional members adherent to RASAs, 1,651 additional members adherent to statins, and 414 additional members adherent to oral antidiabetics. Although medication expenditure increased for all 3 medication classes (RASAs: $274,963; statins: $730,083; oral antidiabetics: $100,529), medical costs decreased across all classes (RASAs: -$4,098,848; statins: -$5,549,699; oral antidiabetics: -$917,968). Total net health care costs decreased by $3,823,885 for RASAs (-$3.19 per member per month [PMPM]), $4,819,616 for statins (-$4.02 PMPM), and $817,438 for oral antidiabetics (-$0.68 PMPM). The entire Medicare Advantage population scenario analysis saw reductions in total health care costs of $1,081,394,737 for RASAs, $1,362,987,376 for statins, and $231,171,496 for oral antidiabetics.

CONCLUSIONS

Dispensing chronic medications with blister-packaging for Medicare Advantage health plan patients was modeled to reduce HCRU and health care costs. Future studies are needed to assess whether the impact of blister-packaging medications is tied to reductions in HCRU and health care costs in real-world settings.

Improving Adherence and Reducing Health Care Costs Through Blister-Packaging: An Economic Model for a Commercially Insured Health Plan

Purpose

To model the potential clinical and economic impact of blister-packaging medications for chronic conditions on medication adherence and healthcare costs in a commercially insured population.

Methods

A health economic model was developed to evaluate the potential impact of blister-packaging chronic medications for a commercially insured population. The chronic medication classes assessed were renin-angiotensin-system (RAS) antagonists, statins, non-insulin oral antidiabetics, and direct oral anticoagulants (DOACs). The model was designed to reflect the perspective of a hypothetical commercially insured health plan with 100,000 members, over a one-year time horizon. Literature-based or best available epidemiologic references were used to inform the number of patients utilizing each medication class, the impact of blister-packaging on the number of patients who become adherent, as well as the impact of medication adherence in a commercially insured population on healthcare costs for each medication class assessed. Impact on costs was measured in total net healthcare costs, as well as being stratified by medical costs and medication costs.

Results

Following the blister-packaging intervention, there were an additional 591 patients adherent to RAS antagonists, 1196 patients adherent to statins, 169 patients adherent to oral antidiabetics, and 25 patients adherent to DOACs. While pharmacy costs increased, these costs were more than offset by the reduction in medical costs. Overall, the increase in patients adherent to therapy due to blister-packaging led to a reduction in total healthcare costs of $879,312 for RAS antagonists (-$0.73 per-member per-month (PMPM)), $343,322 for statins (-$0.29 PMPM), $78,917 for oral antidiabetics (-$0.07 PMPM), and $120,793 for DOACs (-$0.10 PMPM).

Conclusion

Blister-packaging chronic medications in a commercially insured population has the potential to reduce healthcare costs. Future research is needed to confirm these findings in real-world settings and to fully understand the clinical and economic implications of blister-packaging chronic medications.

Evaluating Pharmacist-Driven Interventions in a Primary Care Setting to Improve Proportion of Days Covered and Medication Adherence

Background: Medication nonadherence is the leading cause of poor health outcomes and increased risk of hospitalizations. Previous studies have shown that pharmacist interventions can help improve medication adherence and CMS quality measures. Objective: The purpose of this study was to examine the impact of clinical pharmacists' interventions on medication adherence and PDC scores for ACEi/ARBs, statins, and noninsulin antidiabetic medications in the primary care setting. Methods: This observational study was conducted at four primary care clinics to evaluate PDC scores pre- and post-pharmacist interventions from April 2020 to December 2020. Eligible patients were Humana Part D beneficiaries with a baseline PDC score <85%. The primary outcome of this study was to evaluate the average change in final PDC scores, and 1-month change in PDC scores following a pharmacist intervention. Secondary outcomes were number and types of adherence barriers identified, interventions provided by the pharmacist, and barriers and interventions category (pharmacy, patient or physician-related). Results: A total of 89 barriers were identified and 208 interventions were completed. A statistically significant difference in the average change of final PDC score from baseline was seen among those on ACEi/ARBs (72.5 to 78.0, p = 0.004) and statins (73.3 to 76.6, p < 0.001). Similarly, a statistically significant change was observed from baseline to 1-month PDC among those on ACEi/ARBS (72.5 to 75.4, p = 0.001) and statins (73.3 to 74.9, p < 0.001). Conclusion: Pharmacists located in a primary care setting improved medication adherence and PDC score for patients on ACEIs/ARBs and statins.

Impact of star ratings on Medicare health plan enrollment: A systematic literature review

BACKGROUND

The Medicare star ratings program was developed by the Centers for Medicare and Medicaid Services in 2007 as an approach to evaluate health plan performance and quality.

OBJECTIVE

This study aimed to identify and narratively describe studies that attempted to quantitatively assess the impact that Medicare star ratings have on health plan enrollment.

METHODS

A systematic literature review (SLR) was conducted of PubMed MEDLINE, Embase, and Google to identify articles that quantitatively assessed the impact of Medicare star ratings on health plan enrollment. Inclusion criteria consisted of studies that conducted quantitative analyses to estimate the potential impact. Exclusion criteria consisted of qualitative studies and studies that did not directly assess plan enrollment.

RESULTS

This SLR identified 10 studies that sought to measure the impact of Medicare star ratings on plan enrollment. Nine of the studies found that plan enrollment increased in accordance with increases in star ratings or that plan disenrollment increased with decreases in star ratings. One study conducted of data before the implementation of the Medicare quality bonus payment found contradictory results from one year to the next, whereas all the studies that assessed data after implementation found increases in enrollment in accordance to increases in star ratings or increases in disenrollment for decreases in star ratings. One concerning finding from some of the articles included in the SLR is that increases in star ratings had less of an impact on enrollment in higher-rated plans for ethnic and racial minorities and older adults.

CONCLUSIONS

Increases in Medicare star ratings led to statistically significant increases in health plan enrollment and decreases in health plan disenrollment. Future studies are needed to assess whether this increase has a causal association or is caused by additional factors outside of or in addition to increases in overall star rating.

Development of a value-based care and population health internship for student pharmacists

INTRODUCTION

Pharmacists assist in achieving desired outcomes and reducing costs of care within newer value-based payment models. The purpose of this article is to describe a summer internship for first- and second-year student pharmacists to gain exposure to value-based care.

METHODS

University Health Network is a clinically integrated health network and accountable care organization in East Tennessee. Two student interns completed consecutive seven-week programs alongside clinical pharmacist specialists in the primary care settings of the network. Program requirements included direct patient care for chronic disease state management, topic discussions, formal writing assignments and presentations, and a quality improvement project. Student perception of internship activities was measured using a Likert type survey and free response questionnaire.

RESULTS

Student interns responded positively to program requirements with feelings of enhanced preparedness for advanced pharmacy practice experiences and post-graduate residency positions. Additionally, interns perceived themselves as more competitive for post-graduate positions having completed the internship.

CONCLUSIONS

As the US continues to move toward value-based payment models, student pharmacists must be well prepared to contribute to quality and population health initiatives. Student pharmacists benefit from an internship in a clinically integrated health network by gaining an improved understanding of the future of United States healthcare, an expanded clinical skillset, experience in demonstrating a pharmacist's value to the healthcare team, and the ability to overcome barriers to pharmacy services. A pharmacy internship within a clinically integrated health network may help prepare students to successfully contribute to value-based models of healthcare.

Impact of medication therapy management (MTM) service model on multi-morbidity (MMD) patients with hypertension: a pilot RCT

BACKGROUND

This study explored the impact of MTM service on MMD patients with hypertension.

METHODS

A total of 120 MMD inpatients from September to November 2019 were received and randomly divided into intervention group and control group. General services for noninfectious chronic diseases were given to the control group, while a standard MTM service was given to the intervention group. Patients' blood pressure, EQ-5D utility value, readmission rate, drug-related problems, and average daily medication therapy cost were compared between the two groups and within the groups. This was done at the initial admission phase and in the first, third, sixth, and twelfth months after discharge.

RESULTS

The intervention group had significantly lower blood pressure and average daily medication therapy cost 12 months after discharge compared to the control group (systolic blood pressure: P = 0.023, diastolic blood pressure: P < 0.001, average daily medication therapy cost: P = 0.049); the number of DRPs decreased in both groups 12 months after discharge; the number of DRPs solved in the intervention group in the third, sixth and twelfth months after discharge were statistically higher compared with that in the control group (P = 0.013, P = 0.012, P = 0.001); there was no significant difference in the EQ-5D utility value and readmission rate between the two groups (P > 0.05).

CONCLUSIONS

MTM implementation in MMD patients can improve health outcomes and reduce healthcare-related costs among MMD patients.

TRIAL REGISTRATION

Chinese Clinical Trial Register ChiCTR2200065111, date of registration: October 28, 2022.