Blogs: Comprehensive Medication Management--and getting the meds right

By Terry McInnis, president, Blue Thorn Inc.
A health care model that yields a positive ROI, improves care and leaves patients and clinicians satisfied? Can't beTerryMcInnis done, you say? 

You're close: Few areas in health care can claim a positive ROI while improving outcomes and satisfaction. Comprehensive medication management, or CMM, is one that can.  CMM is the subject of a report by Health2 Resources and my firm, Blue Thorn Inc.. Get the medications right: a nationwide snapshot of expert practices--Comprehensive medication management in ambulatory/community pharmacy was sponsored by a grant from the Community Pharmacy Foundation.  

We knew, even
before we began our research, that CMM improves outcomes and controls costCMM report
s when targeted to high-risk populations. But just how significantly CMM bent the cost curve astonished even me, and I've been studying this for a long time.  

The CMM pr
ograms featured in Get the medications right were at different points of maturity, and reported a range of savings. Each example was unique in scope and population, so direct comparisons are impossible. Still, CMM programs in the literature consistently demonstrate cost savings, just like the practices featured in our research. 

Perhaps the biggest surprise was HealthPartners in Minnesota--a health plan. A robust financial analysis uncovered an 11:1 ROI for CMM; this led to the plan's decision to offer CMM to all its beneficiaries (85 percent of which are commercial customers) with a pharmacy benefit. As HealthPartners puts more risk on the shoulders of providers, it demonstrates that pharmacists, as part of the care team, can reduce costs and improve outcomes. This should be a wake-up call for other health plans!  

Here are a few more bottom-line outcomes included in our report:
  • Goodrich Community Pharmacy reported that, with CMM, medication costs remained flat while other costs of care went down. In fact, medication costs often increase in CMM programs, but they are more than offset by declines in overall cost of care. 
  • The Center for Healthy Hearts reported an 86 percent reduction in inappropriate emergency department use for one cadre of uninsured patients. That makes for a significant reduction in total cost of care for the hospital. 
  • At William S. Middleton Memorial Veterans Hospital, CMM services contributed to a 27 percent reduction in primary care workload.

There are several reasons CMM enhances the bottom line:

  • CMM often targets the most complex--and most costly--cases.
  • CMM reduces physician workload, opening access and allowing physicians to meet the acute needs of more patients. More patients get the appropriate care they need.
  • CMM programs have demonstrated reductions in emergency department and hospital admissions, as well as improvements in chronic conditions and other illnesses.

All of this has a powerful impact on patients, providers and ROI.  

Margin and mission: Accomplished!
To be sustainable, CMM must be deployed efficiently to improve outcomes and lower the total cost of care. Teresa L. Hodgkins, PharmD, BCACP, vice president of clinical quality initiatives at Desert Oasis Health Care, made that point in Get the medications right: a nationwide snapshot of expert practices."No margin, no mission. In order to have the opportunity to work with patients to optimize the use of medications--which is what pharmacists are trained to do--it also has to make financial sense to your organization to deploy pharmacists in this manner."   CMM does make financial sense. Get the medications right and improve the bottom line. It's that simple. GTMR: Make it a priority!    

Learn more about the report here.   

by Katherine H. Capps,  president, Health2 Resources
 Katie Capps
If you want to upset me, tell me "Oh, it's just semantics." Words, and the way we use them, matter. How we label things matters. If you need ibuprofen, you don't say "I'd like an analgesic." And if you want a Pepsi, you don't ask for a cola--or worse, a "Coke." Call a rose by any other name and you'll just confuse the heck out of everyone.
In health care, we need more clarity and precision in our language. There's a saying attributed to Confucius that goes something like this: "The beginning of wisdom is to call things by their proper names." It's something I've been thinking about a lot lately, prompted by my role as project director for a new report on comprehensive medication management.
That report, Get the medications right: a nationwide snapshot of expert practices--Comprehensive medication management in ambulatory/community pharmacy, was released last month by my firm, Health2 Resources, and Blue Thorn Inc. It shows how pharmacists, as both medication experts and clinicians, are optimizing medication use in team-based care and making an impact on the communities--and patients--they serve. Sponsored by a grant from the Community Pharmacy Foundation, the report draws on responses from 618 practices across the country. It highlights the importance and the role of the clinical pharmacist in patient care. It also features a number of interviews with successful CMM practices. Those practices we interviewed forced me to think about semantics.
   CMM report

Although the pharmacists interviewed understood what CMM entails, some used more general terms, such as "medication therapy management." Although correct--CMM is a form of medication therapy management (MTM) the way Coke is a cola—it does not differentiate CMM from other forms of MTM such as Part D Comprehensive Medication Reviews, disease-state medication management, or medication reconciliation.  


In effect, it confuses payers, patients, and policymakers,  and it doesn't give the clinical pharmacist practices enough credit for the systematic and team-based integrated care CMM requires.

Defining our terms
Comprehensive medication management encompasses a number of activities and involves a whole-patient approach that begins with the needs of the individual, not the condition. CMM programs seek to optimize medications by identifying and resolving drug therapy problems that stand in the way of clinical goals. In The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes,[1] it's defined as
the standard of care that ensures each patient's medications (whether they are prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended.
By any other name
Is it still comprehensive medication management if you call it something else? If certain program elements and processes are in place, the answer is "yes." But when you call it by another name, it becomes difficult to discuss CMM's unique value. That can lead to confusion. Patients, providers and payers already lack a basic understanding of CMM. Why further cloud the issue?
Yes, this is about semantics. Words matter.
We cannot educate patients, physicians, health plans and policymakers if we don't use the right terms, set expectations about what they can and should expect, and then deliver on those expectations.
By providing clarity and offering real-world examples, we believe this report will start many important conversations about comprehensive medication management. As the title says, it will help us Get the medications right.
It is my fervent hope that we will have the wisdom to get the name right, too.
Learn more about the report here.

by Terry McInnis, MD, MPH, CPE, FACOEM, president, Blue Thorn Inc.

Dr. Terry McInnis

In May, health care industry insiders and outsiders alike were stunned. A report announced medical errors are the third leading cause of death.


Me? I’m not stunned. Forgive me, but this is not news. We’re coming up on 17 years since the release of To Err is Human, the Institute of Medicine’s damning report on patient safety, and we still see similar headlines every few years. The fault lies with our uncoordinated system of care, with medications being the least coordinated of all.


Medication-related errors are a top preventable cause of serious adverse health events (including deaths).[2] The problem is far more nuanced and systemic than misunderstanding labeling or patient “non-adherence.” Failure to treat conditions and appropriately dose medications, coupled with inadequate counseling, can be deadly.


Lack of a systematic and coordinated approach to medications has contributed to this crisis; the solution lies with the professionals who are experts in medications--pharmacists.

 CMM report

This solution, comprehensive medication management (CMM), is the subject of a report released May 24 by Health2 Resources and my firm, Blue Thorn Inc.: Get the medications right: a nationwide snapshot of expert practices--Comprehensive medication management in ambulatory/community pharmacy. It shows how pharmacists, as both medication experts and clinicians, are optimizing medication use in team-based care and making an impact on the communities they serve. Sponsored by a grant from the Community Pharmacy Foundation, the report draws on responses from 618 practices across the country.


Clinical pharmacists working collaboratively with physicians and other clinicians can identify and fix a patient’s medication-related problems. They ensure the appropriate, effective and safe use of medications. As a result, they improve outcomes and the bottom line.


This is not a test

We knew before our research began that CMM practices improve clinical outcomes and patient satisfaction while controlling costs. What this report shows is how robust and integrated these practices are. From our research, we learned that CMM has become a widely accepted practice that supports value-based care. It is here to stay. Health systems, patients, physicians and payers have come to understand the value of advanced clinical pharmacy services and the importance of integrating these services into existing care-delivery models.


Yet, in many places, CMM has yet to be tried, much less embraced. This isn’t unexpected, given that pharmacists have not generally been recognized as providers and are vastly underutilized.[3],[4]


Despite many CMS initiatives around value-based care, little attention or funding has been directed toward CMM integration into PCMH and ACO structures—even though the Affordable Care Act calls for such efforts[5]. Part D MTM demonstrations, even "enhanced" ones, still focus on the medications first, not the patient.


Let me be clear: Drug-focused Part D MTM has nothing to do with patient-centered integrated comprehensive medication management. Period.


It’s time for the sort of transformation Get the medications right documents. That requires leadership from pharmacists, physicians, payers, policymakers--and it will be increasingly demanded by patients.


Recognize clinical pharmacists for what they are: patient care providers. It’s time to take CMM to scale. CMM isn’t emerging. It’s here. The need for appropriate, effective and safe use of medications is undeniable. Further delay--given the high cost in lives and money--is stunningly unconscionable.

[1] The original study appeared in BMJ (Makary Martin A, Daniel Michael. “Medical error—the third leading cause of death in the US BMJ 2016”; 353 :i2139)

[2] Medication Errors, AHRQ Patient Safety Primer, March 2015

[3] “An Era of Growth and Change: A Closer Look at Pharmacy Education and Practice.” Feb. 2014 University of California

[4] Mossialos E, et al., “From ‘retailers’ to health care providers: Transforming the role of community pharmacists in chronic disease management.” Health Policy, 2015

[5] Sec 3503-