Others may think of disease state management programs when they think about MTM. Programs where the pharmacist works with the patient to treat a specific disease...diabetes, asthma/COPD, hypertension, or hyperlipidemia.
Most of the talk that I see about medication therapy management revolves around the community pharmacy setting. But what about in the hospitals?
I write this with a specific case in mind. A case where pharmacist involvement could have saved the patient, the community pharmacist, and several nurses a significant amount of time on a weekend.
First the details of the case. Patient is admitted and has several stents placed. Patient does not tolerate clopidogrel, so the patient is started on prasugrel. The patient is insured by a government-funded program that does not cover prasugrel without a prior authorization. After spending a few days as an inpatient, the patient is discharged on Saturday afternoon.
For those who work in a community pharmacy, you know what happens next. The pharmacy processes the claim for the prasugrel and receives the "Prior Authorization required" message. Now the community pharmacist gets to tell the patient's spouse that the medication is not covered, knowing that it will take several days for the prior authorization to be approved. The labeling of the prasugrel states that it must be stored in the original container with the desiccant. We inform the patient's spouse that they can pay the retail price now, then get a refund once the claim is approved.
That didn't go over well. About ninety minutes later the pharmacy receives a call from a nurse case manager who is fairly hot over the issue. The patient neeeeds this medication. I don't doubt that one bit, but it requires a prior authorization. So the nurse case manager says that she will take care of the PA.
Another hour passes and the nurse case manager calls back. The PA desk is closed for the weekend. That doesn't surprise me one bit. The nurse case manager calls back. What are we going to do? The patient neeeeds this medication. The patient just had several stents placed.
This is where I want to throw the lack of preparation on your part doesn't constitute an emergency on my part back in the nurse case manager's face. But I have a patient who needs their medication. I don't want a couple hundred bucks of medication go out the door without having some sort of arrangement set up, just in case the prior authorization isn't approved. In the end, the patient went home with the prasugrel after the financials had been worked out.
Where was the pharmacist in this case? Did the hospital pharmacist have any role in the discharge planning for this patient? If they did, did they do anything other than glance at the chart a few times during the time that the patient was admitted.
I've said this before and I'll say it again. A medication regimen that the patient can afford and will take regularly is far more effective than the clinically superior regimen that the patient can't afford and won't take. That's one of the keys to my view of medication therapy management.
As soon as it was determined that the prasugrel would be the patient's home-going medication, somebody at the hospital (pharmacist) should have checked to see if the medication would be covered by the patient's insurer. It took me under 15 seconds to see that the medication would be covered with a prior authorization, and I was able to see what the copay would be once approved.
That's part of the practice of medication therapy management. Making sure the patient can afford the medications. It's a place where the hospital pharmacists can impact the care that the patients receive, but it may be beneath the duties of a clinical pharmacist.
I practice community pharmacy in a very rural area. The closest major teaching hospital is over sixty miles away. There are five cities with major teaching facilities within two hours of my pharmacy. These cities have eight hospitals that I would say are top-notch. Of these eight hospitals, only two of them regularly have prior authorizations taken care of prior to the patient being discharged.
Hello hospital pharmacy directors. If only two of the eight major teaching facilities take care of PAs prior to discharge, you can imagine how well the local city/county hospitals take care of PAs.
MTM pharmacists....maybe this is an area where you can expand your practice.