Tuesday, February 8, 2011

MTM opportunity?

When you hear the words medication therapy management, what do you think of? I imagine that a majority of us think of the comprehensive medication review that occurs in a community pharmacy setting. The patient brings in brings all the medications and herbal products that they put in/on their body and the pharmacist goes over them with the patient, looking for any issues that may exist.

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.

* * * * *

I intentionally used the title nurse case manager during the story for a reason.

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.


JAlonso96 said...

Hello!!!! Hospitals have a limited formulary that mostly includes less expensive drugs, which are covered by most plans. PA's what PA's?

pharmcy chick said...

the next question for the Doc. What would you do if Prasugrel was not available. What did ANY patient do before the drug was available? This isn't so much an issue of "he NEEDS THIS med", but the patient NEEDS SOME med...We have been doing stents long before plavix and effient were around. Somehow we managed and brought patients out of it successfully. I totally agree that if Dr's are going to prescribe certain meds then payment/coverage should be one consideration when holding the pen to the pad, but at the same time, we need to look at the 3rd option nobody considered: WHAT ELSE COULD WE USE?

Anonymous said...

Criminy (hospital pharmacy here)--many hospitals are 'non-profit' and would have NOTHING to do with whether a patient's drugs are covered or not by the patient's insurance. I'll be interested in getting hooked up with insurance information, when and only when there is one-payor system.

We have a little thing called the reconciliation record when the patient enters the hospital. It's like pulling eye-teeth to get it correct, without investigating which insurance carrier a patient is enrolled.

John Woolman said...

Interesting story. So many of the pharmacy blog posts tell UK readers more about the realities of US Health Care than any number of editorials or papers in NEJM or JAMA. So I had a think about what might happen in the UK in a case like this. First thing is that the patient would be sent out of hospital with a few days supplies of their meds, with a note to their family practitioner about what they are on in their hand with a hard +/- electronic copy sent to their family practitioner. It's up to the patient to get the prescription from the Family practitioner. Sometimes when a hospital prescribes a fairly new drug there may be some delay in this.

Prasugrel is licenced in the UK for for the prevention of atherosclerotic events after stent placement or other PCI IN COMBINATION WITH ASPIRIN. So giving prasugrel alone is "off label" and may well require negotiation between the family practitioner and the hospital and possibly the Primary Care Trest. PCTs the local bodies that currently deliver funding (but are to be abolished with funding put directly into the hands of the family doctors. Sigh. new mercedes all all round).

Clopidogrel monotherapy may be used in a patient who can't tolerate aspirin for patients who have had an occlusive vascular event and/or symptomatic peripheral vascular disease. If such a patient couldn't tolerate Clopidogel he would get his Praugrel almost automatically, with any discussions not involving the patient.

The National Institute for Clinical Excellence (NICE), cited as an example of a death committee during the Obamacare polemics, has advised that prasugrel woth aspirin is the choice following PCC for an acute coronary syndrome only if immediate PCI is needed for ST elevation MI, or stent thrombosis has occurred withc lopidogrel or the patient has diabetes mellitus.

Fine, so the patient who needed it would come home with a few days supply of prasugrel. Usually, there isn't going to be much hassle over his getting a prescription. What happens's when he takes it to the pharmacist? If he is over 60, on most state funded benefits, has one of a fairly short list of chronic dideases or has bought a "season ticket' for all his medicines, he ticks a box on the back of his prescription signs it and the medicine is handed over. If he doesn't fit into any of those categories there is a co-pay of about US$12. (After paying that, the net cost of 28 days supply to the NHS is about US$77).

So the big difference, from the patient's point of view, is that any argument about whether or not the patient gets the drug doesn't involve the patient or indeed the pharmacist. The pharmacist doesn't have to deal with the shroud waving nurse on a Saturday afternoon. All he has to do on that Saturday afternoon when present with the prescription is excercise reasonable care over the patient's entitlement to getting it without the nominal co-pay and to be sure he has it in stock.

And the other big difference, I pay income tax plus other payroll taxes at around 40% of income and a sales tax of 20% on just about everything except food and books.

Which system is better? Not for me to say, but they are certainly different.

Eric, RPh said...

When a patient is discharged with an order for prasugrel, enoxaparin, or dabigatran, you can put money on it that the prescription is going to require prior authorization.

It does the patient no good to have a prescription for these meds if it is going to take a few days for the insurance to approve them.

That's why the patient's care should be managed. The hospitals that do this well usually call-in the order for medication a day or so ahead of time to 1- make sure it is covered and 2- make sure it is in stock.

I know how difficult it is to figure out which medications a patient is on upon admission. I get at least a half-dozen calls every day from hospitals to get the patients' med lists. But it is more important to make sure that they will take their homegoing medications.

Simple rule of thumb for you hospital guys and gals...if the pharmacist who purchases the meds gripes about a particular medication being ordered, that's your red flag that it may require a PA when the patient is discharged.

Again...possible opportunity for medication therapy management. Who's going to do it? Pharmacists? Or are we going to let these nurse case managers take over a portion of our profession.

Mike said...

Eric -- GREAT post. Rings true with all of us in the retail trenches.

To hospital RPhs -- most good hospitals (for-profit AND non-) will get a PA for discharge meds when appropriate. I work about an hour away from an Ivy League hospital that does it routinely. With the increasing costs of medications, and the complexity of third-party formularies, it's simply become part of the profession.

There is more to being a good pharmacist than knowing a bunch of clinical equations.

Anonymous said...

Don't appreciate Mike's attitude.

I work in a small county (non-profit) hospital, several at present, in fact. I worked in a rather larger regional hospital a few years back--non-profit. In each case, 'non-profit' means the hospital gets its major funding from the government, and necessarily has a very tight budget in providing medications. Which means, we pay very, very close attention to what we buy to have on the shelf.

Sometimes we belong to buying groups which involve several hospitals in the corporation, but the bottom line is that we have seriously (penalties involved) monitored closed formularies.

The outlandish expensive drugs that no government agency would cover are not going to be used in my hospital!

Where the expensive drugs come from are a. samples that the primary care physician sends home at follow-up visit day 1 after discharge, b. the retail pharmacy where the patient's insurance will allow the patient to get filled on a prescription that the patient goes home with, that we in the hospital did not provide.

Do not 'blame' us hospital pharmacists for our 'clinical expertise' when we ascertained the best drug for the patient with vancomycin-resistant enterococcus resistant to cipro, ampicillin, penicillin, tetracycline, etc. gets started on IV twice daily 600 mg linezolid for 2 days then is sent home on oral Zyvox! That was the best we pharmacists could come up with that had an oral dosage form.

It was not my business to call over to the drug manufacturer and enlist the patient in a patient assistance program for the drug at home. I could get the forms, if necessary, but I do not have information about patients insurance coverage of costs at the hospital.

If the patient's insurance company will not allow filling a script without prior authorization, then I should think that as registered pharmacist, you could more successfully argue in our patient's best interest that they should get their $7.00/pill script filled? WE can work together on these matters. You and I are the drug therapy experts.

Eric, RPh said...

If the hospitals have such tight formularies that require watching every penny and certain medications aren't stocked due to price, that's the red flag that the insurance probably won't cover the medication.

The community pharmacist doesn't have access to the medical records to know #1-what the diagnosis is, and #2-what the C&S results were.

Plus, community pharmacists don't have a couple days with the patient. We have minutes. And in those minutes we find out that their insurance isn't going to cover the $3000/month voriconazole prescription that was written by some resident at the teaching facility.

I'm sure the resident didn't just decide willy-nilly to send the patient home on the medication. There was some clinical consideration.

That's where the pharmacy department needs to take over the case management when it comes to discharge medications. It does the patient no good to be on a medication when they are an inpatient, only to have the treatment suspended for three days while a prior authorization is processed. Especially when the patient has been hospitalized for a week or so.

Heck, phoning in the order a day before discharge would at least give the community pharmacy a chance to submit a claim to see if the medication is going to be covered and to find out a price.

This purpose of the post isn't to place blame, it's to identify an opportunity to give the patient the best care possible.

Anonymous said...

Great back and forth! Plain and simply, hospital staff pharmacists do not have (time) nor access to individual patient insurance coverage. I am guessing if individual patient information was placed in the computer at the same time as order-entry, someone in a billing office somewhere would have to run daily updates about the drugs and plan details of all insurance companies.

Personally, as I recall when receiving hospital bills, drug costs itemization is not sent in a timely fashion. Often, payment of hospital bills is cumbersome, and very rarely are the drug costs separate so that one could pay them at the time of dismissal.

Major hospitals have Formulary P & T Committees that meet regularly to decide which drugs are going to be readily available in inventory, and those in which prescribers are going to have to jump hoops.

In my small hospital, no one in the pharmacy dept sees what the doc is writing for discharge. We rarely know when the doc is going to dismiss the patient.

Docs, at my small hospital are enerally good about knowing that they're going to have to supply their patient with samples to go home on.

Perhaps, this issue needs to be addressed in larger hospitals, but sorry to say, when I worked in larger hospitals, pharmacy was less engaged in individual patients holistic care, more general policy issues to benefit the hospital bottom line.

When I work in some psych hospitals, medication adherence and compliance is a major factor and consideration of discharge, and psych social workers are often involved in these settings.

Perhaps, social worker involvement is lacking in larger hospitals to ensure patients have access to their medications? Perhaps, the pharmacy and social worker could work more together?

When I worked in the VA system, of course drugs came from the VA, but there was a triage call center set up to handle issues of getting the drugs from VA prescribers. Also, the VA Formulary is very tight, and docs would not prescribe drugs that patients couldn't get in the system. Doesn't mean that a retail shop would have the anti-rejection drug that the VA carries on the spot, but many times the issue is a benefits-related question, whether the patient has been 'approved' for VA benefits and prescription services at the same time that they need the drug.

This is a just one more nail in the coffin of questioning why there are so many private insurers. There SHOULD simply be single payor!

Lest you say I don't 'understand' the issue, I have occasionally picked up retail shifts in small towns in the midwest, in which I've had discharged patients bring a list of drugs from a.) major city hospital hundreds miles away, sometimes in different time zones, or b.) local nursing home ton of meds, to be filled STAT, as the spouse is either dropping off the list on a Friday afternoon before settling the patient at home, or bringing the list, after the patient is settled at home with the oxygen, hospital bed, etc., The problems with those lists were not only expense, but first of all the prescriber is someone who's not allowed to write scripts outside the facility, or can't read the writing, can't figure out the drug or doses, writes for weird quantities, etc. In the case of ER scripts, often the prescriber is off-duty (and inaccessible), and no one else wants to clarify or authorize the scripts.

The seamless transfer from facility to facility is hampered a great deal by lack of access to basic patient information! And, some retail pharmacies don't even have a very good computer system to keep track of duplicate or discontinued scripts, discontinued scripts, histories, allergy information, etc.

Anonymous said...

I have interned at a hospital that had a small team of case managers and pharmacy technicians who identified patients in the hospital 'close' to discharge who were on medications that would most likely require a PA. They had a preset list of common drugs in need of PAs. The Electronic Health record flagged these patients and the case managers and pharmacy technician would initiate the PA paperwork. There were also protocols for certain agents where they would forward the info to one of the pharmacists to evaluate if there was a more cost effective treatment option. The would also contact the patient's pharmacy ahead of time to ensure stock of medication.

The hospital also has a protocol where all patients who discharged from the hospital with certain key high risk diagnosis/exacerbation would be contacted within 2 weeks post discharge to confirm PCP visits and adherence to meds and check on well being of the patient.

The team also worked with indigent patients, to set them up with patient assistance programs to help cover medication costs. It was a cool system, they initially started the service with grant money they received few years back.

As more and more health system's obtain Electronic Health Record Systems, identifying patient's who may need a PA initiated becomes a lot easier to stream line. The system can be handled by pharmacy technicians rather than dedicating a pharmacist to the task.

Anonymous said...

Commenter at 10:34; do you think there are more facilities that are doing this? This sounds like what should be done. JCAHO is not mandating it, yet, but this sounds like the way to go for ensuring care is transferred from tertiary to primary care settings. May you, please, reference this? Thanks

Anonymous said...

University of Wisconsin Hospital has system set up like described above