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Comprehensive medication reviews: Better health, lower costs

Older adults in the U.S. take more prescription medications than any other age group: According to a report by the Centers for Disease Control and Prevention, about one-third of adults in their 60s and 70s use five or more prescription drugs. (The most commonly used drugs are prescribed for cholesterol, high blood pressure, and diabetes medications.)

“With multiple medication use, patients are at an increased risk of adverse effects,” said Dani Markus, a pharmacist who leads product development and clinical initiatives to optimize medication use at Cardinal Health Outcomes™. The Outcomes™ Personal Pharmacist Network provides medication therapy management (MTM) services – including conducting medication reviews, ensuring patient adherence, addressing gaps in therapy, referring patients to other care providers and more – to patients nationwide.

“Medication-related problems include inappropriate dosing; negative interactions between various prescriptions, or between prescriptions and over-the-counter medications; drug-disease interactions (when a medication prescribed to treat one condition worsens another condition or even causes a new one); gaps in medications; medication non-adherence (not taking medications as prescribed); or taking medications that are no longer needed.”

Any of these problems can cause a wide range of side effects, including falls, cognitive decline, increased hospital admissions and increased use of emergency departments. The more prescriptions and supplements a person takes, the higher the risk of side effects, Markus said.

The benefit of a comprehensive medication review (CMR)

With a CMR, pharmacists use their medication expertise to review all of a patient’s medications, looking for any potential problems. As defined by the National MTM Advisory Board, “a CMR is a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them with the patient’s caregiver and/or prescriber. A CMR is an interactive person-to-person consultation conducted between the patient and/or caregiver and the pharmacist and is designed to improve patients’ knowledge of their prescription, over-the-counter (OTC) medications, herbal therapies and dietary supplements, identify and address problems or concerns that patients may have, and empower patients to self-manage their medications and their health condition(s).”

During the conversation – which typically takes approximately 30 minutes – the pharmacist asks questions to learn whether the patient faces any challenges in taking medications as prescribed. These might include financial or transportation barriers that make it hard to get prescriptions filled or refilled, lack of care coordination among providers, or a lack of understanding about what a medication is for.

“The CMR provides a great opportunity to educate the patient about each prescription, how it works, and why it’s necessary – or why it isn’t necessary,” Markus said. At the end of the conversation, the pharmacist develops a comprehensive medication list and a customized action plan to provide to the patient and the patient’s other health care providers. 

CMRs have been shown to increase patient engagement by empowering patients in their own care: These comprehensive reviews with pharmacists help patients manage their chronic conditions better, reduce hospital admissions and emergency department visits, and reduce costs. CMRs are considered so important that the Centers for Medicare & Medicaid Services (CMS) requires health plans to provide an annual CMR to all members who are covered by Medicare Part D and meet specific eligibility criteria, including having multiple chronic conditions, taking multiple prescriptions, and meeting an annual medication cost threshold.

Partnering with Community Health Group to provide quality CMRs

For several years, Outcomes™ has leveraged its scalable technology and expansive network of pharmacies to deliver a variety of MTM services to the patient members of Community Health Group (CHG), a nonprofit group health plan in San Diego County, California. CHG serves more than 320,000 members, including many older adults and a significant number of Spanish-, Vietnamese-, and Arabic-speaking patients.

In 2019, CHG and Outcomes™ wanted to measure just how much impact CMRs have. Ross Frei, Outcomes™ senior product manager, explained, “Both our organizations believe in the core value of the CMR – we’ve seen how CMRs can improve the health and quality of life for patients. But CMS reporting requirements only ask for a “yes” or “no” response to the question of whether the patient received a CMR. That simply doesn’t lead to solid evidence about the real value of a CMR. We wanted to be able to quantify the results.”

Ashley Teijelo, CHG’s former pharmacy director, said, “We started with a shared vision: We want to provide CMRs to empower patients to better manage their medications and their health conditions. And we want to understand the expected return on investment for a pharmacist-led program based on the health care costs of members who received a CMR versus those who did not. We knew when we began this analysis that we wanted to expand our CMR program to reach more patients, and we needed a better understanding of the cost, the impact, and the savings.”

The Outcomes™ team provided in-depth training to the small pharmacy staff at CHG; then, over the course of 2019, the Outcomes™ Personal Pharmacist Network and the CHG pharmacists conducted one-on-one CMRs with about 1,000 patients through the Connect™ Platform, a digital solution that provides easy access to patient-specific information to resolve medication problems, deliver clinical services and educate on key health care topics.

For the 2019 benefit year, they targeted patients who met certain criteria:

  • Had three or more chronic conditions (asthma, chronic obstructive pulmonary disease [COPD], congestive heart failure [CHF], diabetes, hypertension, dyslipidemia, and/or bone disease [either arthritis or osteoporosis]).
  • Had prescriptions for at least eight medications covered by Medicare Part D.
  • Were likely to incur one-fourth of the annual cost threshold for covered part D drugs. (In 2019, the annual cost threshold was $4,044.)

Analyzing the results

At the end of the benefit year, the team studied the records of all patients who were enrolled in CHG for all 12 months and who met the CMR criteria above, then compared total health care costs, pharmacy costs, and medical costs. CHG members who received a CMR averaged a 5% lower total cost of care compared to the members who did not. They also spent less time in the hospital, decreased their overall cost of care, and had improved health outcomes.

They repeated the process in 2020, and again studied the patient records at the end of the year. This analysis showed even more savings: Those who had a CMR averaged a nearly 17% lower total cost of care.

In 2020, CHG members who received a CMR also realized:

  • A nearly 43% decrease in inpatient acute care costs;
  • A 42% decrease in outpatient emergency room costs;
  • A more than 34% decrease in inpatient non-acute care costs; and
  • A nearly 36% decrease in overall medical costs.

“We can’t be sure that all of the savings are the result of CMRs,” Teijelo said. “Those members who were more willing to participate in CMRs may be more engaged with their providers generally, and more likely to ask questions about their medications – and therefore more likely to have better health outcomes even without the CMR. In addition, 2020 was a highly-unusual year; hospitals were overwhelmed with COVID-19 patients, and the COVID-19 pandemic made it more difficult, if not impossible, for patients with non-COVID conditions to visit physician offices or emergency departments.

“However, anecdotally I can say that as the Outcomes™ pharmacists and our staff pharmacists conducted CMRs, we often heard comments from our members, like, ‘Wow. No one ever told me that,’ about various medications they were on, how the medications impact the body, and how they interact with each other. Those ‘aha!’ moments are really meaningful for patients.”

Frei said, “In this analysis, the CMR did increase the cost of pharmacy services and specialty services, but even when these are factored in, the reduction in health care costs is very significant.”

Added Markus, “We were pleased to see the positive impacts of the CMRs. Better health for less cost is what we all want. The success of this partnership points to the powerful role pharmacists can play in improving patients’ health.”