Impact of a Medicare MTM Program: Evaluating Clinical and Economic Outcomes | Page 3
Published Online: February 25, 2014
Rita L. Hui, PharmD, MS; Brian D. Yamada, PharmD; Michele M. Spence, PhD; Erwin W. Jeong, PharmD; and James Chan, PharmD, PhD
This study, as far as we know, is the largest in size with 172,660 participants and a long follow-up time of 12 months to evaluate MTM services. The validity of our results was strengthened, as the size of the study population allowed us to detect very small differences in outcomes. Our study matched MTM to control patients by age, gender, location, and DxCG score. The ability to match at a 1:4 ratio also increased the power and provided greater precision in estimates and tests. We decided to use DxCG as a matching criterion because all but 1 of our outcomes was related to resource utilization. Matching non-MTM-eligible patients may avoid some of the selection bias. Several previous MTM studies analyzed populations of patients who opted in versus those who opted out of MTM participation. Patients who opted in for MTM services may have been more engaged in their healthcare, favoring results for patients enrolled in MTM. The matching in our study was not perfect, as subjects in MTM services had a higher disease burden at baseline, with greater hospitalization, ED visits, and medication costs. This may be due to the fact that eligibility for MTM required meeting a threshold annual medication cost and having multiple chronic conditions. The control group in our study were Medicare members, without 2 of the chronic conditions as stated in KP MTM criteria; or having a lowerthan- threshold annual Part D medication cost. After matching for age, gender, and DxCG, we found that our control group did not have the same disease burden in terms of prior hospitalization and ED visit rate and medications used, when compared with MTM study group. We used CCI and specific prior utilization to adjust the outcomes and conducted a difference in differences comparison in order to account for these baseline differences. It is impossible to conduct a cohort study that avoids all selection bias because MTM eligible patients have a higher disease burden by definition when compared to all non-eligible Medicare enrollees. The current study matched with a control group with less disease burden, based on baseline utilization. Hence, the primary outcome of mortality would be expected to be lower in the control group. Yet, we observed a favorable mortality rate in our MTM intervention group.
Given that KP is an integrated care system and the current study was limited to patients in California, there might be limited generalizability of the results.
The retrospective nature of this study inherently requires a level of caution when interpreting the results. Our study did not examine into what specific components or processes from the MTM program were associated with the outcomes. For example, pharmacist-led discontinuation of skeletal muscle relaxants, a class of medications to be avoided in the elderly, may have been a significant factor in the reduction in inpatient hospitalization. We also did not evaluate any surrogate markers, such as blood pressure, lipid levels, or glycated hemoglobin. Since the 2 groups were not matched on disease burden and not everyone would have these surrogate markers measured during the time period, we decided to look at outcomes that we could observe for the entire cohort. We also did not estimate the return on investment for the MTM services provided at KP California, as other studies had investigated this matter extensively.6-8,23,24
This study is the largest to date, helping to supplement and strengthen available literature. Studies such as ours are essential to ensure that MTM services continue to provide a positive impact on health outcomes. The KP California Medicare MTM program provides targeted services that, when combined with other healthcare services, are likely to improve patient outcomes. Although the direct effect of specific interventions was not investigated, it can be noted that there is a reduction in mortality and inpatient hospitalizations when usual care is supplemented with a pharmacist-led MTM program.
Author Affiliations: Pharmacy Outcomes Research Group, Kaiser Permanente Drug Information Services (RLH, MMS, JC); Kaiser Permanente Drug Information Services, PGY-2 Pharmacy Resident in Drug Information (BDY); Kaiser Permanente Southern California Medicare Medication Therapy Management (EWJ).
Funding Source: This study was funded by Kaiser Permanente Drug Information Services.
Authorship Information: Concept and design (RLH, BDY, MMS, JC); acquisition of data (RLH, MMS); analysis and interpretation of data (RLH, BDY, MMS, EWJ, JC); drafting of the manuscript (RLH, BDY, EWJ); critical revision of the manuscript for important intellectual content (RLH, BDY, MMS, EWJ, JC); statistical analysis (RLH, BDY); provision of study materials or patients (EWJ); administrative, technical, or logistic support (RLH).
Author Disclosures: The authors (RLH, BDY, MMS, EWJ, JC) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Address correspondence to: Rita L. Hui, PharmD, MS, 1800 Harrison St, Ste 1301, Oakland, CA 94612. E-mail: Rita.L.Hui@kp.org
1. Centers for Medicare and Medicaid Services. Prescription Drug Coverage - General Information. 2012. 10-29-2012.
2. Centers for Medicare & Medicaid Services: Medication Therapy Management. 2012. 10-29-2012.
3. American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc (2003). 2008;48(3):341-353.
4. Bluml BM. Definition of medication therapy management: development of professionwide consensus. J Am Pharm Assoc (2003). 2005; 45(5):566-572.
5. Pellegrino AN, Martin MT, Tilton JJ, Touchette DR. Medication therapy management services: definitions and outcomes. Drugs. 2009;69(4): 393-406.
6. Isetts BJ, Schondelmeyer SW, Artz MB et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc (2003). 2008;48(2):203-211.
7. Pindolia VK, Stebelsky L, Romain TM, Luoma L, Nowak SN, Gillanders F. Mitigation of medication mishaps via medication therapy management. Ann Pharmacother 2009;43(4):611-620.
8. Smith M, Giuliano MR, Starkowski MP. In Connecticut: improving patient medication management in primary care. Health Aff (Millwood). 2011;30(4):646-654.
9. Smith SR, Catellier DJ, Conlisk EA, Upchurch GA. Effect on health outcomes of a community-based medication therapy management program for seniors with limited incomes. Am J Health Syst Pharm. 2006;63(4):372-379.
10. Welch EK, Delate T, Chester EA, Stubbings T. Assessment of the impact of medication therapy management delivered to home-based Medicare beneficiaries. Ann Pharmacother. 2009;43(4):603-610.
11. Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc (2003). 2006;46(2):133-147.
12. Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc (2003). 2008;48(1):23-31.
13. Fox D, Ried LD, Klein GE, Myers W, Foli K. A medication therapy management program’s impact on low-density lipoprotein cholesterol goal attainment in Medicare Part D patients with diabetes. J Am Pharm Assoc (2003). 2009;49(2):192-199.
14. Gillespie U, Alassaad A, Henrohn D et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169(9):894-900.
15. Moczygemba LR, Brannier JC, Gabrillo ER. Outcomes of a Medicare Part D telephone medication therapy management program. J Am Pharm Assoc (2003). 2012;52(6):e144-e152.
16. Pinto SL, Bechtol RA, Partha G. Evaluation of outcomes of a medication therapy management program for patients with diabetes. J Am Pharm Assoc (2003). 2012;52(4):519-523.
17. Stockl KM, Tjioe D, Gong S, Stroup J, Harada AS, Lew HC. Effect of an intervention to increase statin use in medicare members who qualified for a medication therapy management program. J Manag Care Pharm. 2008;14(6):532-540.
18. Watkins JL, Landgraf A, Barnett CM, Michaud L. Evaluation of pharmacist-provided medication therapy management services in an oncology ambulatory setting. J Am Pharm Assoc (2003). 2012;52(2): 170-174.
19. Winston S, Lin YS. Impact on drug cost and use of Medicare part D of medication therapy management services delivered in 2007. J Am Pharm Assoc (2003). 2009;49(6):813-820.
20. DxCG I. Guide to the Diagnostic Cost Groups (DCGs) and DCG Software, Release 4. Waltham, MA: 1999.
21. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-383.
22. Brown RS, Peikes D, Peterson G, Schore J, Razafindrakoto CM. Six features of medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Aff (Millwood). 2012; 31(6):1156-1166.
23. Barnett MJ, Frank J, Wehring H et al. Analysis of pharmacist-provided medication therapy management (MTM) services in community pharmacies over 7 years. J Manag Care Pharm. 2009;15(1):18-31.
24. Ramalho de OD, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm. 2010;16(3):185-195.