Collaborative DTM Reduces Hospitalization and Healthcare Costs in Patients With Diabetes Treated With Polypharmacy
Published Online: March 14, 2014
Lauren Brophy, PharmD, FAHM; Amanda Williams, PharmD; Eric J. Berman, DO, MS; David Keleti, PhD; Karen E. Michael, RN, MSN, MBA; Margaret Shepherd, RPh, FAHM; Scott A. Fox, MS, MEd; Christine Jacobs, MA; Susan Tan-Torres, MD, MPH; Andrea D. Gelzer, MD; and Mesfin Tegenu, MS, RPh
According to the American Pharmacists Association, drug therapy management (DTM) is a service that optimizes therapeutic outcomes by way of pharmaceutical interventions intended to (1) elicit changes in drug regimens; (2) reduce the incidence of adverse drug events; and (3) improve adherence. Formerly an underutilized component of the healthcare team approach to treating patients, implementation of DTM services has been facilitated by a payment framework created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
DTM is frequently a stand-alone service consistent with a traditional, siloed approach to healthcare. Although an integrated approach to healthcare is preferred, DTM as a component of a segmented healthcare system has demonstrated impressive quality improvements and cost savings. The Minnesota Medicaid Medication Therapy Management program realized healthcare cost savings of $3768 per patient per year between 2006 and 2007.1 The North Carolina ChecKmeds medication therapy management program for more than 15,000 Part D seniors saved an estimated $13.2 million in healthcare costs in 2010.2 The Iowa Medicaid Pharmaceutical Case Management program demonstrated a significantly improved mean Medication Appropriateness Index score among participants compared with baseline (P <.001) over a 9-month period between 2000 and 2001.3 Managed care organizations (MCOs), occasionally employing pharmacy benefits managers (PBMs),4 have also increasingly incorporated DTM services into benefit offerings, demonstrating positive outcomes.5,6 While DTM service providers are primarily pharmacists, a pharmacist is not a prerequisite for a DTM program. In fact, in 10% of 2012 Medicare Part D programs, a case manager provided DTM-type services.4
Not all patients, however, benefit from DTM services, and intervention should focus on those at highest risk. Comorbidities such as cardiovascular disease, hypertension, and nephropathy7 frequently accompany a diagnosis of diabetes, and patients with multiple comorbidities are often managed with polypharmacy. Polypharmacy increases the risk of medication-related problems (MRPs), reducing population health and driving up health care costs, a problem complicated by the prescription of more medications than clinically warranted. Polypharmacy also promotes suboptimal adherence,8 resulting in underutilization of preventative, lower-cost primary care services and overutilization of higher-cost emergency department (ED) services.9,10 Thus, despite lower medication-related costs from low adherence and reduced pharmacy utilization, costs are transferred to the medical sphere via less effective emergency care, thereby increasing overall healthcare costs.
DTM is a valuable service proven to improve healthcare quality and reduce costs. Various DTM delivery models exist. A literature search revealed a lack of DTM programs that incorporate a care manager in addition to a pharmacist (see Table S1 in Appendix). The value of DTM services may be enhanced with an integrated approach that includes a care manager. This study was designed to evaluate the effects of a PBM/health plan–administered, collaborative DTM program that incorporates both a pharmacist and a care manager targeted to high-risk patients with diabetes treated with polypharmacy. We were primarily interested in determining whether the DTM program would reduce medical utilization and total costs (pharmacy + medical). We hypothesized that DTM intervention would reduce medical utilization, as measured by ED visits and inpatient admissions, and generate total cost savings, despite a predicted increase in pharmacy costs.
Population and Study Design
PerformRx, the fully owned PBM of AmeriHealth Caritas Family of Companies (ACFC), serves just under 3 million health plan members. Partnering Medicaid MCOs and fully owned ACFC subsidiaries Keystone First (KF) and Ameri- Health Caritas Pennsylvania (ACP) serve about 290,000 and just over 126,000 members, respectively, as of January 2014. These 3 entities jointly developed a collaborative, Utilization Review Accreditation Commission–accredited DTM program to improve member care. PerformRx was responsible for the pharmacy-based management component of the DTM program. KF and ACP supplied the DTM program participants and executed the care management (CM) component.
This retrospective study was designed as a quasi-experiment with comparison group. The targeted participants were patients with diabetes (International Classification of Diseases, Ninth Revision, codes for diabetes [250.xx] or 1 diabetes medication within the previous year) being treated with polypharmacy (unique generic code number count of >15). This patient population was selected because the likelihood of comorbidities with diabetes and polypharmacotherapy put these patients at high risk for MRPs and nonadherence.9
The study population analyzed consisted of 954 DTM participants (n = 690 KF, n = 264 ACP) reviewed by a pharmacist for DTM services. The matched control group consisted of 810 DTM participants (n = 600 KF, n = 210 ACP) not reviewed by a pharmacist for DTM services, but who may have received autonomous CM services. The baseline period (November 1, 2009-October 31, 2010) was followed by a 1-year measurement period (November 1, 2010-October 31, 2011). Members enrolled in the plan for less than 6 months during baseline or measurement periods were excluded. Additionally, members reviewed by a pharmacist in the final 3 months of the measurement period (August 1, 2011-October 31, 2011) were excluded because recommendations made during that time would not have had the standard 3-month time frame allowed for follow-up and outcome determination. Analysis was performed 6 months postmeasurement, allowing sufficient lag time to receive medical claims.
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