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Stimulating Comprehensive Medication Reviews Among Medicare Part D Beneficiaries
William R. Doucette, PhD; Jane F. Pendergast, PhD; Yiran Zhang, MS, BS Pharm; Grant Brown, PhD; Elizabeth A. Chrischilles, PhD; Karen B. Farris, PhD; and Jessica Frank, PharmD
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Stimulating Comprehensive Medication Reviews Among Medicare Part D Beneficiaries

William R. Doucette, PhD; Jane F. Pendergast, PhD; Yiran Zhang, MS, BS Pharm; Grant Brown, PhD; Elizabeth A. Chrischilles, PhD; Karen B. Farris, PhD; and Jessica Frank, PharmD
This article describes a study of an intervention to engage Medicare Part D beneficiaries in obtaining a comprehensive medication review.
ABSTRACT

Objectives: To assess the impact of a patient engagement intervention utilizing the Medication User Self-Evaluation (MUSE) tool on the completion percentage of comprehensive medication reviews (CMRs) among Medicare Part D beneficiaries.

Study Design: A case-control study.

Methods: Beneficiaries from 2 Medicare Part D plans were randomly assigned to 3 study arms (1 control arm plus 2 intervention arms for 2011 and 2012, respectively). Each beneficiary who participated in the MUSE intervention met 3 inclusion criteria and was matched with a single control group beneficiary based on: gender; age (within 5-year interval); plan type (ie, Medicare Prescription Drug Plan, Medicare Advantage Prescription Drug Plan); number of unique prescriptions; pharmacy medication therapy management (MTM) training status; and time period (2011, 2012). The outcome of interest was whether or not the beneficiary received a CMR in the 6 months following the index date. Generalized estimating equation (GEE) models were used to compare CMR percentages over time and between MUSE intervention groups. This study used MTM service claims data.

Results: The final sample of 1015 beneficiaries received MUSE intervention, of which 1007 were successfully matched to a control beneficiary. The estimated odds of having a CMR among those who received the MUSE intervention were 2 times that of their counterparts (P = .0048) across both study years. 

Conclusions: Given the strong evidence found for a positive association between participation in a CMR and the MUSE intervention, Part D plans could use the MUSE to engage targeted beneficiaries in using pharmacist-provided MTM services.
 
Am J Manag Care. 2015;21(6):e372-e378
Take-Away Points
 
Among Medicare Part D beneficiaries, the low uptake of comprehensive medication reviews (CMRs) remains a concern. To our knowledge, there has been limited effective stimulation of beneficiaries to seek CMRs. This study assessed the impact of a Medication User Self-Evaluation (MUSE) intervention tool designed to engage beneficiaries’ use of CMRs.
  • The MUSE tool was found to be associated with a higher completion rate of CMRs, providing significant empirical evidence of the importance of enhancing awareness and applying personalized information. 
  • It is feasible that the MUSE tool can be used by Part D plans and other stakeholders to help engage targeted beneficiaries to use such pharmaceutical services.
Medicare Part D plans have been required to offer medication therapy management (MTM) programs to eligible enrollees since 2006.1 CMS has expanded the scope of MTM services since then, further acknowledging the benefits of avoiding drug-related problems, optimizing medication outcomes, and decreasing healthcare costs.2 Currently, the comprehensive medication review (CMR) serves as a fundamental component of that expansion, as Part D plans must offer an annual CMR to all eligible MTM program enrollees.3 An annual CMR must involve an interactive review and consultation that cover all of a beneficiary’s medications obtained through contact with a pharmacist or other qualified provider.3,4

Despite this requirement, the participation in CMRs has been lower than anticipated. The national median CMR completion rate among MTM eligibles was only 10.9% based on the 2014 display measure report, using the 2012 performance data submitted by Part D plans.5 CMS has attempted to improve the situation by imposing additional requirements, including the use of a 3-component standardized format—a CMR cover letter, a medication action plan, and a personal medication list—for a written summary of CMR results, setting the CMR completion rate as a display quality measure for plans, and possibly applying the CMR completion rate to Star ratings for drug plans in 2016.4,6-9 Still, the policy changes alone have had limited effect on engaging Part D beneficiaries to use CMRs, because they regulate the activity of plan sponsors but not the behavior of beneficiaries.

One barrier to CMR participation revealed in previous studies is that the majority of eligible Medicare Part D beneficiaries are unaware of or do not understand MTM services. These factors result in relatively low expectations of personal benefit from such services, including CMRs, and underscore the importance of finding effective ways to encourage beneficiaries to participate in MTM services.10-15 Recently, in exploring Australian patients’ utilization of Home Medicines Review (HMR)—a pharmacist-provided service available in Australia for patients’ medication assessment—Carter et al16-18 found that increased patient expectations of receiving useful medication information can motivate eligible patients to use that service. Although many of the details of HMR differ from CMR, the two are similar in that a pharmacist conducts a comprehensive interview with the patient about their medications. The findings of Carter et al are informative to us: it is likely that highlighting the CMR as a valuable medication information source would stimulate Medicare beneficiaries’ engagement in MTM services. Also, the literature has shown that patients generally seek more health information than what they receive19-21; specifically, they would like information that is tailored to them during their physician visits,21 which could translate to getting medication information in a CMR during a pharmacy visit.22,23 These findings suggest the importance of exposing Part D beneficiaries to personalized information regarding eligibility and potential benefits from the CMR. Offering such personalized advice may require direct input from Part D beneficiaries, such as health information and behaviors. It is insufficient to rely solely on prescription claims, as Medicare Part D plans often do.

Motivated by these findings, a patient engagement intervention was implemented as part of an MTM quality improvement project. The intervention utilized the Medication User Self-Evaluation (MUSE) tool (Figure), which was validated to be useful in targeting MTM services among Medicare Part D beneficiaries by estimating their likelihood of benefiting from the services.24 The MUSE incorporates 7 items as a self-reported questionnaire: it asks about the number of medical conditions; whether the patient has forgotten to take medications; if cost-related issues exist regarding prescriptions; if there have been hospitalizations in the past 6 months; and the number of prescribed medications, physicians, and pharmacies utilized. Part D beneficiaries’ responses were used to provide their own likelihood of benefiting from a CMR. It was expected that calling Medicare beneficiaries to complete the MUSE would stimulate them to seek a CMR if they were given feedback to expect a benefit from a CMR.

Objective

The objective of this study was to assess the impact of the MUSE intervention on the completion percentages of CMRs among a cohort of Medicare Part D beneficiaries.

METHODS

Study Design & Setting

OutcomesMTM, an MTM program administrator, provided a sampling frame of eligible Medicare beneficiaries and staff for the implementation of the MUSE intervention. OutcomesMTM has extensive experience in MTM program administration, having administered pharmacist-delivered clinical intervention programs for more than 10 years, covering more than 5 million patients. The pharmacists in OutcomesMTM’s network have been trained to deliver MTM services, identify potential drug therapy problems, and take steps to resolve such issues using a secure Web-based documentation and billing platform. The participant pharmacies and beneficiaries in this study were from 2 of OutcomesMTM’s Medicare Part D clients: a Medicare Prescription Drug Plan (PDP; ie, Plan A) and a Medicare Advantage Prescription Drug plan (MA-PD; ie, Plan B). The eligibility criteria for both plans were consistent over the study period.

The study design was a case-control study implemented in 2011 and 2012. The MUSE intervention cases were 2 targeted subsets—1 in 2011 and 1 in 2012—randomly selected to be offered the MUSE intervention, while controls were matched from a control arm. Both cases and controls received the usual MTM services through OutcomesMTM’s program, but only the intervention group was offered the MUSE. Two time periods allowed separation of temporal effects from study intervention effects.

Within the larger sampling frame of beneficiaries, only those who met 3 inclusion criteria were selected randomly to receive the MUSE intervention; criteria included being 65 years or older, having received at least 12 prescription fills of any medication during a 6-month pre-intervention period (April 1 to September 30 in 2010 or 2011), and having been continuously enrolled during the time frame of interest (2 prescription fills at least 150 days apart).25 This ensured that beneficiaries were eligible for a CMR under Medicare Part D, were continuously enrolled through the monitoring window, and were taking several medications for chronic conditions. The final targeted sample sizes for the MUSE intervention were 2843 beneficiaries in 2011 and 3247 in 2012. The study was approved by the University of Iowa Institutional Review Board.

Intervention

The patient engagement intervention (ie, MUSE intervention) was designed to stimulate participation in CMRs among Medicare Part D beneficiaries. Beneficiaries in the intervention arms received a letter from OutcomesMTM describing MTM services, and notification of a patient engagement telephone call. Operationally, the contact process was done on a rolling weekly basis to notify beneficiaries of the phone call that they would receive within the upcoming week. The beneficiaries in the control arm were not contacted by study personnel during the study period. The week after the mailing, outreach personnel at OutcomesMTM called beneficiaries, primarily during the day. If a contacted beneficiary agreed to participate, the outreach staff member and beneficiary worked through the MUSE tool together during the phone call.

The call script was programmed into a Microsoft Access database, which also collected the beneficiary’s responses during the call. Access was programmed to immediately predict the likelihood of benefit from receiving a CMR (ie, low, moderate, and high), using beneficiary responses and a validated prediction equation.24 The beneficiary was told their predicted category and given specific information on getting a CMR, though CMR appointments were not made during the call. It was the beneficiary’s choice to decide whether or not to take the next step to schedule a CMR on their own with their local pharmacist.

Matching Process

Using de-identified claims data, each beneficiary who participated in the MUSE intervention was matched to a single control beneficiary from the same time period (2011 or 2012) from the control group who did not receive the outreach phone call with the MUSE tool. Using information on prescription fills and demographics from OutcomesMTM, an exact match was required for plan, number of unique prescriptions, pharmacy training status, and gender, while age was matched to within 5 years. This process used a greedy algorithm and was conducted for each time period. When multiple matches were found, 1 was randomly selected and the remaining ones were returned to the candidate pool.

Only pharmacies in OutcomesMTM’s pool that are designated as “trained and contracted” are able to bill for CMRs; thus, MTM training is an important factor on which to be matched when evaluating the effect of the MUSE on CMRs. A beneficiary was considered associated with a trained and contracted pharmacy if they had obtained at least 1 prescription in the year of interest from such a pharmacy.

Outcome

The study outcome was whether or not the beneficiary received a CMR in the 6 months following the index date. For the intervention arms, the index date was the date of the telephone contact in the MUSE intervention. Matched beneficiaries from the control arm were given the same index date so that the pair would be monitored for a CMR in the same 6-month period. The chosen observation window was assumed to give potential beneficiaries sufficient time to complete a CMR if they wanted to do so, but not so long as to become unrelated to the MUSE intervention. The intervention year was incorporated to allow assessment of change in environment over time. CMRs performed outside the 6-month window were not counted.

Data Analysis

Generalized estimating equations were used to model CMR percentage over time and between those who did and did not receive the MUSE intervention, incorporating correlation due to the matching. The MUSE intervention indicator was 1 if the beneficiary received the intervention, and 0 if they did not. Year was also treated as a binary variable, set to 1 for 2012 and 0 for 2011. Two-way interactions were explored. The logit link and binomial distribution for the outcome were assumed. All statistical analyses were performed in SAS version 9.3 (SAS Institute, Cary, North Carolina).

RESULTS

 
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