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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.
In 2011, 348 MUSE records were received by the study analytic team from OutcomesMTM. This reflected a 12.2% acceptance rate of MUSE intervention (ie, responding to the MUSE questionnaire) among the initial sample (n = 2843). In 2012, 667 MUSE records were received, representing a 20.5% acceptance rate among the sample (n = 3247). Reasons for the low acceptance rate reflected several issues. According to records of those making MUSE phone calls, nearly half of the study sample could not be reached (eg, their registered telephone number was no longer correct or they were not home to answer the call). Voicemail messages were left for those who had answering machines, and if the beneficiary did not respond by returning the call after 2 messages were left, they were deemed to have opted out of the study. Some individuals who answered the phone simply chose not to participate and opted out at that time.

Excluding those who opted out or could not be reached, the final sample size of those who participated in the MUSE intervention was 1015, of whom 1007 were successfully matched to a control beneficiary (Table 1). Relaxation of the matching criteria was only moderately successful in matching the other 8, so they were eliminated from the analyses. There were 343 and 664 matched beneficiaries in the 2011 and 2012 groups, respectively. Of those, 4.77% (n = 48) of the intervention group and 2.38% (n = 24) of the control group had a CMR in either 2011 or 2012.

Using the quasi-information criterion for model selection,26 the interaction of intervention/control with year was dropped. Thus, in the final model, the likelihood of having a CMR was modeled as a function of receiving a MUSE intervention and the intervention year, with no interaction. This implied that the interaction term was not needed, as the effect of time did not differ across the 2 groups.

Based on this model, the estimated odds of having a CMR among those who received the MUSE intervention were double that of their corresponding control beneficiaries (P = .0048), across both study years (Tables 2 and 3). In 2011, 2.33% of the MUSE intervention participants had a CMR in the 6-month observation period, whereas 0.58% of the control group beneficiaries had one, resulting in an observed odds ratio of 4.09. In 2012, 6.02% of the beneficiaries in the MUSE intervention had a CMR, whereas 3.31% of the control group did so, resulting in an observed odds ratio of 1.87. Since the yearly odds were not significantly different, the modeled pooled estimate of the odds ratio of the MUSE intervention over control was 2.06.

A large increase in the odds of having a CMR was seen between 2011 and 2012 in both study groups. The odds of having a CMR in 2012 were estimated to be more than 3 times the odds of doing so in 2011 (P = .0004), across both groups. Members of the control group had observed odds of having a CMR in 2012 that were 5.87 times larger than the corresponding odds in 2011. In the MUSE intervention group, the observed odds of a CMR were 2.69 times higher in 2012 than in 2011. The final model estimate, which combines information in the intervention and control groups, was an odds ratio of 3.33 for the year of 2012 over 2011.

DISCUSSION

In this study, the delivery of the MUSE was associated with a higher completion percentage of CMRs, implying that the MUSE intervention engaged beneficiaries in seeking a pharmacist-provided medication review. Three possible explanations for this association can be considered: first, the MUSE intervention includes interactive communication between outreach personnel and the beneficiaries. The interactive communication is deemed to be more compelling than 1-way communication, encouraging participants to pay closer attention and to remember more of the information that was delivered.27 Similarly, the MUSE intervention would be more noteworthy to the beneficiaries than a general promotional activity such as a flyer introducing the CMR service. Interpersonal contact could increase the likelihood that beneficiaries become aware of the CMR during the MUSE intervention, which could stimulate future CMR participation.

Second, earlier research showed that interventions tailoring information to individuals are more effective than untailored ones in promoting health behavior change.28-30 Such tailoring could contribute to the effectiveness of the MUSE intervention, given that MUSE recipients received personalized advice about their potential to benefit from receiving a CMR. As such, the advice—versus non-personalized advice—would be more meaningful during the period when beneficiaries were deciding whether or not to obtain a CMR. This is also supported in a study by Tang and colleagues,21 suggesting that individually tailored information is most welcome to patients.

Third, through the MUSE phone call, beneficiaries’ expectations of benefiting from a CMR could enhance their willingness to receive a CMR, and in turn stimulate their engagement in such pharmacist-provided medication review services. Having perceived value from a health service mirrors the recent findings of an Australian research group.16-18 By introducing the CMR as a low-cost medication information resource, the MUSE intervention may have led beneficiaries to expect an outcome of reduced medication concerns through participation in a CMR in the future.

It was observed that the overall CMR percentage increased from 2011 to 2012. One explanation for this may be the influence of CMS on Medicare plans. CMS has implemented a series of policy changes for MTM programs, focusing on Medicare plans; these changes include the obligation to offer an annual CMR, the requirement of using a standardized format for giving patients a summary of the CMR, and the inclusion of the CMR completion rate as a display quality measure in Star ratings going forward. These policy changes emphasized the importance of CMRs so that plans would pay more attention to promoting them. In addition, pharmacies that have contracts with multiple Part D plans would have seen increased demand for CMRs, and consequently expanded their CMR capacity.

Another potential explanation focuses on interpersonal influence by physicians, friends, or family members. General practitioners’ social influence has been found to affect patients’ acceptance of such medication review services in Australia.18 The strong relationship between a patient and physician, involving high levels of trust, could have a direct influence on patients’ health behaviors. Specifically, if the physician promoted the usefulness of pharmacist-provided medication review services, the patient would be more likely to believe that participation in a CMR is beneficial. With the recent growth of MTM services, it is believed that physicians became more supportive, which in turn increased patients’ overall acceptance of the CMR over the 2 years. As more and more beneficiaries experience CMRs, they might talk to their family members or friends about the benefits of such services.31 These positive word-of-mouth messages could have contributed to the observed increased CMR percentages as well.

The 7-question MUSE tool was effective in collecting helpful patient-reported information within a short period of time. Having such tailored information can improve the quality and efficiency of the interactive communication between the outreach personnel and the beneficiaries. Thus, the use of tools, such as the MUSE intervention, is promising for stimulating medication reviews in the future due to their potential to improve the efficiency and personalization of interactive communication through standardized interventions.

Limitations

As with any study, some limitations exist. Only 2 Medicare Part D plans were included, which restricts the generalizability of the findings, though one was a PDP and the other was an MA-PD. Also, some beneficiaries could not be invited to participate in the MUSE intervention because the available contact information was either not current or inaccurate. Such poor maintenance of accurate contact information reinforces the importance of updating patients’ details in a timely manner to support likewise timely outreach activities. Additionally, beneficiaries were responsible for scheduling a CMR themselves with the local pharmacist; even if the MUSE score indicated a high likelihood of benefiting from a CMR, while they might have fully intended to do so, some otherwise willing patients may not have made an appointment with the pharmacist after the MUSE call.

Future Research

Future research is needed in several areas. More beneficiaries from a variety of Medicare Part D plans could be examined to see if a patient engagement tool, such as the MUSE, stimulates participation in CMRs. For example, this study involved community pharmacists providing the CMRs. Some Part D plans rely only on their own pharmacists providing such services over the telephone. The use of the MUSE tool likely could help these plans target their telephone outreach.

Pharmacist-provided medication reviews, such as CMRs, have been promoted within the US healthcare system for several years. However, the low participation rate in CMRs implies a lack of engagement on the part of beneficiaries in choosing or accepting such services. This study suggests that incorporating an intervention like MUSE into the promotion of CMRs—by Part D plans, accountable care organizations, pharmacies, and other stakeholders—could be helpful in patient engagement. The MUSE tool used in this intervention could also assist these stakeholders to screen targeted beneficiaries by adding self-reported information into their screening process.

CONCLUSIONS

The MUSE intervention may be associated with participation in CMR services among Medicare Part D beneficiaries. In addition, the completion percentage of CMRs increased from year to year with the enhanced promotion of MTM services. The MUSE tool can be used by Part D plans and other stakeholders to assist in engaging targeted beneficiaries to receive pharmacist-provided medication reviews.

Acknowledgments

The authors wish to acknowledge Scott Egerton and John Witt for their help with data collection, data management, and initial summaries of the data.

Author Affiliations: College of Pharmacy (WRD, YZ) and College of Public Health (GB, JFP, EAC), University of Iowa, Iowa City, IA; College of Pharmacy, University of Michigan (KBF), Ann Arbor, MI; OutcomesMTM (JF), West Des Moines, IA.

Source of Funding: This study was funded by a grant from the Agency for Healthcare Research and Quality, #1R18HS18353.

Author Disclosures: Dr Frank is an employee of OutcomesMTM. Drs Doucette, Pendergast, and Farris, and Ms Zhang, Ms Chrischilles, and Mr Brown report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (WRD, JFP, JF, KBF); acquisition of data (WRD, JF); analysis and interpretation of data (WRD, JFP, YZ, GB, EAC, KBF, JF); drafting of the manuscript (WRD, YZ, GB, EAC, JF); critical revision of the manuscript for important intellectual content (WRD, JFP, YZ, GB, EAC, KBF, JF); statistical analysis (JFP, YZ, GB); provision of patients or study materials (WRD, JF); obtaining funding (WRD); administrative, technical, or logistic support (WRD, JF); and supervision (WRD, JP).

Address correspondence to: William R. Doucette, PhD, University of Iowa College of Pharmacy, 115 S Grand Ave, 518 PHAR, Iowa City, IA 52242-1112. E-mail: william-doucette@uiowa.edu.

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