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The American Journal of Managed Care November 2019
Population Health Screenings for the Prevention of Chronic Disease Progression
Maren S. Fragala, PhD; Dov Shiffman, PhD; and Charles E. Birse, PhD
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Comprehensive Health Management Pharmacist-Delivered Model: Impact on Healthcare Utilization and Costs
Leticia R. Moczygemba, PhD, PharmD; Ahmed M. Alshehri, PhD; L. David Harlow III, PharmD; Kenneth A. Lawson, PhD; Debra A. Antoon, BSPharm; Shanna M. McDaniel, MA; and Gary R. Matzke, PharmD
Value Assessment and Heterogeneity: Another Side to the Story
Steven D. Pearson, MD, MSc
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Joshua J. Ofman, MD, MSHS
Multimodality Cancer Care and Implications for Episode-Based Payments in Cancer
Suhas Gondi, BA; Alexi A. Wright, MD, MPH; Mary Beth Landrum, PhD; Jose Zubizarreta, PhD; Michael E. Chernew, PhD; and Nancy L. Keating, MD, MPH
Medicare Advantage Plan Representatives’ Perspectives on Pay for Success
Emily A. Gadbois, PhD; Shayla Durfey, BS; David J. Meyers, MPH; Joan F. Brazier, MS; Brendan O’Connor, BA; Ellen McCreedy, PhD; Terrie Fox Wetle, PhD; and Kali S. Thomas, PhD
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Richard H. Stanford, PharmD, MS; Anna D. Coutinho, PhD; Michael Eaddy, PharmD, PhD; Binglin Yue, MS; and Michael Bogart, PharmD
CKD Quality Improvement Intervention With PCMH Integration: Health Plan Results
Joseph A. Vassalotti, MD; Rachel DeVinney, MPH, CHES; Stacey Lukasik, BA; Sandra McNaney, BS; Elizabeth Montgomery, BS; Cindy Voss, MA; and Daniel Winn, MD
Importance of Reasons for Stocking Adult Vaccines
David W. Hutton, PhD; Angela Rose, MPH; Dianne C. Singer, MPH; Carolyn B. Bridges, MD; David Kim, MD; Jamison Pike, PhD; and Lisa A. Prosser, PhD
Prescribing Trend of Pioglitazone After Safety Warning Release in Korea
Han Eol Jeong, MPH; Sung-Il Cho, MD, ScD; In-Sun Oh, BA; Yeon-Hee Baek, BA; and Ju-Young Shin, PhD
Multipayer Primary Care Transformation: Impact for Medicaid Managed Care Beneficiaries
Shaohui Zhai, PhD; Rebecca A. Malouin, PhD, MPH, MS; Jean M. Malouin, MD, MPH; Kathy Stiffler, MA; and Clare L. Tanner, PhD

Comprehensive Health Management Pharmacist-Delivered Model: Impact on Healthcare Utilization and Costs

Leticia R. Moczygemba, PhD, PharmD; Ahmed M. Alshehri, PhD; L. David Harlow III, PharmD; Kenneth A. Lawson, PhD; Debra A. Antoon, BSPharm; Shanna M. McDaniel, MA; and Gary R. Matzke, PharmD
Pharmacist-provided comprehensive medication management led to a significant difference in emergency department visits and a cost savings of $2.10 to $2.60 for every $1.00 spent relative to a comparator group.
ABSTRACT

Objectives: To (1) examine the impact of the Comprehensive Health Management Patient Service (CHaMPS) on unplanned hospital admissions and emergency department (ED) visits in patients with chronic conditions, (2) describe the number and type of pharmacist interventions, and (3) determine the cost savings of CHaMPS.

Study Design: Retrospective, cross-sectional design with a matched comparator group.

Methods: CHaMPS integrated pharmacists within family medicine clinics to optimize medication use among patients with chronic conditions. Outcomes were the change in unplanned hospital admissions and ED visits from baseline to 180- and 365-day postintervention periods between the CHaMPS and propensity-matched comparator groups. Descriptive, bivariate (t tests and McNemar tests), and multivariate (general linear models) statistical analyses were used. Pharmacist interventions are reported and a cost-benefit analysis was conducted.

Results: A total of 624 patients (312 in the CHaMPS group and 312 in the comparator group) were included. Unplanned hospital admissions decreased in the CHaMPS group and increased in the comparator group (not significant). ED visits remained stable in the CHaMPS group but increased significantly in the comparator group, resulting in a significant mean change in ED visits between the groups at the 180- and 365-day postintervention periods (P = .03 for both periods). Pharmacists provided a total of 5705 medication-related problem, education, and medication reconciliation interventions (18.3 per patient). The benefit-cost ratio ranged from 2.1:1 to 2.6:1.

Conclusions: CHaMPS achieved its goals by demonstrating a positive impact on ED visits and a benefit-cost ratio greater than 1.0. The cost savings of the embedded pharmacist model are most beneficial from a payer perspective or an accountable care organization approach to healthcare.

Am J Manag Care. 2019;25(11):554-560
Takeaway Points

Pharmacists were embedded within family medicine clinics to deliver comprehensive medication management to patients with chronic conditions.
  • Emergency department visits significantly increased in the comparator group at 180- and 365-day postintervention periods.
  • The intervention resulted in a cost savings of $2.10 to $2.60 for every $1.00 spent.
  • Outcomes were a result of 5705 medication-related problem, education, and medication reconciliation interventions (18.3 per patient) delivered by pharmacists.
In 2016, the cost of healthcare reached $3.3 trillion,1 with an estimated 85% of these costs attributable to chronic conditions.2 Nearly two-thirds of Americans have at least 1 chronic condition, with 42% having 2 or more, and the chronic disease burden is increasing.3 Given that medications are the primary treatment for chronic conditions, some stakeholders have recommended more emphasis on managing medications for chronic conditions.4-6 Without proper medication management, problems such as medication nonadherence, suboptimal dosing regimens, and adverse drug events can lead to costly emergency department (ED) and hospital visits.4,6,7 In fact, a recent report estimated that non­optimized medication therapy results in approximately $530 billion in medication-related morbidity and mortality costs for healthcare payers each year,4 and another found that medication nonadherence leads to increased costs of up to $289 billion annually.8 National organizations, such as the CDC9 and the Patient-Centered Primary Care Collaborative,6 as well as a report to the United States Surgeon General,10 have highlighted the pharmacist’s role in optimizing medication outcomes on healthcare teams. Nevertheless, the integration of pharmacists into team-based care teams has not been widely adopted. For example, a study of patient-centered medical homes (PCMHs) reported that only 9% included a pharmacist.11 One challenge to integrating pharmacists within care teams is the fact that pharmacists are not recognized providers for Medicare reimbursement, which influences coverage decisions by other payers. Further, reports have shown mixed results regarding the impact of pharmacists on reducing ED and hospital visits.12 However, recent reports have found cost savings driven by a reduction in ED and hospital use.13,14 With a shift to healthcare models that focus on value-based payments for achieving quality indicators, such as accountable care organizations, pharmacists have the opportunity to contribute to patient outcomes by using their unique knowledge and skills regarding optimization of medication use.

The current study examines a pharmacist–physician model, Comprehensive Health Management Patient Service (CHaMPS), which embedded pharmacists in family medicine clinics to provide comprehensive medication management (CMM) to patients with chronic conditions. This retrospective, cross-sectional study with a matched comparator group adds to the contemporary evidence related to the impact of pharmacists on health services utilization and costs for patients with chronic conditions. The objectives were to (1) examine the impact of CHaMPS on unplanned hospital admissions and ED visits, (2) describe the number and type of pharmacist interventions for CHaMPS patients, and (3) conduct a cost-benefit analysis to determine the cost savings of CHaMPS.

METHODS

Study Design and Population

The Martin Health System electronic health record (EHR) system was the data source. Martin Health System, located in Stuart, Florida, is a nonprofit, community-based healthcare organization with 3 hospitals and 7 family medicine clinics. The CHaMPS group consisted of 312 patients who had a minimum of 3 face-to-face pharmacist visits, were enrolled in CHaMPS for at least 90 days, and met eligibility criteria in 2015 or 2016. CHaMPS eligibility criteria included (1) diagnosis of at least 1 of 5 specific disease states (diabetes, congestive heart failure [CHF], hypertension, hyperlipidemia, and asthma/chronic obstructive pulmonary disease [COPD]); (2) at least 1 ED visit or hospital admission in the previous 18 months with an ED or admitting diagnosis related to one of the selected disease states; and (3) a physician referral to CHaMPS. The comparator group consisted of patients who met CHaMPS eligibility criteria in 2015 or 2016 but were not referred to CHaMPS. Also, the patient’s physician had to have 10 or fewer referrals to CHaMPS. A total of 899 patients met comparator group eligibility criteria. Propensity score matching, using nearest neighbor matching without replacement, was applied to match CHaMPS and comparator group patients on a 1-to-1 basis. The matching variables included age, gender, race, insurance type, Charlson Comorbidity Index (CCI) score, current smoker status (yes/no), body mass index (BMI), and diagnosis (yes/no) of diabetes, CHF, hypertension, hyperlipidemia, and asthma/COPD. After the matching criteria were applied, 312 patients were identified for the comparator group.

Pharmacist–Physician Care Model

CHaMPS was based on the principles of CMM.6 The first CHaMPS encounter, a face-to-face pharmacist visit, was scheduled within 14 days of referral, with subsequent face-to-face visits at 2- to 3-week intervals for 1 to 2 months and as needed thereafter. The initial visit was 60 minutes, and subsequent visits ranged from 30 to 60 minutes depending on patient needs. During the initial CHaMPS visit, individual therapeutic goals were set for the patient’s chronic disease(s) based on evidence-based guidelines and interaction with the patient and their primary provider. Medication-related problems (MRPs) were identified and pharmacists performed interventions in collaboration with the patient or physician to resolve them. Pharmacists communicated with physicians about recommendations via the EHR and face-to-face. The patient’s clinical status, which included review of all symptoms and signs, relevant laboratory results, and monitoring measures, was assessed at each visit. A medication care plan included a list of the patient’s disease state(s), pertinent laboratory results compared against goals, and medications. Medication optimization was monitored by the pharmacists and disease status was updated based on feedback from patients and providers. Pharmacists delivered CHaMPS at 4 family medicine clinics and spent 2 to 3 days a week in each clinic.


 
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