BETHESDA, MD 14 May 2010—Medicare Advantage provider XLHealth has turned to the University of Maryland (UMd) School of Pharmacy to train the company`s pharmacists to provide medication therapy management (MTM) services for patients with serious chronic conditions.
Once trained, XLHealth`s pharmacists conduct in-depth reviews of the medication regimens with patients over the telephone, a process that takes about 40 minutes, according to the company. The pharmacists then work with the patients` health care providers to optimize medication regimens, said Andrea Hershey, vice president of pharmacy at the Baltimore-based company.
The overall goal is to improve health outcomes and reduce hospitalization costs, she said.
"I would like to see what we`re doing here to be a model for what [the Centers for Medicare and Medicaid Services] thinks we should do for medication therapy management in Medicare," Hershey said.
Although XLHealth has provided MTM services in the past, the work was done by outside pharmacists. For the new endeavor, Hershey said, the company has hired six full-time pharmacists and hopes to have six more on staff by this summer.
"We wanted to have pharmacists in-house to provide more complex medication therapy management services" than was possible using outside pharmacists, Hershey said. She said the preference is to hire pharmacists who have completed a residency program, but the overall need is for good clinicians who can provide complex patient care.
"I trained as a clinical pharmacist, so I had a vision for what services we should provide to our members," Hershey explained.
A key factor in the training arrangement is Hershey`s working relationship with her former teacher, David Roffman, UMd professor of pharmacy practice and science. Roffman is a cardiology specialist and the coordinator for the XLHealth project, which runs through the end of this year and pays for all costs associated with conducting the training sessions.
Roffman held an introductory session on clinical decision-making in January for the XLHealth pharmacists. His subsequent sessions addressed heart failure, myocardial infarction, hypertension, and hyperlipidemia.
Roffman estimated that he spends about 15–20 hours a month on the teaching project.
"Right now, it`s a little intense for me because the first three or four months is all my stuff," he said. In addition to preparing the cardiology lectures, Roffman also applies for continuing-education approval for the sessions.
He said his overall approach is to help the pharmacists identify suboptimal drug therapy regimens and intervene to improve patient care.
Each monthly training session consists of two parts—a 90-minute participatory lecture followed two weeks later by a one-hour case study on the previous topic.
During the case study, Roffman said, "we engage in a discussion of what`s the best way to manage these patients, to optimize their therapy, to monitor their progress."
About half of the pharmacists are in the room with the lecturer in Baltimore and the rest participate by phone or video conference, Roffman said. Several of the pharmacists live in Florida, one of six states where XLHealth operates its Medicare Advantage special needs plan, dubbed Care Improvement Plus.
"We try to make it as interactive as possible," Roffman said of the training sessions.
He said the XLHealth pharmacists are seasoned practitioners, many of whom have had some experience in clinically focused settings.
"They have the sophistication of experience to allow them to focus in on where the important problems are—much more than a student would be able to. So they know what the routine issues in practice are and the challenges, to some extent, of what it takes to change behaviors in practitioners. That`s no easy task," Roffman said.
His goal for the pharmacists is to give them the confidence and skills "to push the envelope of pharmaceutical care in the real world."
For a patient with heart failure, he said, that could mean persuading prescribers to use b-blockers and angiotensin-converting-enzyme (ACE) inhibitors aggressively to get the best possible response.
"Most heart failure patients are on those drugs. But they are on a small dose, and the physician is satisfied that they`re doing OK, and they`ll leave it alone," Roffman said. "But in order to really optimize therapy you have to try to push the ACE inhibitors toward the target doses in the large, well-controlled trials and not just leave them on some piddling dose."
Another intervention for such a patient might be to contact the prescribing physician about adding an aldosterone antagonist to the medication regimen, because clinical trials have demonstrated the therapy improves survival and decreases the risk of hospitalization, Roffman said.
"This . . . level of intervention where you really try to be the initiator of optimization of therapy rather than the responder to an already-written prescription is kind of a different level of practice than most pharmacists are involved in," Roffman said. He said XLHealth wants its pharmacists to take that type of approach to Care Improvement Plus enrollees` therapy.
Enrollees in the special needs plan are, on average, 76 years old take 8–10 medications for chronic conditions, and have 11 different health care providers, Hershey said. Many of the approximately 71,000 enrollees are dually eligible for Medicare and Medicaid, and most lack a high-school education. The plan serves patients in Arkansas, Georgia, Maryland, Missouri, South Carolina, and Texas.
Special needs Medicare Advantage plans were authorized in the Medicare Modernization Act of 2003. The plans provide coordinated care for beneficiaries who are institutionalized, dually eligible for Medicare and Medicaid, or suffer from severe or disabling chronic conditions.
Nearly 1.3 million Medicare beneficiaries, including almost 1 million dual eligibles, were enrolled in a special needs plan in March, according to Centers for Medicare and Medicaid Services data.
"There`s a tremendous opportunity here for medication therapy management" in the special-needs population, Hershey said.
Roffman said he thinks the university`s partnership with XLHealth is unusual and provides "a wonderful opportunity for pharmacy as a profession" to work with the private sector.
He said he is scheduling other faculty members through the end of the year to lead training sessions on diabetes, asthma, depression, palliative care, end-of-life care, gastroesophageal reflux disease, constipation, dementia, Alzheimer`s disease, sleep disorders, osteoporosis, and falls.
