Comprehensive Medication Management Supports Population Health & Value-Based Care Performance

What if you were presented with an intervention that could improve quality outcomes and reduce costs among the most complex patients attributed to your health plan, ACO, or practice? You’ve likely heard many such claims. However, you’d probably pay attention if the field-based studies demonstrated that it could…

• Lower treatment costs ($35,740 versus $44,529) in people with poorly controlled diabetes mellitus.
• Decrease LDL-C, Hemoglobin A1c, and systolic blood pressure.
• Achieve an average Hemoglobin A1c reduction of 2.4% and estimated cost savings of $950 - $1,169 per patient for those whose HbA1c decreased ≥ 1%.
• Identify medication-related problems, including issues with appropriateness/effectiveness (33%), safety (20%), medication non-adherence (21%), and insufficient patient self-management (12%).
• Reduce avoidable appointments to primary care by 27% to open access for others.
• Achieve >90% patient and clinician satisfaction.
• Produce an estimated return on investment of between 3.5:1 and 12:1 for patients with chronic conditions.

This is not a secret, high-priced, proprietary product or service solution. It is Comprehensive Medication Management (CMM). ?

Comprehensive Medication Management

CMM is defined as:

"…the standard of care that ensures each patient's medications (whether they are prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended. CMM includes an individualized care plan that achieves the intended goals of therapy with appropriate follow-up to determine actual patient outcomes. This all occurs because the patient understands, agrees with, and actively participates in the treatment regimen, thus optimizing each patient's medication experience and clinical outcomes.”

McInnis, Terry, et al., editors. The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. 2nd ed. PCPCC Medication Management Task Force collaborative document.

Clinical pharmacists typically offer CMM as part of interprofessional teams. There are ten essential functions required. In brief, the ten steps are:

1. Identify patients not achieving the clinical goals of therapy.
2. Understand the patient’s medication experience, history, preferences, and beliefs.
3. Identify actual use patterns of all medications (e.g., prescription, over the counter, supplements).
4. Assess each medication for appropriateness, effectiveness, safety, drug interactions, and adherence.
5. Identify all drug therapy problems.
6. Develop a care plan that includes therapeutic changes to achieve optimal outcomes.
7. Ensure the patient agrees to and understands the plan; communicate the plan to the prescriber for consent/support.
8. Document all steps and current clinical status versus goals of therapy.
9. Follow-up evaluations to assess and reassess outcomes; adjust as necessary.
10. Iterate over time; coordinate care with other team members and focus on personalized goals to achieve optimal outcomes.

CMM Supports Population Health & Value-Based Payment Models

The American College of Clinical Pharmacy describes the delivery of CMM as follows:

Clinical pharmacists work in collaboration with other providers to deliver CMM that optimizes patient outcomes. Care is coordinated among providers and across systems of care as patients transition in and out of various settings.

CMM is highly aligned with population health initiatives and performance under value-based care payment (VBP) models in which, ideally, interprofessional teams work to achieve quality and cost outcomes that improve the lives of people and populations who entrust their care to them. Under risk-based payment, CMM will also help organizations attain better performance on many HEDIS? and Medicare Part C and D measures that could be positively affected by medication optimization. Some examples include:

• Pharmacotherapy Management of COPD Exacerbation (PCE*)
• Asthma Medication Ratio (AMR)
• Controlling High Blood Pressure (CBP)
• Persistence of Beta-Blocker Treatment After Heart Attack (PBH)
• Statin Therapy for Patients with Cardiovascular Disease (SPC)
• Glycemic Status Assessment for Patients with Diabetes (GSD)
• Blood Pressure Control for Patients with Diabetes (BPD)
• Statin Therapy for Patients with Diabetes (SPD)
• Antidepressant Medication Management (AMM)
• Pharmacotherapy for Opioid Use Disorder (POD)
• Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)
• Potentially Harmful Drug-Disease Interactions in Older Adults (DDE)
• Use of High-Risk Medications in Older Adults (DAE)
• Deprescribing of Benzodiazepines in Older Adults (DBO)
• Use of Opioids at High Dosage (HDO)
• Use of Opioids from Multiple Providers (UOP)
• Risk of Continued Opioid Use (COU)

?*Abbreviations refer to NCQA HEDIS measures.

Medication Therapy Management vs. Comprehensive Medication Management

CMM is related to but distinct from Medication Therapy Management (MTM). MTM is a medication-focused strategy focusing on specific conditions for Medicare beneficiaries covered by Part D prescription drug plans. In contrast, CMM, as the name suggests, is broader, person-centered, and a more comprehensive approach to medication adherence and optimization.

MTM was added as a covered benefit under Medicare Part D through The Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003. Prescription drug plans were required to develop MTM programs for Medicare beneficiaries that addressed five components: a medication review, a medication record, a medication-related action plan/intervention/referral, and documentation with appropriate follow-up. The Centers for Medicare & Medicaid Services (CMS) specifies criteria Medicare beneficiaries must meet before these services are offered, including:

• Have multiple chronic diseases [a list of 10 core chronic diseases is provided], with three chronic diseases being the maximum number a Part D plan sponsor may require for targeted enrollment and
• Are taking multiple Part D drugs, with eight Part D drugs being the maximum number of drugs a Part D plan sponsor may require as the minimum number of Part D drugs that a beneficiary must be taking for targeted enrollment, and
• Are likely to incur annual costs for covered Part D drugs greater than or equal to the specified MTM cost threshold.
• Are at-risk beneficiaries (ARBs), that is, beneficiaries with an active coverage limitation under a drug management program.

The following services must be included (at a minimum) in MTM programs:

1. Interventions for both beneficiaries and prescribers.
2. An annual comprehensive medication review (CMR) is performed by a pharmacist or other qualified provider.
3. Quarterly targeted medication reviews (TMRs) with follow-up interventions when necessary.
4. Information about safe disposal of prescription drugs.

Implementing CMM

The GTMRx Institute published several use cases illustrating CMM in action across multiple care settings (e.g., Federally Qualified Health Center, health systems, community care practices, Department of Veterans Affairs, accountable care organizations, and integrated delivery systems). A challenge for CMM is that, unlike MTM, there is no direct payment for the services under Part D. However, when implemented as part of a team-based approach, CMM has demonstrated a considerable return on investment (ROI), estimated to be between 3:1 to 5:1, and as high as 12:1 (Note: the authors of the study use the term “Comprehensive Medication Therapy Management”).

While some advocates propose that pharmacists should be able to bill CMS for CMM under Fee-For-Service directly, other proponents focus on the value CMM brings to value-based payment models and an ROI generated through performance-based compensation (e.g., shared savings, population-based payments, pay-per-performance) and improvements in Part C and Part D Star ratings for Medicare Advantage plans. Further, as summarized in Comprehensive Medication Management: A Missing Ingredient In Value-Based Payment Models: ?

Clinical pharmacists providing CMM services in?collaborative practice?with a physician and other licensed practitioners can significantly contribute to advances in quality,?equity, and access through approaches to care that identify barriers to medication optimization, help close gaps in care, and reduce unwarranted variation in cost.

Collaborative practice, or team-based care, is described by the American College of Physicians in its Team-Based Care Toolkit as a:

…model of care strives to meet patient needs and preferences by actively engaging patients as full participants in their care, while encouraging and supporting all health care professionals to function to the full extent of their education, certification, and licensure.

Depending on a patient's needs and the care setting, the team of healthcare professionals could include nurse practitioners, physician assistants, nurses, pharmacists, medical assistants, social workers, behavioral health specialists, and others.

Implications for U.S. Healthcare Costs

Beyond the opportunity to improve outcomes under value-based payment models, CMM and MTM programs could help the U.S. reduce drug spending, which exceeded $400 billion?in 2023. An analysis of commercial health plan spending by the Health Care Cost Institute of 2022 data showed that prescription drugs account for 23.3% of costs. In 2018, researchers estimated that the U.S. spent an estimated $528.4B, equivalent to 16% of total U.S. healthcare expenditures, because of illness and death from non-optimized medication therapy. A summary report (2011) from the National Priorities Partnership documents that inpatient preventable?medication errors cost approximately $16.4B, and outpatient preventable medication errors cost about $4.2B.

What's your experience with Comprehensive Medication Management?

Michael S. Barr, MD, MBA, MACP, FRCP

Sr. Director, Population Health Improvement

The Population Health Alliance (PHA) is committed to Quality and Continuity of Care.?Our key priorities are advancing value-based care, improving consumer engagement, and addressing social determinants and health equity.

PHA, through its Advancing Primary Care Workgroup, is developing a Medication Optimization Tool. If you are a PHA member and want to join the group, please email?[email protected]?. If your organization is not a PHA member,?join now!