Comprehensive Medication Management (CMM) has become a more widely used way to improve outcomes and reduce costs for high-risk patients. But despite its promise and success in a number of health systems, payors, and provider organizations, a variety of barriers are keeping its adoption slower than desired.
Here are six of these, gleaned from the results of a study that includes feedback from more than 600 pharmacists and pharmacy leaders.
1. Lack of clarity around the empowered ‘provider’ role for pharmacists
A major barrier to greater CMM adoption is the general lack of differentiation between pharmacists in the pharmacy and the clinical pharmacists who oversee CMM programs.
In CMM, the pharmacist’s role is not that of a prescription-filling professional behind the counter, taking phone calls and answering patient questions. Instead, the clinical pharmacist involved in these programs brings pharmacologic expertise and functions as part of the care team. That means he or she actually sees and assesses patients, makes medication therapy recommendations or changes, documents in the medical record, and often rounds with the physician and/or other clinical provider. In fact, many clinical pharmacists have residency training in pharmacy practice/medication management, geriatrics, behavioral health, or other disciplines.
Such activities fall into the Patient-Centered Primary Care Collaborative (PCPCC)’s definition of CMM, which summarizes it as a whole-patient approach that begins with patients and seeks to optimize their medications by identifying and resolving drug therapy problems that are preventing them from reaching their goals of therapy.
Differentiating the roles of retail pharmacist and clinical pharmacist is essential to empowering the latter to fully participate in CMM. In addition, their full integration into the care team requires that provider organizations develop broad collaborative practice agreements that enable them to add, remove, or change a patient’s drug therapy without having to ask the physician for permission each time.
2. Limited reimbursement, and a lack of financial incentives
Although the Center for Medicare and Medicaid Services (CMS) and some payors pay for Medication Therapy Management (MTM) and Enhanced Medication Therapy Management (eMTM) CMM is not a reimbursable service. It’s been embraced primarily as a cost-reduction strategy for provider organizations and systems that have taken on risk agreements.
Given the high return on investment and improvement in patient outcomes, CMM should be reimbursed by payors. And, one of the steps toward this is an improvement in the state scope of practice and payor recognition of the valuable role of clinical pharmacists.
Currently, reimbursement for pharmacists’ services varies widely and frequently is relegated only to pilot projects or grant funded initiatives. Add to this the fact that the number of states that have given provider status to pharmacists is very small. The good news is that this is changing, with states such as California implementing state bills that declare pharmacists as healthcare providers, and able to provide healthcare services. Still, we’ve got a long way to go in terms of payor reimbursement.
3. Disconnection between pharmacy and clinic
The fact that pharmacy and clinic are so often two separate departments, buildings, or in many cases, companies (think Walgreens versus your primary care doctor’s office) leads to patients not being seen by a pharmacist in a timely manner, communication inefficiencies, and patient lack of understanding that a pharmacist can be a part of their care team.
In CMM, the pharmacist sees patients in the clinic along with other clinicians, maintaining a sufficient schedule of appointments that accommodates patients, often in the same building. Telepharmacy is another option that's become more prevalent, with many patients preferring its convenience over an in-person visit, and especially when travel distance and/or patient mobility are an issue.
4. Inadequate access to the electronic health record (EHR)
Giving clinical pharmacists read-and-write access to the medical record is imperative to improving patient care, safety, and communication efficiency. In a CMM environment, access to the EHR is paramount, and collaborative practice agreements provide the foundation that enables pharmacists to add/delete medications, changes dosages/strengths, and more.
Case studies of successful CMM programs indicate that when pharmacists are given access and authorship permissions to the records of the patients they serve, program success increases. The pharmacist has more insight into the patient’s condition, appointments, test results, and diagnoses, and can more adequately assess their condition and modify or discontinue therapy. Without such access and permissions, communication and efficiency are hampered.
5. Limited provider and patient awareness
Even among our own profession there is a lack of knowledge about the advantages and benefits of CMM.
A colleague of mine’s mother has vascular dementia. For more than a year she was unsuccessful at asking her mom's physicians for a referral to a CMM program, so that mom’s medications and clinical condition could be reviewed. Meanwhile, the well-intentioned primary care physician, psychiatrist, and nurse practitioner all failed to find a regimen to properly manage her mother’s behavior and condition.
My colleague’s experience is unfortunately quite common. And she’s an informed caregiver; many family members and patients themselves don’t have a clue about what CMM is or what it can do for them. This must change so that providers and their staff are educated about how to offer patients and family members the option. Even if it’s not reimbursed by the patient’s plan or CMS, patients should be enabled to make an informed choice about available programs or independent clinical pharmacists - even if that choice is to pay for the services out of pocket.
6. Not enough residency program slots
Developing an effective CMM program requires residency and/or mentorship that goes beyond pharmacy school training. Moving the clinical pharmacist’s knowledge base from a pharmacology to a care delivery mindset requires additional skills, developed through post doctorate programs. Unfortunately, the number of residency program slots for this kind of training is insufficient to fill the positions that would speed adoption of CMM programs. Only when the number of residency slots is expanded could more pharmacists access the type of training they need for this purpose.