Importance of Massachusetts Collaborative Drug Therapy Management Act 2008 Essay

Collaborative Drug Therapy Management (CDTM), involving a collaborative effort between physicians and pharmacists, address practical courses of cost effective health care management. The economic value of CDTM has been well-documented in many circles and this process has been established in many states of the U S as a means of reducing the high costs of health care delivery, particularly associated with Medicare. It is envisaged that the initiative of Massachusetts to bring CDTM legislation will help provide the best possible treatment, while simultaneously cutting increasing costs of health care delivery.

Pharmacists are the health professionals specifically trained to dispense prescription medication and provide a wealth of other pharmaceutical services. They have the crucial role in clinical care as they have the potential to decrease errors, costs and the demand on emergency and primary care physicians while improving patient outcomes. Collaborative drug therapy management (CDTM) with active involvement of pharmacist in prescription medication is a viable opportunity to capture new revenue streams within the health care industry, but the criticism includes the compromise of patient care at the expense of earnings.

Importance of an ideal cost effective health care delivery system

Main focus in health care management is continuity of care, equitable access, and quality and safety. It is criticized that the U S health care delivery system is fragmented, which fosters “frustrating and dangerous patient experience, especially for patients obtaining care from multiple providers in a variety of setting. It also leads to waste and duplication, hindering providers’ ability to deliver high-quality, efficient care.” (Shih, Davis and Schoenbaum).

Major factors contributing to fragmentation of health care delivery system in the U S are: absence of single national entity or set of policies guiding the health care system; states divide their responsibilities among multiple agencies; and primary care system is fragile. Poor performance of the U S health care system derived from fragmentation leads to dangerous patient experience, medical errors, high cost, waste, and duplication.

Introducing electronic health record systems for easy accessibility of patient information, coordinated patient care among multiple providers, accountability and collaboration among providers, easy access to appropriate care and information to patients, and continuous innovation of the system are important steps for an ideal high performance health care delivery system identified by the Commonwealth Fund Commission.

Inclusion of medication therapy management programs (MTM) in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) is considered as a big leap in recognition of pharmacist-provided appropriate drug therapy management for cost effective health care delivery. Pharmacists were the only health care professionals specifically named in MMA to provide medication management services. With the introduction of Medicare Reform Act of 2003 a new Medicare Part D prescription drug program was created in the U S and fresh fillip has been given to pharmacists and medication therapy management (MTM) in reducing other more costly health care services.

MTM, in part, may be defined as “a form of face-to-face assessment or intervention between pharmacist and a patient and a patient or caregiver that is provided to optimize and improve the response to medications and to help avoid potential treatment-related medication interactions or complications.” (External and Internal Assessment, 10). However, it is argued that there was no consensus definition of medication therapy management services in MTM provision, as prescribed in MMA Statute.

Importance of CDTM in Medicare management

The Part D Medicare program provides beneficiaries with the option to enroll into private health plans that have contracts with Medicare to provide drug coverage. It is perceived that Collaborative Drug Therapy Management (CDTM) would provide access to enhanced valuable pharmacy services that are calculated as part of the premium to all the Medicare recipients. Health care reform initiative enacted in Massachusetts in 2006 set goal to ensure affordability and adequacy of insurance coverage through health insurance plans that offer enough financial protection as well.

Massachusetts Health Insurance Connection, established to facilitate purchase of quality, affordable health insurance by small businesses and individuals who lack access to employer-sponsored health coverage is an integral part of state’s comprehensive health insurance reform. Reports state that health care reform plan implemented in Massachusetts in 2006 has yielded impressive results as the ‘state’s uninsured rate was cut nearly by half at the end of the plan’s first year, and residents saw a significant drop in their out-of-pocket expenses’.

The “minimum creditable coverage” standard established in Massachusetts is aimed to help protect residents from becoming underinsured. The standard mandates all insurance plans to provide a broad scope of key benefits, including preventive and primary care, prescription drugs, and maximums for annual deductibles and out-of-pocket spending.

Role of pharmacists in effective medical practice

It is experienced that pharmacists’ intervention in medication management and authorizing pharmacists to prescribe select medication and monitoring therapy has potential benefits for medical practice. Though physicians are responsible for managing patients’ care, including drug therapies, research evidence suggests that involving clinical pharmacists in managing drug treatment may reduce costs and improve the quality of care. (Report to the Congress: Medicare Coverage of Nonphysician Practitioners). Indian Health Service (IHS) model of protocol-based prescribing by pharmacists is acclaimed by the Institute of Health (IOH) to be “beneficial for patient satisfaction and pharmacist-physician relationships, reduction in physical referrals, and improvement in clinic efficiency.” (Emmerton, et al, 217-225).

It is envisaged that prescribing by protocol can lead to ‘containment of drug costs, reduction in medical practitioner visits, integration with medication reviews, and improving access to medicines’ (Quoted by Emmerton, Lynne et al, 2005). Studies conducted earlier and field evidence suggest that prescribing drugs and monitoring by hospital and community pharmacists are appropriate to improve patient health outcomes and possibly reduce health care costs. Research demonstrates that by having pharmacists involved directly in the medication process, there has been a reduction of 28 percent in morbidity and mortality for drug-related events during hospital visits, with a related cost savings of $76.6 billion (Malloy and DeBellis, 2006).

Literature review suggests that drug management has the potential to improve the quality of care for Medicare beneficiaries by reducing the incidence of adverse drug effects, improving patient outcome, and improving patient compliance with drug therapy. Drug management mainly focus on managing the drug therapy treatment of high-risk patients, those taking wide array of medications, or those with specific diseases, such as asthma, diabetes, heart attack, or hypertension.

The strategy to incorporate reimbursement codes that are specific to pharmacists performing medication therapy management (MTM) enables patients to obtain the type of care that is necessary to improve their health, and for healthcare providers to consider feasible cost-effective alternatives to healthcare delivery that might not have been present before (Texas State Board of Pharmacy, 2008). However, one of the most significant weaknesses related to CDTM services is that: “Many pharmacists, however, are not actively engaged in collaborative DTMSs, even in the states that have legislative approval, because of various obstacles including

1. difficulty in obtaining physician acceptance,
2. lack of support from directors and support personnel,
3. slow processes for getting credentialing status,
4. inadequate knowledge of billing and clinical skills,
5. indifferent attitude of pharmacy practitioners,
6. lack of a cohesive vision for practice models,
7. insufficient space to perform the services, and
8. outcomes failing to meet expectations” (Kuo et.al, 2004, p. 345).

Apprehensions about pharmacist role in medical care

Research has demonstrated that patients are often unaware of the services pharmacists are able to provide and are unlikely to appreciate the roles and responsibilities of pharmacists. In a competitive market, buyers and sellers of health care will naturally scrutinize the system to ensure that care and product are being provided in the most cost-effective manner. The role of pharmacists will be measured on the basis of care and services a patient receives. Every patient will seek optimum returns for which they are paying and expect fulfillment of their expectations. Since patients generally evaluate the services for value, convenience, and quality of care, extensive education about outcomes and cost-effectiveness of new services are paramount.

When all the stakeholders in health care compete with each other to extract optimal benefits they should be reminded that appropriate drug therapy is generally safer and more cost effective than other forms of treatment and that the personal and economic consequences of inappropriate drug use are enormous. Hence, it is recommended that: “Credentialing and privileging for pharmacists are important and complex issues intended to protect patients from incompetent providers, to safeguard organizations from malpractice allegations, and to meet regulatory agency and third-party payer requirements.” (Harris, et al., 19e).

Relevance of CDTM Act in Massachusetts

Collaborative prescribing, to some extent, was in operation throughout the past 25 years, and 27 American States had some form of legislation allowing this practice by 2001. Earlier prescribing collaboration includes aminoglycoside and pharmacokinetic dosing services, anticoagulant therapy adjustment and chemotherapy, and antiemetic management. Federal government recognized pharmacists as an integral part of health care team by involving them in medication therapy management as part of the Medicare Modernization Act of 2003, and the Collaborative Drug Therapy Management (CDTM) legislation is designed to create wider role for pharmacists among health care team.

So far 43 other States in the U S have already passed similar legislations, and the practice has proven to improve quality of care, reduce errors, and save money in the state where it is currently allowed. However, it is viewed that authorizing pharmacists to prescribe drugs will exacerbate quality health care.

Main problems highlighted in authorizing pharmacists to prescribe drugs is that it may remove interaction with physicians undertaking diagnosis, create extra workload for the prescriber, complicate reimbursement for prescribing, require pharmacists to compromise other professional duties, and arguably lead to more room for error by involving more staff.’ (Emmerton, et al, 217-225).

All pharmacists may not be willing to shoulder the responsibility of diagnosis, prescribing, and follow-up, including an awareness of competence required to undertake ‘dependent’ prescribing. In addition, there may be implementation issues such as coordination of information and access, accreditation, education, accountability, and competency assessment, determination of scope of practice, and gaining of prescriptive authority (Shaw, J, 2002 and Aldouse, J, 2003).

Keeping prescribing and dispensing as separate entity is important for ensuring selection of appropriate treatment for the patient, and alienating physicians from prescribing is perceived to affect optimal patient outcome. This may prompt other professionals in health care to feel that prescribing pharmacists interfere on their area of professional responsibility, leading to professional grudge and breach in working relationships.

However, it is worth noting that pharmacists are not devoid of performance lapses. Holdford (2006) argues that “many pharmacists do not fulfill their professional roles because they do not know what to do or how to do it as a result of inadequate education, training, and supervision.” (Holdford, 02). In addition, their choice of prescription may be influenced by advertisements and some individual material benefits. It is experienced that sales people and drug manufacturers are likely to interfere in CDTM, because any personal preference by pharmacists may boost or deter the prospect of a particular manufacturer.

Institute of Medicine cites that drug manufacturing is a $122 billion industry and estimated $2.5 billion is spent on pharmaceutical advertising annually. The managed care industry reports that from 1999 to 2000, prescriptions written for the top 50 most heavily advertised drugs rose 245 percent, compared to 43 for all other drugs combined. (Moore). ‘Health care for all, report that in 2005, pharmaceutical companies spent $12 billion nationally in marketing to physicians (some $13,000 /physician), including provision of free samples’. (Goldfield, et al).

The data implies that a small increase in market share can reflect a multimillion-dollar boost for any particular company, and every manufacturer will vie to get the attention of prescribers to promote their product often. It is suggested that ‘reduced marketing to physicians will cut industry influence on prescribing decisions, leading to increased quality of prescribing, reduced complications from inappropriate medications, and reduced costs for both public and private payers.’ Similarly Holdford (2006) suggested that ‘good service scripts’ can improve efficacy of pharmacy students to provide the best care to patients, help enhance effectiveness, efficiency, confidence, and acceptability.

“A collaborative practice agreement is a voluntary, written agreement between a physician and a pharmacist outlining a plan of cooperative practice for drug therapy management. These agreements are limited to care within the scope of practice of the participating physician, or in some states nurse practitioners, and pharmacist.” (Collaborative Practice Agreements: What is Collaborative Practice Agreement).

Under CDTM, having entered a voluntary agreement with a physician, pharmacists may more effectively engage in monitoring and controlling pharmaceutical care, which will enhance safety and cost-effectiveness of medication therapy, as well as quality of life for patients. Bjornson et al. reported a benefit:cost ratio of 6:1 among health care teams, that included a pharmacist, compared with teams that did not have a pharmacist (Thomas et. al, 2006, p. 2490). Though CDTM offers financial advantages, there are still many questions to be answered regarding the long-term influence of CDTM on cost savings.

The A C C P has estimated that the annual cost of drug management under Part B of the Medicare program would be between $500 million and $1.7 billion, depending on the structure and use of the benefit. The lower figure assumes 2 outpatient visits per year for 8 million beneficiaries, and the higher number is based on 4 visits per year for 12 million patients.

These estimates assume an hourly payment rate for pharmacists of $60, with 65 percent of visits lasting 15 minutes, 25 percent lasting 30 minutes, and 10 percent lasting 60 minutes (Medicare Payment Advisory Commission, 2002, p. 24). As a result, it is evident that the long-term fiscal requirements of CDTM have yet to be fully determined, and therefore, it is important to consider that some states are not necessarily prepared to assume the fiscal responsibilities associated with this strategy, particularly since its long-term impact remains unknown.

With the emergence of CDTM the role of pharmacist has become well-defined and influential in healthcare delivery. It is projected that “If the profession of pharmacy does not move toward a cost effective, patient oriented practice, it can expect pharmacy technicians and/or technological advances to replace pharmacists who dedicate themselves solely to the dispensing and sale of medications and other products.” (External and Internal Assessment, 10).

Present Status of CDTM in Massachusetts

The Act establishing Collaborative Drug Therapy Management in Massachusetts has been signed by Governor Deval Patrick on January 15, 2009, and the Bill under Senate number 2706 is now referred to as Chapter 528 of the Acts of 2008. With the enactment of the Chapter 528, Massachusetts pharmacists shall become prescribers, under voluntary contractual relationships with doctors, in an effort to enhance patient outcomes. (Governor Signs Collaborative Drug Therapy Management). The CDTM Act of 2008 passed by the Commonwealth of Massachusetts has amended Section 7 and 9 of chapter 94C and section 24 of Chapter 112 enshrined in the General Law of 2006.

The Act authorizes duly registered pharmacists, to engage in collaborative drug therapy management and to issue written prescriptions in accordance with the provisions and guidelines of section 24 (subsection1 and 2) of chapter 112. Amendment to chapter 94C, section 9, permits a physician, dentist, podiatrist, optometrist, nurse practitioner and psychiatric nurse mental health clinical specialist, physician assistant, certified nurse-midwife, pharmacist, or veterinarian, as limited by various relevant new sections and subsections, when acting in accordance and consistent with federal law and in good faith and in the professional practice for the alleviation or treatment of pain, disease, and suffering can possess controlled substances and cause such controlled substances to be administered by a nurse under his or her direction.

Similarly the Act brought amendment to Chapter 112 of the General Laws by inserting two sections after section 24B. New section defines ‘Collaborative drug therapy management’ as the “initiating, monitoring, modifying and discontinuing of a patient’s drug therapy by a pharmacist in accordance with a collaborative practice agreement. For entering a pharmacist into a collaborative practice agreement, the pharmacist shall:

1. hold a current license to practice pharmacy in the commonwealth and currently be engaged in pharmacy practice in the commonwealth;
2. have at least $1,000,000 of professional liability insurance;
3. have earned a doctor of pharmacy degree or have completed 5 years of experience as a licensed pharmacist or the equivalent;
4. agree to devote a portion of his practice to the defined drug therapy area that the pharmacist shall co-manage; and
5. agree to complete, in each year of the agreement, at least 5 additional contact hours or 0.5 continuing education units of board-approved continuing education that addresses areas of practice generally related to collaborative practice agreements.

Though pharmacists introduced a bill granting much broader collaborative drug therapy, it was strongly opposed by several medical societies. The successful legislation is viewed as the result of consensus and collaboration between pharmacy organizations and the Massachusetts medical society. Passing of the bill was made possible by the concerted effort of pharmacists from all practice settings, students of the APhA chapter of the Massachusetts College of Pharmacy and Health Sciences and active involvement of individuals and MPhA executives.

Conclusion

Pharmacy practice is undergoing constant change with introduction of increasingly complex and expensive drugs, drug regimens, and diagnostic technologies emerging from biotechnology industry, and health care reform. Pharmacists must become participating members of the health care team and work collaboratively with physicians and other health care practitioners to provide total care to the patient.

By creating a collaborative environment the knowledge gained by pharmacists could be utilized to help patients achieve better outcomes from drug therapy, which can provide considerable cost savings to health care system. Incorporating continuous quality improvement program (CQI) that includes peer review for the identification and prevention of dispensing errors will ensure health care cost efficient and error free medication delivery by pharmacies.

Works Cited

Collaborative Practice Agreements: What is Collaborative Practice Agreement. GO2EC. 2008. Web.

Emmerton, Lynne., et al. Dependent Prescribing: Prescribing by Protocol. J Pharm Pharmaceut Sci. 8.2. 2005. Web.

External and Internal Assessment. Texas State Board of Pharmacy. 2006. Web.

Goldfield, Norbert., et al. A Consumer Driven Health Care Cost Control Agenda for Massachusetts: 17 Legislative Proposals. Health Care for All. 2007. Web.

Governor Signs Collaborative Drug Therapy Management. MPHA: Masacchussets Pharmacists Association. 2009. Web.

Harris, Ila M., et al. Developing a Business Practice Model for Pharmacy Services in Ambulatory Settings: Certification and Credentialing. ACCP White Paper. 2008. Web.

Holdford, David. Service Scripts A Tool for Teaching Pharmacy Students How to Handle Common Practice Situations: Introduction. American Journal of Pharmaceutical Education. 70.1. 2006. Web.

Moore, Richard T. Identifying and Preventing Medication Errors. Legislative Policy Association. 2009. Web.

Report to the Congress: Medicare Coverage of Nonphysician Practitioners. Medpac: Medicare Payment Advisory Commission. 2002. Web.

Shih, Antony., Davis, M P H Karen., and Schoenbaum, Stephen. Organizing the US Heath Care Delivery system for High Performance: Overview. The Common Wealth Fund. 2008. Web.