Helping Chronically Ill Patients Manage Medications Saves Lives, Money

Lilo H. Stainton | June 3, 2016 | Health Care
Now there is a push to extend those benefits to New Jerseyans covered by FamilyCare and Medicaid, despite insurance industry concerns

For years, Medicare has paid pharmacists to help ensure that seniors who take multiple medications for chronic diseases are taking these drugs properly — and that the combinations won’t do more harm than good.

Studies show this medication therapy management, or MTM, has saved both money and lives. The process helps weed out duplicate drugs, flags prescriptions that are incompatible, and enables patients to better understand and participate in their own care.

Lawmakers in New Jersey are now looking to expand the use of MTM services to tens of thousands of low-income residents covered by the federal Medicaid program and FamilyCare, the state program that extends insurance coverage to individuals and families who do not have other insurance. The proposal has been largely embraced by physicians and pharmacists — including representatives of both independent drugstores and large chains. But it has raised red flags for health insurance companies concerned about added costs and what they say are inconsistencies with Medicare requirements.

Led by Assemblywoman Pamela Lampitt (D-Camden), the latest proposal (A-1443) passed the Assembly Health Committee Thursday with unanimous support. A Senate version, championed by Sen. Joseph Vitale (D-Middlesex), cleared that chamber’s health committee earlier this year. It now awaits action in the Senate budget committee. A similar effort in 2013 failed to get through both houses before that legislative session expired.

Half of all patients don’t take their medications as prescribed, experts have found. The American Pharmacy Association estimates that improper use of medications costs the American healthcare system more than $290 billion a year and results in millions of unintended and damaging medical outcomes. A representative from Rite-Aid testified Thursday that the Medicare MTM program has in some cases resulted in savings of as much as $6 for every $1 invested — in drug costs alone. The return on investment has gone up to $12 when savings from reduced hospitalizations and better health in general are factored in.

A number of states, including California, Hawaii, Virginia and Wisconsin, have expanded MTM services to cover other groups of patients, primarily low-income residents or those in rural areas with limited healthcare options. Generally they counsel patients on their medications, answer questions and provide feedback to the primary care physician.

[related]In New Jersey, lawmakers amended the proposal to enable certain physicians and advanced practice nurses to provide the MTM sessions, in addition to pharmacists. FamilyCare and Medicaid patients who take multiple medications for a chronic condition would be eligible; the service would be optional, and would not require an additional co-pay. It would require the sessions to be in-person, unless the patient was homebound or otherwise unable to travel.

Lampitt said Thursday that the MTM program has proved very successful in helping Medicare patients manage their prescriptions more effectively. “When you look at another vulnerable population” — low-income residents eligible for publicly subsidized programs like Medicaid and FamilyCare – “we should be extending that same suite of services that have been fine-tuned to them as well. We want better health outcomes.”

Pharmacists urged state officials to ensure the state program aligns with the Medicare requirements for MTM as much as possible. Creating a coordinated system was also a priority for the New Jersey Association of Health Plans, which represents the state’s insurance industry, including some members who have been funding MTM visits for certain private-pay patients for years.

“None of our concerns are with the use or value of the program,” explained Sarah Adelman, NJAHP’s vice-president, noting that it has worked well for some insurance providers and the patients involved. “We’re concerned about inconsistencies.”

Adelman also worried about the added cost of requiring the consultations to be in-person, as that could be challenging for patients who are seriously ill. For some individuals, like those served by a regular home-health aide, a phone call might be more appropriate, she said. (The legislation would not apply to patients in long-term or day programs, in which their care is likely to be closely managed).

Assemblyman Herb Conaway, (D-Burlington), a physician who chairs the health committee, said he understood the industry’s concerns, but felt the in-person visits were important and, in general, that the value of the program outweighed any additional cost. (The legislation does not include a cost estimate at this point).

“I would think nonadherence (to prescribed medications) generally raises costs to the health system and for all of us,” Conaway said, wondering aloud if the state could, “extend the reach of this bill to others that need it too.”