Our healthcare system is beginning to change, and with it has come transformation throughout the branches of medicine. It’s becoming more and more expensive for doctors to see patients, and coupled with the increasing types of medication being created each year, doctors can no longer be the only primary care managers. The role of the pharmacist is changing as they become a more interactive part of the healthcare team. One way in which pharmacists are stepping up is through the practice of Medication Therapy Management (MTM). MTM is a process where pharmacists meet individually with patients to clarify their medication plan. They educate patients about their disease, adjust medications, and refer them to specialists if necessary. This one-on-one time is shown to greatly assist the patient. Patients have to be their own advocate for their health, and the better education and planning that they get from MTM can often provide assistance in self-care. Scholars have discussed the cost effectiveness, medical benefits, and necessity of MTM due to the changing structure of the healthcare and Medicare. I plan to investigate how pharmacists could become just as important as doctors, if not more so, due to the education and information only they can provide.
Quite a few studies have been done to investigate the cost effectiveness of MTM. The most important study involving this was the Asheville Project (Bunting 24), something I will go discuss in detail later. Hospitals and pharmacies are beginning to open up clinics for MTM service because it is covered under Medicare (Gebhart). Many believe the up and coming branch of pharmacy called clinical pharmacy grew from the money saving benefits of MTM (Sipkoff). It is clear that MTM is effective at saving patients and insurance providers money.
Another aspect of MTM, and one even more important than the monetary benefits, is the health benefits has proven to have. Diabetes in particular is a terrible disease that many believe to be one of the best diseases to treat with MTM (Carmichael). Researchers and pharmacists alike believe that the role of the pharmacist should be expanded because of how influential they can be in helping patients handle the disease (Smith). Pharmacists and MTM are particularly effective in community health centers, and studies have shown that this is the patient population that needs the most help (Adashi). Part of the Adashi study forms the crux of my argument. Pharmacists are underutilized because the general public does not understand and recognize their level of education and expansive knowledge of medicine. Pharmacists can be extremely effective as healthcare professionals and just as helpful as doctors in many cases, especially in the case of diabetic patients. Through this article, I will explain diabetes, how the process of MTM specifically helps combat it, the success of MTM, and where I expect the field of pharmacy to go based on changing medical practice and changing federal healthcare.
What is diabetes?
The most effective use of MTM is on the life altering disease of diabetes. Diabetes is one of the most destructive and widespread diseases affecting the United States today. The American Diabetes Association estimates that 25.8 million Americans alive today have been diagnosed with diabetes. This boils down to a fraction of the population, but the skyrocketing rate of the diagnoses is the most important issue. MTM is extremely efficient at helping patients manage their symptoms, but to understand how, we first have to understand the disease itself. Diabetes mellitus is a condition in which either the pancreas no longer produces the hormone insulin or the cells of the body can no longer process insulin (Faralex). The pancreas creates insulin in response to blood sugar, a form of which is the chemical glucose. Insulin absorbed by the cells allows them to accept the glucose in the blood stream that comes from foods ingested. The glucose is converted into energy to allow the cells to do their job. Without the proper use of insulin, the body has a lot less glucose available for energy. An even more important problem is the damage that the glucose left in the blood stream causes for the rest of the body. A plethora of health problems can result, including kidney failure, slow healing of wounds, loss of nerve endings in the feet and legs, and most dangerously, heart disease. It’s predicted that 1.9 million new cases of diabetes will be diagnosed each year, while the disease and its complications contribute to about 240,000 deaths each year (2011 National Diabetes Fact Sheet). The most commonly blamed cause for the growing number of diabetes cases is the increasingly unhealthy lifestyle of the average American, two major aspects being diet and exercise (Dandona). According to a recent study from the United States Department of Agriculture, from the 1970s to the 1990s, fast food rose from 18% to 32% of total calories consumed by Americans (Guthrie). An equally troubling problem is the inactive lifestyle that most Americans live. These two health problems, along with genetic predisposition, contribute to diabetes and explain why the disease is becoming more widespread in recent years.
In addition to its side effects, diabetes is financially devastating to the entire country. In 2007, diagnosed diabetic patients cost the United States $174 billion in Medicare and Medicaid, hospital, and medication costs (2011 National Diabetes Fact Sheet). This did not include the hundreds of thousands of people with pre-diabetes, who have an almost guaranteed chance of developing diabetes within five years, which brought the cost to $218 billion. The American Diabetes Association created a Diabetes Cost Calculator that cites the cost of diabetes in each congressional district. Here in District 4 of North Carolina, the estimated direct cost of diabetes is $226 million and $122 million in indirect costs. Direct costs include the costs of medication, doctors, and hospital visits, while indirect costs are what businesses and employers lose if employees cannot work because of the disease. This disease costs not only the patients, but taxpayers, huge amounts and must be combatted. The major issue is that the main groups of people with diabetes are poor and uneducated. They do not always understand the causes of their diabetes, how their diet contributes to their disease, and how their medications work. Pharmacists are utilizing MTM to help the population through this.
What is MTM?
MTM is a process that can be carried out by all branches of pharmacists, but is usually used by those in community and retail. The overarching purpose of Medication Therapy Management is to connect doctors, pharmacists, and patients and ensure that all parties know everything about the patient’s health. There are four steps. First, the pharmacist meets with the patients and ensures they are not taking any unnecessary medications. Oftentimes, patients will have been prescribed medication for conditions that they no longer have but continue to take the medicine. Pharmacists will also educate the patient about their disease and what they can do to combat it. For diabetic patients, this would mean understanding the relationship between insulin and glucose and learning how to self-adjust their dosage based on sugar consumption. Next, pharmacists accurately document all medications, including vitamins and over the counter drugs, that they patient may be taking. Many diabetic patients have additional health problems, so pharmacists generally educate them about any pain, heart, or cholesterol medication that they take. This includes documenting their medical history as well. In the next step, the pharmacist creates an action plan for the patient. If new prescriptions have been filled or old ones taken off, the patient receives a “Medical Action Plan” (MAP) with direct instructions for all medications. This also includes adjustment of medications, specifically changes in diabetic patient’s insulin dosages. Since diet and exercise are generally concerns for diabetic patients, the MAP will also address any eating restrictions or exercise goals. If additional medical issues have arisen, pharmacists can refer patients to the appropriate specialists. Finally, the pharmacist will schedule follow up appointments so that they can continue to meet and combat the disease as it progresses.
Why is it helpful?
In many studies, MTM has been shown to significantly help diabetic patients manage their disease. Documenting all medications and past medical history is crucial, as the majority of diabetic patients have lots of other health concerns and past problems. As stated before, many diabetic patients are poor and uneducated and any extra attention to ensure that they understand how to take care of themselves can go a long way. Medical accidents occur all the time when patients are not educated and have multiple professionals treating them that are not on the same page. For example, years ago, my grandmother had a stroke that put her in the hospital and almost in a coma. Her multiple doctors almost mistakenly put her in a state of hypoglycemia. Her diet, considering she was in the hospital and barely eating, was vastly different than what she was used to eating at home. Her doctors, however, did not adjust her insulin dosage to account for this change, and continued to give her a high dosage of insulin that dangerously lowered her blood sugar. My mother and aunt, being informed about the disease, advised the nurses to check her blood sugar and probably saved her life. My grandmother was fine, but this is not an isolated incident. Dramatic consequences result when things like this happen to patients who do not know enough to be their own advocate. Most importantly, regularly scheduled medication check-ups are one of the best ways to treat diabetes. As patients change their diet and exercise regimen to better combat their disease, the amount of insulin they need will change as well. More intermittent meetings with medical personal allow the treatment and stabilization of the disease to go much faster. Doctors do not have the time to meet as frequently with their patients as community pharmacists, which is a major reason that MTM is so effective. This process fills a gap in the amount of attention that diabetic patients need to best treat their diabetes.
The Asheville Project
One of the most noted experiments into MTM occurred in Asheville, North Carolina. The success of the Asheville Project promoted both the cost effectiveness and health benefits of MTM. The City of Asheville hired several community pharmacists to meet with city employees and use MTM to help them treat their diabetes. From 2002-2005, community pharmacists met with 620 patients who had diabetes or other vascular system problems (Bunting). They measured many health factors over the three years, including several types of blood pressure, cholesterol, and triglyceride levels. Patients attended several classes about maintaining their cardiovascular health in addition to meeting regularly with their pharmacist to adjust insulin and other medications as needed. The pharmacists were encouraged to involve patients in the treatment process by explaining to them how and why their medications were being changed, and by encouraging patients to ask questions about the process. Throughout the three years, a majority of patients made vast improvements in their health. Sixty seven percent reached their target lowered blood pressure goal and the number of patients at risk for a cardiovascular episode (i.e. a heart attack or stroke) was cut in half. All indicators that they measured lowered to a much healthier level. Clearly, the Asheville Project was a huge success in terms of health, but it also proved the financial benefits of MTM. The average cost per hospitalizations dropped significantly. The cost of medication rose almost threefold, as patients were changing medications more frequently, but the overall healthcare costs on both the patient and the city of Asheville decreased by 45%. Although patients spent more money on their blood pressure medication, their overall health improved significantly and saved everyone money. On all counts, using MTM in Asheville was fruitful in helping the health of the city employees.
The Legacy of Asheville
The Asheville Project provided evidence to the country that pharmacists, armed with MTM, can be a crucial and effective part of the healthcare team. MTM really came to be considered a useful tool in combating chronic disease, particularly diabetes, after the success of the Asheville Project. Pharmacists and health care companies began spreading the word about the process. The pharmaceutical manufacturer GlaxoSmithKlein led the way in lobbying for MTM to be included in federal health plans. This came to fruition in the reworking of the Medicare system. First enacted in 1965 under President Lyndon Johnston, Medicare is a government run program that helps provide health coverage for seniors. It was started to prepare the way for the “baby boomer” generation that is now in the 2000s reaching retirement age. The system has been reformed many times, but currently has four general parts. Simply put, Part A provides coverage for hospital services, B provides for outpatient procedures, C allows outside insurance companies to supplement the government provided healthcare, and D provides coverage for prescription drugs (Medicare News Today). In 2003, the Bush Administration passed the Medicare Modernization Act that included MTM services in Part D. Medicare.gov itself describes MTM as helpful to those with chronic and complex diseases and goes on to explain the steps involved in MTM. Many other groups praise the benefits of MTM, including private companies that provide Part C coverage.
In an interview with Glen Stettin MD, the senior vice president of Medco, one of these private companies, he pointed out the need for MTM in treating these types of diseases (Sipkoff). Two of Medco’s nine centers are designated to specifically handle and treat diabetes. Medco hires clinically trained pharmacists to meet with patients and review their drug plan, educate them, and ensure they are not taking medications they do not need. Medco claims that their most important task, and one that pharmacists in all branches of medicine do, is make sure that doctors prescribed cheaper generic options if available. There is a lot of media attention on scandals that sometimes occur between doctors and drug companies; doctors sometimes receive payoffs to prescribe the drug company’s prescription over all others. Pharmacists have always helped in this check and balance system, but are even more important today with the exponential increase in medications on the market. Patients should not have to pay any more for the medication they are taking because according to Medco, diabetes is the most expensive chronic disease. Diabetic patients make up only 5% of the American population, but account for 15% of total drug spending. Thanks to the Asheville Project, we can see that MTM and the work of pharmacists significantly cut down on the cost of diabetes.
Doctor Treatment vs. Pharmacist Treatment
Another important aspect to investigate is how different, and in some cases better, pharmacists and MTM can treat diabetes than just doctors alone. Unfortunately for the many pre-med students in school at UNC, some scholars project the role of the doctor to change and suffer from changes in the American healthcare system. It is almost frightening the changes that could result due to the 2011 Patient Protection and Affordable Care Act, better known as Obamacare. In an article by Scott Atlas, a professor at Stanford University’s Medical Center, the problems the country will face are outlined. He believes that our current healthcare system will eventually look like that of Canada and the United Kingdom. In comparison to our system, Atlas states that patients in these other healthcare systems have to wait much longer to get treated, have less access to new and improved medication and technologies, less of a choice when it comes to doctors and physicians, and fewer options in their healthcare providing programs. In these systems, the government has a much tighter grip on the health of their citizens. Studies have shown that treatment times are much longer in Canada and the United Kingdom than they currently are in the United States, and Atlas even says “Ironically, while Americans contemplate moving toward these sluggish systems, the Canadian and British governments are spending vast sums studying how to reduce their scandalous waitlists” (Atlas, 1).
Perhaps one of the biggest downfalls to government run care is the lack of access to the most cutting edge medications and technologies. Atlas cites that the United States consistently has the highest cancer and disease survival rate in the world, and it is because of the speed at which American doctors and patients can safely use new drugs. The Federal Drug Administration (FDA) is much faster at approving cutting edge drugs than all government run healthcare systems. The journal “Nature Reviews” released an article showing that of all the drugs between 2000-2005 seeking clearance in the United States and in the European Union, 73% were approved first in the United States (Atlas, 2). This is mostly because of the capitalist system and its lack of price controls. Private drug companies are more willing to submit their drugs to the Unites States first because they can achieve more of a profit, as it costs them less. This same concept of the capitalist economy carries over into medical technology. Because of the lack of price restrictions, machines such as CT scanners and MRIs are more readily available in the United States, and therefore wait times are much less. On average, there are 27 MRI machines per one million Americans versus 5.5 for every million Canadians.
Moving back to diabetic patients, similar deficiencies will be seen in their treatment in the coming years. Government workers will have the task of determining what, if any, treatment patients will received based on whether they deem the treatment necessary. This will clearly all boil down to costs. Whatever saves them the most money is most likely what the government run healthcare system will do, even if this means sometimes sacrificing the health of a patient. Already, almost half of the doctors in the United States have said that they have stopped or reduced taking patients insured by Medicare. Obamacare has cut funding to some aspects of Medicare, meaning that doctors get paid less, which results in it becoming far too expensive for them to practice. In fact, many practices that rely solely or heavily on Medicare patients have fallen into bankruptcy, just leaving the country with a shortage of doctors. The shortage could not come at a worse time; 77 million baby boomers are projected to retire in 2012, and a vast majority of them will eventually be insured by Medicare. The bottom line is that with the changing structure of the American healthcare system, doctors will no longer be adequate in being the sole healthcare provider. Pharmacists will have to fill the void left by the shortage of doctors and inadequacy of the healthcare system.
In addition to the medical and monetary benefits of pharmacist led treatment, there are also psychological aspects. Patients often see their local pharmacist more often than their regular doctor, and this trend can only be projected to increase as we see a decrease in the number of doctors in the coming years. This regular exposure to their pharmacist creates a sense of familiarity. In addition, a community retail pharmacy is generally less frightening than visiting a doctor’s office or hospital. In an interview with Holly Devine, a professor at the Kentucky University School of Pharmacy, she points out that patients would probably be more willing and likely to come to a pharmacy as opposed to a hospital.
The main issue with this supposition is the attitude of the general public towards pharmacies. Very few people would welcome spending more time in the store than they have to, as most Americans live a very hectic life with a busy schedule. Most people that I have talked to would not choose to meet with their pharmacist because of the time, and time is money. The fact that needs to be stressed to Americans is that pharmacist led treatment and practices like MTM will, in the long run, save patients both time and money. Pharmacists can, and will in the coming years, be extremely effective in treating all kinds of diseases, but especially chronic illnesses such as diabetes. Healthcare issues, specifically diabetes, are a problem that many people will face at some point in their lives. How the healthcare system works, how pharmacists fit in, and the excellent service that pharmacists can provide to patients is something that every American should understand and use to their advantage as they grow older.
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