Drug Burden Score Model in the Patient-Centered Medical Home

Cincinnati—Medication therapy management (MTM) often utilizes a combination of prescription drug data and patient demographic information to predict the risk of medication-related complications. At a Pharmacy Partnership Briefing session at the AMCP meeting, attendees learned about a novel drug burden score model and its use within a patient-centered medical home (PCMH) model.

Tim Sullivan, PharmD, director, clinical services at OutcomesMTM, opened his presentation with a brief overview of MTM, which he defined as “the analytical, consultative, educational, and monitoring services provided by pharmacists in order to facilitate the achievement of positive therapeutic and economic results from medication therapy.” Issues including nonadherence, gaps in care, and member education are also addressed through MTM, he said.

MTM services include annual comprehensive medication reviews (CMRs) and quarterly targeted medication reviews (TMRs) that may be pharmacist-initiated or initiated via the clinical rules engine. CMRs are conducted by appointment whereas TMRs are conducted on an ongoing basis as deemed necessary.

“The growth and evolution of the MTM model was spurred by the Medicare Part D provision of the Medicare Modernization Act in 2003,” Dr. Sullivan continued. In 2010, the Centers for Medicare & Medicaid Services (CMS) issued a call letter requiring interactive, person-to-person services, tightening requirements for targeting, and focusing on CMRs as well as TMRs.

With increasing attention being paid by CMS to MTM services, health plans are looking beyond Part D targeted beneficiaries to nontargeted Medicare Part D and commercial members. MTM is being viewed as a strategy to improve quality as applied to the Medicare Star Ratings program.

Dr. Sullivan noted that plans have begun to recognize that community pharmacy and MTM services should play a role in the PCMH model. “In a PCMH, the community pharmacist can deliver the CMR face-to-face and aid in care coordination with additional providers,” he said.

OutcomesMTM has developed a patient risk stratification model, known as the FaCE™ (financial and clinical exposure) Index. The FaCE Index is based on prescription claims data combined with patient demographic information, and is intended to stratify and prioritize members and trigger alerts for enhanced monitoring of medications and the need for pharmacist intervention.

The FaCE Index prioritizes patients based on polypharmacy, multiple physicians, adherence issues, drug therapy problems, volatile medication regimens, and identification of members who may be at high risk for breakdowns and consequences with even a slight variation in medication use. The index generates a risk score on a scale of 0 to 10; 10 equates to higher risk and signals immediate need for intervention and 0 equates to lowest risk.

Dr. Sullivan concluded his presentation with an overview of the next steps for the FaCE Index. He said OutcomesMTM plans to use the index to elevate high-risk patients on network pharmacist queues and to create enhanced pharmacist alerting systems. They also plan to develop platform visualizations to help pharmacists understand the scoring.

The session continued with a presentation from Winston Wong, PharmD, associate vice president, pharmacy management, CareFirst BlueCross BlueShield, Baltimore, Maryland. Dr. Wong’s comments focused on a novel drug burden score and its use within the PCMH model.

CareFirst utilizes a model based on drug volatility score. The model works to identify members taking medications that have a high probability of not being taken correctly, leading to clinical breakdown. Such medications have a high level of side effects, drug interactions, or complex regimens that contribute to noncompliance.

Drugs currently driving the drug volatility score include antiretrovirals, antipsychotics, basal-insulins, antitransplant rejection drugs, oral hepatitis C drugs, antiplatelet medications, and anticoagulants, Dr. Wong said.

Dr. Wong ended his presentation by highlighting the impact of MTM. He said the focus on quality is going to remain important and the changing healthcare environment will create a need for new approaches to healthcare. Pharmacists, using a proactive, wellness approach, are “well positioned to help patients manage their medications,” he said.

“Tools like the drug burden score are needed to help prioritize and focus our limited resources,” Dr. Wong added.