You are on page 1of 96

NEBRASKA COMMUNITY PHARMACY DEMOGRAPHICS 2015:

ASSESSMENT OF NEBRASKA PHARMACISTS AND CORPORATE EMPLOYERS ABOUT MEDICATION THERAPY MANAGEMENT AND CHRONIC DISEASE MANAGEMENT

Kimberly Galt, PharmD, PhD, FASHP, NAP Professor and Principal Scientist, Center for Health Services Research and Patient Safety Creighton University

August 2015

The assistance of the following persons is gratefully acknowledged:

Kari Majors, Program Manager Nebraska Department of Health and Human Services - Public Health

Jamie K. Hahn, Program Manager Nebraska Department of Health and Human Services Public Health

Joni R. Cover, J.D., Executive Vice President Nebraska Pharmacists Association

Kevin Fuji, MA, PharmD, Assistant Professor and Director Creighton Health Services Research and Patient Safety Center, Creighton University

Ted Kaufman, Research Application Administrator Creighton Health Services Research and Patient Safety Center, Creighton University

Danielle Wing, Community Health Education Senior Nebraska Department of Health and Human Services - Public Health

Jack D. Anderson, undergraduate research assistant, Creighton University

Haley A. Sturges, undergraduate research assistant, Creighton University

This project was completed under Contract from the Nebraska Department of Health and Human Services Division of Public Health Chronic Disease Prevention and Control Program.

Executive Summary of Findings

Overview. This report summarizes a study of pharmacists and corporate pharmacy

managers who employ pharmacists about the clinically-related services, including medication

therapy management (MTM) services, offered to patients by Nebraska pharmacists who work in

ambulatory care work settings. These findings will help to determine the readiness of

pharmacists in the state of Nebraska to reliably produce these services and the extent to which

companies that employ pharmacists incorporate these services into business strategies.

Findings. Nearly two-thirds (64 percent) of all pharmacies have provided MTM services

in the past 12 months. The majority of pharmacists within the state are providing MTM and

direct patient care services; one fourth of pharmacists have been formally trained largely through

their employers. Pharmacies providing MTM services nearly exclusively deliver the patient-

centered service via face-to-face/in-person or telephone. These services allow patients to access

chronic disease management and other care services through stronger relationships that provide a

consistent care regimen through interaction with pharmacists. These benefits offer a promising

outlook on the provision of MTM and direct patient care services. While pharmacies still

experience significant barriers related to MTM, a great opportunity for the State of Nebraska

exists in further promoting MTM and direct patient care services among Nebraska community

pharmacies. Strategies to consider in advancing these services include:

A large portion of pharmacists could charge for MTM services who are not. Pharmacists

predominately view MTM and direct patient care services as part of their regular work

duties. This is an important growth area for improving access to services.

Corporate pharmacy managers view MTM and direct patient care services through a broader

lens; as a tool to retain customers, improve relationships, and realize financial gain long-

term. As such, managers should consider methods to enhance pharmacists’ performance of

these services.

There is opportunity to promote improvement in workflow, work organization, and

recognition of performance by pharmacists with corporate pharmacy managers as

corporations further develop the models of MTM and other direct care services of

pharmacists.

Pharmacies are rapidly becoming a new vehicle by which to provide patient care, and

corporate pharmacy managers are attempting to determine how to most efficiently and

effectively expand their patient care business portfolios.

Pharmacy managers understand direct patient care services as a package, with MTM as one

service offered within it. Pharmacy managers see the need for collaboration among many

entities and providers to improve patient outcomes, but are unsure how to position within the

health care landscape. Help with making good decisions would be beneficial.

A partnership between industry leaders, healthcare professionals, and the State of Nebraska

could be formed to share experiences related to direct patient care services and identify

potential successful business practices that support high quality patient care services.

Pharmacists’ promotion of MTM service provision directly to patients would potentially

increase access rapidly to patients whose local pharmacists presently offer this.

Conducting state wide training of pharmacists for chronic disease management/MTM. A

standardized training process could be provided to pharmacists in the state of Nebraska.

Conducting state wide training of Community Health Workers about how to refer patients to

MTM services and direct patient care services from pharmacists would increase patient

access to these services.

A majority of pharmacists in community pharmacy practices provide blood pressure checks,

offer to teach how to use blood pressure checking products/devices, offer to teach how to use

blood glucose products/devices, offer medication adherence assistance, provide home

delivery of medications and supplies, and give immunizations. It makes sense for

pharmacists to extend their clinical expertise in these areas and promote their advancement to

be providers of chronic disease self-management, hypertension and diabetes self-

management education to the corporate pharmacy managers and professional association

leadership of pharmacy.

Offer educational opportunities and training to pharmacists to become educators of patients

in self-management areas of chronic disease management, hypertension and diabetes.

Almost half of the pharmacists in community practices have collaborative practice

agreements in place, primarily for immunization and vaccination services. Transforming

pharmacy practice to provide immunization and vaccine services have displayed the ability

of pharmacists to offer expanded clinical services, and a significant opportunity for growth

exists for pharmacists in establishing practice agreements with providers to offer additional

services related to medication therapy monitoring and management within pharmacy walls.

Conclusions. Pharmacists are engaging at a growing pace in the delivery of MTM and

direct care services to patients. The last 5 years has shown substantial growth in the adoption of

MTM service provision across Nebraska. While many pharmacists provide or will be providing

MTM and direct patient care services within the near future, these services remain underutilized

by patients, resulting in substantial loss of opportunity for improvements in patient outcomes.

Teaching other community-based resources, such as Community Health Workers, about how and

when to refer patients to pharmacists to receive these services could substantially increase patient

access in many communities where pharmacists are offering MTM and other services and are

ready to receive more patient involvement now.

Pharmacy corporate managers are actively pursuing options to best position themselves

to continue offering pharmacist-provided direct patient care services, and leverage these

offerings to team-based approaches with other health care entities/providers. Collaborative

practice agreements are in place in near half of the pharmacies in the state, demonstrating a

model of integration of pharmacists’ services into the delivery of care to patients that extends

provider care plans (chronic disease management) and public health priorities (immunization).

Other models of integration that have some examples include contributing to patient care in

Accountable Care Organizations (ACO) and Patient Centered Medical Homes (PCMHs) through

pharmacists-delivered MTM services, as an example. These models need further advancement.

Corporate pharmacy managers are generally unsure about how to implement such arrangements.

Concurrently, pharmacists practice conditions, which are already efficient based upon the needs

of dispensing and counseling of patients, are often impeding pharmacists from promoting these

services to patients beyond their current level of engagement. Workload and traditional

workflow and organization within pharmacies make it difficult for pharmacists to “add work” in

many of the pharmacies that responded to the survey. This, despite the fact that most pharmacies

indicated their intention to try to improve the conditions so that they could offer/or expand their

offering of these services. Many are reporting they are near ready and intend to offer these

services soon. Corporate pharmacy managers recognize that MTM and direct patient care

services exist in an overwhelmingly piecemeal and fractured system; for MTM to be truly

successful within the state of Nebraska, full integration, both of pharmacists across healthcare

and of MTM within the pharmacists’ workflow and pharmacy operations, is needed.

Table of Contents

Executive Summary

2

Introduction

10

Background and Significance

10

Purpose

11

Design and Methods

11

Mixed Methods Approach

11

Survey of Nebraska Pharmacists in Charge of Community Pharmacies

12

Methods

12

Response Rates

13

Findings

15

Interviews of Corporate Pharmacy Employers of Pharmacists in Nebraska

45

Methods

45

Participation

45

Findings

46

Interpretation When Survey and Interview Findings are Compared

57

Limitations

58

Conclusions and Recommendations

59

Figures

Fig. 1: Convergent Parallel Design

11

Fig. 2: Services of Interest Provided by Pharmacists in Community Pharmacies

13

Fig. 3: Pharmacies Studied

14

Fig. 4: Collaborative Practice Agreements with Providers: All Pharmacies

16

Fig. 5: Familiarity with Community Health Workers (CHWs)

18

Fig. 6: Pharmacist Provided MTM Services in Last 12 Months: All Pharmacies

19

Fig. 7: Formal MTM Training Program Attendance: All Pharmacies

22

Fig. 8:

Length of Time Providing MTM Services: All Pharmacies

23

Fig. 9: Average Number of Patients who receive MTM Services in a Month:

Pharmacies of Interest

25

Fig. 10: Identification of Patients as Candidates for MTM Services: Pharmacies of Interest

Fig. 11: Ways Patients and Providers are Made Aware of MTM Services:

26

Pharmacies of Interest

27

Fig. 12: Amount Pharmacists Charge for MTM Services: Pharmacies of Interest

29

Fig. 13: Pharmacy Compensation to Pharmacists for Providing MTM Services:

Pharmacies of Interest

31

Tables

Table 1: Nebraska Pharmacies by License Type and Response Rate

61

Table 2: Services Provided through Corporations at the Local Community Level

62

Table 3: Services Provided through Corporations at the Local Community Level [Settings where MTM services are likely to occur]

64

Table 4: Services Provided through Corporations at the Local Community Level [Settings where MTM services are not likely to occur]

65

Table 5: Collaborative Practice Agreements with Providers

66

Table 6: Collaborative Practice Agreements with Providers [Settings where MTM services are likely to occur]

66

Table 7: Collaborative Practice Agreements with Providers [Settings where MTM services are not likely to occur]

66

Table 8: Implementation of a Bi-Directional Referral Process

67

Table 9: Implementation of a Bi-Directional Referral Process [Settings where MTM

services are likely to occur]

68

Table 10: Implementation of a Bi-Directional Referral Process [Settings where MTM services are not likely to occur]

69

Table 11: Familiarity with Community Health Workers (CHWs)

70

Table 12: Familiarity with Community Health Workers (CHWs) [Settings where MTM services are likely to occur]

70

Table 13: Familiarity with Community Health Workers (CHWs) [Settings where MTM services are not likely to occur]

71

Table 14: Pharmacist Provided MTM Services in Practice within the Last 12 Months

72

Table 15: Pharmacist Provided MTM Services in Practice within the Last 12 Months [Settings where MTM services are likely to occur]

72

Table 16: Pharmacist Provided MTM Services in Practice within the Last 12 Months [Settings where MTM services are not likely to occur]

72

Table 17: Mechanism(s) Used by Pharmacists to Deliver MTM

73

Table 18: Mechanism(s) Used by Pharmacists to Deliver MTM [Settings where MTM services are likely to occur]

73

Table 19: Mechanism(s) Used by Pharmacists to Deliver MTM [Settings where MTM services are not likely to occur]

74

Table 20: Organizational Structures

74

Table 21: Organizational Structures [Settings where MTM services are likely to occur]

75

Table 22: Organizational Structures [Settings where MTM services are not likely to

occur]

75

Table 23: Formal MTM Training Program Attendance

76

Table 24: Formal MTM Training Program Attendance [Settings where MTM services are likely to occur]

76

Table 25: Formal MTM Training Program Attendance [Settings where MTM services are not likely to occur]

76

Table 26: Length of Time Providing MTM Services

77

Table 27: Length of Time Providing MTM Services [Settings where MTM services

are likely to occur]

78

Table 28: Length of Time Providing MTM Services [Settings where MTM services

are not likely to occur]

79

Table 29: Number of Patients who Receive MTM Services in a Month

80

Table 30: Number of Patients who Receive MTM Services in a Month [Settings where MTM services are likely to occur]

81

Table 31: Number of Patients who Receive MTM Services in a Month [Settings where MTM services are not likely to occur]

82

Table 32: Identification of Patients as Candidates for MTM Services

83

Table 33: Identification of Patients as Candidates for MTM Services [Settings where

84

Table 34: Identification of Patients as Candidates for MTM Services [Settings where

MTM services are likely to occur]

MTM services are not likely to occur]

85

Table 35: Ways Patients and Providers are Made Aware of MTM Services

86

Table 36: Ways Patients and Providers are Made Aware of MTM Services [Settings

where MTM services are likely to occur]

87

Table 37: Ways Patients and Providers are Made Aware of MTM Services [Settings

where MTM services are not likely to occur]

88

Table 38: Amount Pharmacists Charge for MTM Services

89

Table 39: Amount Pharmacists Charge for MTM Services [Settings where MTM services are likely to occur]

90

Table 40: Amount Pharmacists Charge for MTM Services [Settings where MTM services are not likely to occur]

90

Table 41: Pharmacy Compensation to Pharmacists for Providing MTM Services

91

Table 42: Pharmacy Compensation to Pharmacists for Providing MTM Services [Settings where MTM services are likely to occur]

92

Table 43: Pharmacy Compensation to Pharmacists for Providing MTM Services [Settings where MTM services are not likely to occur]

93

Table 44: Challenges Pharmacies face when Providing MTM

94

Table 45: Challenges Pharmacies face when Providing MTM [Settings where MTM

services are likely to occur]

95

Table 46: Challenges Pharmacies face when Providing MTM [Settings where MTM

services are not likely to occur]

96

NEBRASKA COMMUNITY PHARMACY DEMOGRAPHICS 2015: ASSESSMENT OF NEBRASKA PHARMACISTS AND CORPORATE EMPLOYERS ABOUT MEDICATION THERAPY MANAGEMENT AND CHRONIC DISEASE MANAGEMENT

INTRODUCTION

This report summarizes a study of pharmacists and corporate pharmacy managers who

employ pharmacists about the clinically-related services, including medication therapy

management (MTM) services, offered to patients by Nebraska pharmacists to who work in

ambulatory care work settings. Participants were provided the definition of MTM services

adopted by Medicare; a pharmacist-provided patient care program consisting of five core

elements: (a) Medication Therapy Review, (b) Personal Medication Record, (c) Medical Action

Plan (includes patient’s self-management plan), (d) Intervention and Referral, and (e)

Documentation and Follow-up.

BACKGROUND AND SIGNIFICANCE

Pharmacists are occupying roles in innovative care models through which they are

offering services to patients designed to reduce the risk of harm and injury from suboptimal and

inappropriate medication use and errors through advising prescribers and advising patients in

medication self-management. National initiatives through federal agencies such as the Centers

for Disease Control and concurrently professional organizations, such as the American

Pharmacists Association, are advocating for patients to have both economic and geographic

access to pharmacists’ patient care services including MTM services. Access to these services is

subject to the pharmacistscapacity (extent of skills and engagement), incorporation of these

services into business strategies of companies that employ pharmacists, and patient demand.

PURPOSE

This project seeks to determine the readiness of pharmacists in the state of Nebraska to

reliably produce these services and the extent to which companies that employ pharmacists

incorporate these services into business strategies.

DESIGN AND METHODS

Mixed Methods Approach

This exploratory study uses a mixed methods approach to analyze findings by comparing

and relating the results of a statewide survey of pharmacists and interviews of the major

corporate pharmacy managers who employ pharmacists in Nebraska. The survey and interviews

are independent studies, conducted following the rigorous principles appropriate for the

respective research design and method. Then the findings of each are compared using the

rigorous principles of mixed methods analysis. A convergent parallel design governed the data

collection, analysis, and interpretation best describes the overall research design. Figure 1

displays the research design.

QUANTITATIVE STUDY Survey of Nebraska Pharmacists in Charge of Community Pharmacies

QUALITATIVE STUDY Interview of Corporate Pharmacy ManagersPerspectives

Compare and Relate Findings from each study
Compare and
Relate Findings
from each study
’ Perspectives Compare and Relate Findings from each study Fig. 1. Convergent Parallel Design Interpretation 11

Fig. 1. Convergent Parallel Design

Interpretation
Interpretation

SURVEY OF NEBRASKA PHARMACISTS IN CHARGE OF COMMUNITY PHARMACIES

METHODS

Study sample. For our purposes, we have sub-classified all of the pharmacies that are

licensed in the state of Nebraska that provide prescription services into two groups: Pharmacies

of Interest which are pharmacies likely to provide MTM services, along with other services

related to chronic disease management and Other Pharmacies which are pharmacies not likely to

provide these services, based upon the primary purpose and patients each of the pharmacies is

formed to serve. Pharmacies of Interest include Independent (independently owned), Mass

Merchandise, Traditional Chain, Grocery Chain, and Health System/Clinic Pharmacies for a total

number of 419. Other Pharmacies include Hospital Outpatient, Home Care, Specialty, LTC

Facility/Pharmacy, and Other for a total number of 82. The total number of licensed community

pharmacies in Nebraska sent the survey is 501. Pharmacies are distributed by license type

between these two groups as shown in Table 1.

Survey design and administration. An expert team designed the content and layout of a

written response, self-administered survey. The survey was piloted and took between 10-15

minutes to complete. A first mailing to all licensed community pharmacies was sent on May 26,

2015, followed by a reminder postcard one week later. A second survey mailing was sent June

11, 2015, to pharmacists who had not completed the first mailing. Follow-up phone calls to non-

respondents were made during the week of June 22, 2015. Residual third mailing surveys were

sent via mail, facscimile, or email to pharmacists upon request as a result of the follow-up phone

calls. The specific services that were examined in the survey are shown in Figure 2.

Services Offered to Patients

Medication Therapy Management Services Blood pressure checks Offer to teach how to use blood pressure checking products/devices Hypertension self-management education Point-of-care blood glucose testing or hemoglobin A1C testing Offer to teach how to use blood glucose testing products/devices Diabetes self-management education Point-of-care INR testing for monitoring anticoagulation Comprehensive anticoagulation management Smoking/tobacco cessation education Comprehensive drug therapy review Medication adherence assistance Home delivery of medications and supplies Immunizations Other Miscellaneous Clinical Services

Fig. 2. Services of Interest Provided by Pharmacists in Community Pharmacies.

RESPONSE RATES

In total, 343 responses were received for a final overall response rate of 68 percent.

Response rates by each pharmacy type are shown in Table 1. Pharmacies of Interest comprise

the bulk of community pharmacy licenses within Nebraska (Figure 3). The highest rate of

response was from Health System/Clinic Pharmacies (80 percent response) and the lowest rate of

response was from Traditional Chain Pharmacies (58 percent response). Other Pharmacies

Pharmacies Studied a

Pharmacies

of Interest

Health Grocery System/Clinic Traditional Chain 3% Chain 12% 19% Specialty 3% Mass Other Merchandise
Health
Grocery
System/Clinic
Traditional
Chain
3%
Chain
12%
19%
Specialty
3%
Mass
Other
Merchandise
Pharmacies
Home Care
Other
Chain
17%
2%
2%
17%
Hospital Outpatient
6%
Independent
Other
33%

LTC

Facility/Pharmacy

4%

Pharmacies

a. Other Pharmacies category differs by 1% when Figure 3 is compared to Tables. This is due to rounding error of software programs used to analyze data and present data.

Fig. 3. Pharmacies Studied

comprise a small percentage of community pharmacy licenses in Nebraska and are typically not

situated to offer MTM or pharmacist-provided direct patient care services. However, response

rates for Other Pharmacies were also significant, with a combined average of 68 percent

responding. The highest rate of response was from Long Term Care (LTC) Facility/Pharmacies

(79 percent response) and the lowest rate of response was from Home Care Pharmacies (55

percent response).

.

FINDINGS

Services Provided through Corporations at the Local Community Level

The services listed are predominantly provided in Pharmacies of Interest on the

community level (Table 2). The most common services provided at all pharmacies include

medication adherence assistance, immunizations, and blood pressure and blood glucose testing

product/device use lessons.

Among Pharmacies of Interest, the majority of pharmacies provide blood pressure

checks, offer to teach how to use blood pressure checking products/devices, offer to teach how to

use blood glucose products/devices, medication adherence assistance, home delivery of

medications and supplies, and immunizations (Table 3). Particularly noteworthy patient services

the Pharmacies of Interest are not widely providing include formal hypertension self-

management education, diabetes self-management education, and comprehensive anticoagulation

management.

As expected, very few of the services listed are provided in Other Pharmacies (Table 4).

A few of these pharmacies provide home delivery of medications and supplies, diabetes self-

management education, and medication adherence assistance. However, these services are not

offered to a significant degree. The majority of these pharmacies do not provide these types of

services, instead typically focusing on other specific and/or specialty pharmacy services.

Implications. Pharmacists are actively assisting patients with proper blood pressure and

blood sugar monitoring, particularly with an emphasis on how to use products. There is a

substantial opportunity for community pharmacies to advance the quality and depth of formal

education to patients in self-management education for hypertension, diabetes, and other formal

programs for chronic disease management.

Collaborative Practice Agreements with Providers

Pharmacies of Interest are much more likely to have established collaborative practice

agreements than Other Pharmacies (Table 5). Among Pharmacies of Interest, a little over half

had collaborative practice agreements with providers (Table 6). Overall, pharmacies with

practice agreements in this category were overwhelmingly providing immunization and

vaccination services, while a handful of agreements also included services such as point-of-care

and rapid diagnostic testing.

For the select few Other Pharmacies that had established agreements, services included

immunization and vaccination services and specialty pharmacy services such as dose

modification and limited prescriptive authority (Table 7).

Implications. Many pharmacists have collaborative practice agreements in place,

primarily for immunization and vaccination services. Immunization and vaccine services have

displayed the ability of pharmacists to offer expanded clinical services, and a significant

opportunity for growth exists for pharmacists in establishing practice agreements with providers

to offer additional services within pharmacy walls.

Collaborative Practice Agreements with Providers: All Pharmacies

No Yes 47% 48% No
No
Yes
47%
48%
No

Response

5%

Fig. 4. Collaborative Practice Agreements with Providers: All Pharmacies.

Implementation of a Bi-Directional Referral Process

Relatively few pharmacies have bi-directional referral processes. Among all pharmacies,

Pharmacies of Interest are more likely to have referral processes in place compared to Other

Pharmacies (Table 8). However, Pharmacies of Interest largely do not have bi-directional

referral processes established for patient care services (Table 9). The most common service

referral processes are for immunizations, home delivery of medications and supplies, medication

adherence assistance, blood glucose testing products/devices, and blood pressure checking

products/devices. Particularly noteworthy patient services for which these pharmacies do not

have an established referral process include hypertension self-management education, diabetes

self-management education, and comprehensive anticoagulation management.

Similarly, the majority of Other Pharmacies do not have bi-directional referral processes

for patient care (Table 10). Some have referral processes for home delivery of medications and

supplies and medication adherence assistance; however, the number of these pharmacies is small.

These processes may not be applicable to their practice types.

Implications. Bi-directional referral processes remain underdeveloped within the state. A

substantial opportunity for care connectedness and expanded access to providers exists through

bi-directional referral processes. Understanding the influences on bi-directional referral in the

environment of the healthcare sector is needed to advance the opportunity between pharmacists

and providers in the current healthcare landscape.

Familiarity with Community Health Workers (CHWs)

Familiarity with Community Health Workers (CHWs) is very low among all pharmacies

(Table 11). Pharmacies of Interest remain largely unfamiliar with CHWs and CHWs are

uninvolved with pharmacies and pharmacist-provided patient care. Only a small handful of

pharmacists in this category were familiar with CHWs and even fewer pharmacists involved

CHWs in patient care or referred patients to CHWs (Table 12). Other Pharmacies were similar

in this regard (Table 13).

Implications. A tremendous opportunity for growth exists within the state for CHWs to

make referrals to pharmacists. Most pharmacists are unaware of CHWs and the opportunity that

they provide to refer patients who have medication adherence needs back to pharmacists.

Educating pharmacists about CHWs and teaching CHWs how to refer to pharmacists is a

potential statewide strategy.

Familiarity with Community Health Workers (CHWs)

15% 60 15% 10% 40 9% 10% 7% 9% 7% 20 16% 7% 7% 7%
15%
60
15%
10%
40
9%
10%
7%
9%
7%
20
16%
7%
7%
7%
0
All Pharmacies
Pharmacies of Interest
Other Pharmacies
Pharmacists are familiar with CHWs
CHWs are involved with patients that use pharmacist's services
Number of Pharmacies

CHWs refer patients to the pharmacist for serviceswith patients that use pharmacist's services Number of Pharmacies Pharmacist refers patients to CHWs for assistance

Pharmacist refers patients to CHWs for assistancewith patients that use pharmacist's services Number of Pharmacies CHWs refer patients to the pharmacist for

Fig. 5. Familiarity with Community Health Workers (CHWs).

Pharmacist Provided MTM Services in Practice within the Last 12 Months

Nearly two-thirds (64 percent) of all pharmacies have provided MTM services in the past

12 months (Table 14). This service is predominantly provided in Pharmacies of Interest on the

community level. However, a handful of Other Pharmacies are providing MTM, but not to the

degree and scope of Pharmacies of Interest. The majority of Pharmacies of Interest (71 percent)

has provided MTM within the last 12 months (Table 15). These services were most prominent

among Mass Merchandise Chain Pharmacies and Grocery Chain Pharmacies. MTM has largely

not occurred to a similar magnitude within Health System/Clinic Pharmacies.

Other Pharmacies have overwhelmingly not provided MTM within the last 12 months

(Table 16). Within this category, about half of Specialty Pharmacies have provided MTM;

however, this number of pharmacies is small. Overall, pharmacies in this category have not

provided MTM as many do not see MTM as an applicable service to their practice setting.

Implications. The majority of pharmacists within the state are providing MTM and direct

patient care services. These services allow patients to access chronic disease management and

other care services, develop stronger relationships with pharmacists, and establish a more

consistent care regimen through interaction with pharmacists. These benefits offer a promising

outlook on the provision of MTM and direct patient care services. While pharmacies still

experience significant barriers related to MTM, a great opportunity for the State of Nebraska

exists in further promoting MTM and direct patient care services among community pharmacies.

Pharmacist Provided MTM Services in Last 12 Months: All Pharmacies 250 64% 200 150 36%
Pharmacist Provided MTM Services in
Last 12 Months: All Pharmacies
250
64%
200
150
36%
100
50
0
Yes
No
Number of Pharmacies

Fig. 6. Pharmacist Provided MTM Services in Last 12 Months: All Pharmacies.

Mechanism(s) Used by Pharmacists to Deliver MTM

Pharmacies providing MTM services nearly exclusively deliver the patient-centered

service via face-to-face/in-person or telephone (Table 17). These two mediums of delivery are

the most common among all pharmacies. Pharmacies of Interest predominantly deliver MTM

services via face-to-face/in-person or via telephone. Only one pharmacy in this category provides

MTM services via telehealth videoconferencing (Table 18). Other Pharmacies delivered MTM

services primarily via telephone, with a smaller portion conducting face-to-face/in-person (Table

19).

Implications. Pharmacists predominately deliver MTM services through traditional

methods of face-to-face/in-person or via telephone. Medicare standards require that MTM be

offered face-to-face, unless the patient specifically agrees to an alternative communication

method. As technology continues to progress, opportunities for telehealth videoconferencing or

electronic-based MTM services (potentially through EHRs) may become available. It is likely

the traditional methods of face-to-face/in-person will continue as the primary delivery mode.

Organizational Structures

Overall, relatively few pharmacies provide MTM as part of an Accountable Care

Organization (ACO) or Patient-Centered Medical Home (PCMH) (Table 20). Those that do are

among the Pharmacies of Interest category. These pharmacies overwhelmingly listed

OutcomesMTM 1 and Mirixa 2 , two companies that identify patients who are eligible for MTM

based upon the patient’s insurance program, or other software as the ACO, rather than the ACO

1 OutcomesMTM, West Des Moines, IA. Company website: www.outcomesmtm.com

2 Mirixa, Reston, VA. Company website: www.mirixa.com

entity itself. It is unknown if these pharmacies are also accessing patient candidate names

through software provided through an ACO directly. A few pharmacies report providing MTM

services through a PCMH. For those pharmacies, many listed OutcomesMTM and Mirixa or

other software as the PCMH, rather than identifying the PCMH entity itself. Again, the

relationship between the software and PCMH is unknown (Table 21).

Of the Other Pharmacies, only one specialty pharmacy indicated provision of MTM as

part of an ACO and as part of a PCMH (Table 22).

Implications. Pharmacists remain largely uninvolved with ACOs and PCMHs. A large

opportunity for growth exists in this area to educate pharmacists about these models and to

integrate pharmacists within these organizations to improve patient access.

Formal MTM Training Program Attendance

Approximately one-fourth (26 percent) of all pharmacists providing MTM have

completed a formal MTM training program. Both Pharmacies of Interest and Other Pharmacies

have very similar formal training completion rates among pharmacists (Table 23). Among

Pharmacies of Interest, formal training programs completed by pharmacists include

OutcomesMTM or Mirixa training or corporate-based training (Walgreens, Dillon Stores,

Kroger, etc.). Several others indicated training from a university or professional-based

association. Some pharmacists indicated they will be completing training in the near future

(Table 24).

Only a handful of pharmacists in the Other Pharmacies category have been formally

trained in MTM. Those who have received formal training indicated medical condition-specific

training (anticoagulation, diabetes management) or corporate-based training. Most have not

received formal training in the provision of MTM (Table 25).

Implications. Training programs completed by pharmacists are typically done so within

the corporate structure (MTM vendor or corporate business). The similarity of these training

programs is uncertain, and a substantial portion of the pharmacist workforce could still benefit

from receiving training in provision of MTM and direct patient care services. A standardized

training process could be developed for pharmacists throughout the state of Nebraska. The

American Pharmacists Association offers a 21 hour continuing education program in MTM

service provision. This program should be considered.

Formal MTM Training Program Attendance: All Pharmacies 74% 300 250 200 150 100 26% 50
Formal MTM Training Program
Attendance: All Pharmacies
74%
300
250
200
150
100
26%
50
0
Yes
No
Number of Pharmacies

Fig. 7. Formal MTM Training Program Attendance: All Pharmacies.

Length of Time Providing MTM Services

The majority of all pharmacies providing MTM have offered the service for the past 5

years (Table 26). The highest concentration of length of time providing MTM services is

between 1 and 5 years among both categories of pharmacies. Among Pharmacies of Interest, the

majority of pharmacies have been providing MTM between 1 and 5 years, with the bulk of those

providing services for less than 2 years. This relatively recent initiation of MTM services

indicates the rapid expansion of pharmacy-provided clinical services. Several pharmacies have

begun MTM services within the past year and several have been providing MTM for over 5

years (Table 27).

Among Other Pharmacies, the provision of MTM has been occurring steadily over our

identified time frame increments. Pharmacies within this category have not realized a significant

and rapid pickup of MTM services (Table 28).

Implications. The provision of MTM services within Nebraska’s pharmacies is relatively

new (within the last 5 years). With this recent development, barriers and roadblocks are expected

before reaching full integration and implementation of direct patient care services delivered

through pharmacies. This concept still has significant opportunity for growth within the state,

particularly related to pharmacists being recognized as providers, patients becoming aware of

these services and their benefits, pharmacy workflow operations, and compensation/

reimbursement for services. A significant uptake of these services has occurred within Nebraska

pharmacies with much room for expansion.

Length of Time Providing MTM Services:

All Pharmacies

100 22% 20% 17% 18% 5% 6% 4% 0 < 6 months months to <
100
22%
20%
17%
18%
5%
6%
4%
0
< 6 months
months to < 1 year
6
1
to < 2 years
2 to <3 years
to < 5 years
3
5
to < 10 years
Number of Pharmacies

Fig. 8. Length of Time Providing MTM Services: All Pharmacies.

Number of Patients who receive MTM Services in a Month

Overall, pharmacies report experiencing monthly patient loads for MTM provision

between 0 and 199+ (Table 29). Within Pharmacies of Interest, a majority of pharmacies (79

percent) have monthly average patient loads of 0-19 patients for the provision of MTM services.

Overall, MTM patient loads for pharmacies were relatively modest (Table 30).

Other Pharmacies generally experience a lower (0-2) number of patients per month. A

few pharmacies within this category serve average patient loads of more than 50 patients per

month (Table 31).

Implications. Pharmacists delivering MTM and direct patient care services experience

smaller monthly patient loads, revealing an opportunity for increased promotion and education

about MTM and direct care services to patients, particularly patients with chronic disease

conditions, in Nebraska. Additionally, these numbers display the opportunity for the State of

Nebraska to foster changes necessary to allow for full implementation of MTM services within

pharmacies by dismantling barriers related to compensation/reimbursement and workflow

operations. While these services are relatively new and patient loads relatively low, the initial

uptake of patients utilizing MTM services within Nebraska’s pharmacies is promising and a

tremendous opportunity for growth still exists.

Average Number of Patients who receive MTM Services in a Month:

70 Pharmacies of Interest 29% 60 50 40 17% 17% 16% 30 11% 20 6%
70
Pharmacies of Interest
29%
60
50
40
17%
17%
16%
30
11%
20
6%
10
0
0-2
3-4
5-9
10-19
20-49
50-199
Number of Pharmacies

Fig. 9. Number of Patients who receive MTM Services in a Month: Pharmacies of Interest.

Identification of Patients as Candidates for MTM Services

Overall, the majority of pharmacies identify patients as candidates for MTM through

referrals from MTM vendors (Mirixa, OutcomesMTM, etc.) (Table 32). Pharmacies of Interest

also commonly identify patients through a health plan or pharmacy benefit manager (PBM)

(Table 33). About half of these pharmacies identify patient candidates through referrals from a

health plan or PBM and some pharmacies identify patient candidates that have a specific health

plan. The small number of Other Pharmacies that reported providing MTM services identify

patients through a physician referral or because the patient has a specific disease condition (e.g.

hypertension, diabetes) (Table 34).

Implications. Pharmacists primarily utilize an MTM vendor to identify patient candidates

for MTM. Pharmacists may be limited by the software systems that are used, but given the

current pharmacy workflow environment, pharmacists predominately continue to utilize MTM

vendor systems to identify patient candidates. As strategies are implemented to provide MTM to

more patients, alternative methods (such as direct requests from patients, referrals from CHWs

and others) and internal identification systems within corporations are more likely to emerge as

prominent.

Identification of Patients as Candidates for MTM Services:

Pharmacies of Interest

200 80% 46% 100 27% 17% 13% 0 Patients are referred by an MTM vendor
200
80%
46%
100
27%
17%
13%
0
Patients are referred by an MTM vendor
Bill Insurance/PBM/Medicare
Patients with a specific health plan
Number of Pharmacies

Patients with a documented or suspected medication-related problemPatients with a specific health plan Number of Pharmacies Patients request MTM services (self-referral)

Patients request MTM services (self-referral)with a specific health plan Number of Pharmacies Patients with a documented or suspected medication-related problem

Fig. 10. Identification of Patients as Candidates for MTM Services: Pharmacies of Interest.

Ways Patients and Providers are made Aware of MTM Services

The most common method for pharmacies to promote MTM services to patients and

providers is pharmacy-initiated contact with the patient via telephone, email, mailed letter, or

other medium (Table 35). Pharmacies typically receive targeted lists from MTM vendors and

proactively contact patients to inform them of the pharmacist-provided clinical service. Some

pharmacies utilize a combination of promotion strategies listed within the table, as well.

However, it should be noted that 29 percent of pharmacies did not respond to this question.

About a third of Pharmacies of Interest initiate contact with the patient via telephone,

email, or mailed letter. It is also common for insurance companies, pharmacy benefit managers,

or MTM vendors (Mirixa, OutcomesMTM, etc.) to directly contact the patient to inform him or

her of eligibility of MTM services. Several pharmacies use a combination of tactics to promote

MTM services, as well.

Other Pharmacies typically promote MTM services by initiating contact with patients via

phone, email, or mailed letter from the pharmacy (Table 37). Some pharmacies in this category

contact the patient’s provider or physician and some utilize a combination of promotion tactics.

However, this does not occur to the same degree of pharmacies directly contacting the patient to

promote MTM services and this is a small number of pharmacies in the state.

Implications. Primarily, pharmacies are contacting patients to inform them of their

eligibility for MTM and direct patient care services. When insurance companies, pharmacy

benefit managers, or MTM vendors contact the patient directly, it is possible patients do not view

this as personal as their pharmacist contacting them about their MTM eligibility. Further

promotion of direct contact from the pharmacy to the patient about MTM services could be an

area of growth for the state and an opportunity to train pharmacists/pharmacies about this.

Number of Pharmacies

Ways Patients and Providers are Made Aware of MTM Services: Pharmacies of Interest

100

0

33%

12% 12% 5% 6% 1% 1%
12%
12%
5%
6%
1%
1%

Pharmacy initiates contact with patientPharmacies of Interest 100 0 33% 12% 12% 5% 6% 1% 1% Bill Insurance/PBM/Medicare Direct contact

Bill Insurance/PBM/Medicare12% 5% 6% 1% 1% Pharmacy initiates contact with patient Direct contact from Insurance Provder/PBM/MTM Vendor

Direct contact from Insurance Provder/PBM/MTM Vendorinitiates contact with patient Bill Insurance/PBM/Medicare Communcation with patient at point-of-sale Pharmacy

Communcation with patient at point-of-saleDirect contact from Insurance Provder/PBM/MTM Vendor Pharmacy advertisement Other-multiple Do not promote

Pharmacy advertisementcontact from Insurance Provder/PBM/MTM Vendor Communcation with patient at point-of-sale Other-multiple Do not promote

Other-multiplefrom Insurance Provder/PBM/MTM Vendor Communcation with patient at point-of-sale Pharmacy advertisement Do not promote

Do not promotefrom Insurance Provder/PBM/MTM Vendor Communcation with patient at point-of-sale Pharmacy advertisement Other-multiple

Fig. 11. Ways Patients and Providers are Made Aware of MTM Services: Pharmacies of

Interest.

Amount Pharmacists Charge for MTM Services

A large portion of pharmacies do not charge a fee for provision of MTM (Table 38).

Many pharmacies charge MTM vendor rates or bill insurance, PBM, or Medicare. However,

these rate amounts were largely not specified by respondents. One third or more of Pharmacies

of Interest do not charge for provision of MTM (Table 39). This is common for many

pharmacist-provided services, and MTM is no different. For pharmacies that do charge for

MTM, MTM vendor (OutcomesMTM, Mirixa, etc.) rates are charged, though the amount varies

and was generally not specified. Several pharmacies bill insurance companies, pharmacy benefit

managers, or Medicare, but again, pharmacies generally did not specify a monetary amount.

Though not as common, some pharmacies charge pharmacy-specific rates, ranging from $2 to

$150. These rates commonly depend on the services provided and/or length of time required for

service provision by pharmacist.

Among Other Pharmacies, the majority of pharmacies do not charge for provision of

MTM (Table 40). Only several pharmacies charge MTM vendor rates, but these rates were

generally not specified. Overall, pharmacies are not charging for provision of MTM services.

Implications. With a large portion of pharmacists not charging for provision of MTM

services, pharmacists predominately view MTM and direct patient care services as part of their

regular work duties. Pharmacists are trained to serve patients and view these types of services as

part of their profession, so the need to document and bill for these services is somewhat of a

foreign concept historically to pharmacists. Pharmacists typically do not view these services as a

profit-generating tool for the pharmacy. Rather, the services are an opportunity for pharmacists

to develop a closer relationship with patients to allow them to improve health management and

outcomes. The formalization of MTM services has incorporated the practice of billing and

documentation for these services. This has gradually been adopted over the last five years

among many of the pharmacies offering formal MTM. It is a substantial growth area for

pharmacists in the state.

Amount Pharmacists Charge for MTM Services: Pharmacies of Interest

80

35%

70 60 50 40 16% 15% 30 11% 20 10 0 Number of Pharmacies
70
60
50
40
16%
15%
30
11%
20
10
0
Number of Pharmacies

Charge vendor rates50 40 16% 15% 30 11% 20 10 0 Number of Pharmacies Charge pharmacy-specific fees Bill

Charge pharmacy-specific fees50 40 16% 15% 30 11% 20 10 0 Number of Pharmacies Charge vendor rates Bill

Bill Insurance/PBM/Medicare50 40 16% 15% 30 11% 20 10 0 Number of Pharmacies Charge vendor rates Charge

Do not charge30 11% 20 10 0 Number of Pharmacies Charge vendor rates Charge pharmacy-specific fees Bill Insurance/PBM/Medicare

Fig. 12. Amount Pharmacists Charge for MTM Services: Pharmacies of Interest.

Pharmacy Compensation to Pharmacists for Providing MTM Services

Nearly all pharmacists receive compensation for provision of MTM services as part of

their standard salary pay as most pharmacists are employees of larger pharmacy corporations

(Table 41). Pharmacies of Interest overwhelmingly indicated that compensation for MTM

services is part of the standard pharmacist salary at their pharmacies and no separate pay is

received as a form of compensation (Table 42). Few Pharmacies of Interest indicated they

provide compensation through consideration of merit raises, bonus hours, additional paid time,

or other forms of compensation. Similarly, Other Pharmacies also overwhelmingly indicated

that compensation for MTM services is part of the standard pharmacist salary and no separate

pay is received as a form of compensation (Table 43). Only one pharmacy in this category

indicated their pharmacists receive compensation in some other form not listed on the survey.

Implications. Pharmacists receiving compensation for provision of MTM as part of their

standard pay reinforces the commonly-held viewpoint that these direct patient care services are

part of the pharmacist profession responsibilities. Pharmacists see themselves as an active player

in the patient’s healthcare continuum, but they are not necessarily recognized as a provider by

patients or other healthcare providers. With pharmacists receiving compensation for these

services as part of their regular pay, they are expected to provide MTM within their normal

workflow. Improvements to pharmacy workflow operations could be an important area of

growth given the pay practices of pharmacies within the state. This viewpoint held by

pharmacists is a likely explanation for why pharmacists are not aggressive about recruiting

patients to their services or billing for services. There is opportunity to promote improved

recognition of performance by pharmacists with corporate pharmacy managers.

200

Pharmacy Compensation to Pharmacists for Providing MTM Services:

Pharmacies of Interest

89%

180 160 140 120 100 80 60 40 20 6% 4% 4% 3% 0 Number
180
160
140
120
100
80
60
40
20
6%
4%
4%
3%
0
Number of Pharmacies

Part of standard pharmacist salary - no separate pay received100 80 60 40 20 6% 4% 4% 3% 0 Number of Pharmacies Considered in merit

Considered in merit raisesof standard pharmacist salary - no separate pay received Pharmacists earn additional bonus and/or incentives

Pharmacists earn additional bonus and/or incentivessalary - no separate pay received Considered in merit raises Additional paid time on hourly or

Additional paid time on hourly or overtime basis and/or pay differentialsalary - no separate pay received Considered in merit raises Pharmacists earn additional bonus and/or incentives

Otherearn additional bonus and/or incentives Additional paid time on hourly or overtime basis and/or pay differential

Fig. 13. Pharmacy Compensation to Pharmacists for Providing MTM Services: Pharmacies of

Interest.

Challenges Pharmacies Face when Providing MTM

Overwhelmingly, pharmacists do not have adequate timeis cited as a challenge in

providing MTM (Table 44). Other common challenges faced by pharmacies are disinterested

patients or patients declining participation and lack of insurance companies paying for these

services. Generally speaking, Pharmacies of Interest and Other Pharmacies experienced the

same challenges at relatively the same rates. The most significant differences existed between the

two pharmacy categories for lack of insurance pay and pharmacists having inadequate time.

Among Pharmacies of Interest, the most commonly noted challenge is inadequate time

for the pharmacist to provide an in-depth, comprehensive MTM session to patients (Table 45).

Another significant challenge faced by more than half of pharmacies in this category is a lack of

interest from patients to participate in MTM services offered. Only a few respondents indicated

that a lack of support of MTM services from upper management, a lack of collaborative

relationships with prescribers and physicians, and local physician resistance as significant

challenges to the provision of MTM services.

The majority of Other Pharmacies indicated that the lack of insurance company

reimbursement for provision of MTM services is one of the most significant challenges faced

(Table 46). In addition, nearly half of the respondents in this category also indicated that billing

and documentation difficulties impeded the provision of MTM services. Similar to the Pharmacies

of Interest, nearly half of the respondents in this category indicated a lack of interest from patients

to participate in MTM services as another significant challenge. Inadequate training or experience

and lack of collaborative relationships with prescribers and physicians as challenges faced were

also only selected by a handful of pharmacies.

Implications. Challenges faced by pharmacists are a common aspect of the profession.

Inadequate time to provide MTM and direct patient care services experienced by pharmacists

reveals a workplace setting that is heavily focused on prescription filling and dispensing,

communication with insurance companies, and general pharmacy operations. Generally,

pharmacists feel challenged by the recent push for provision of MTM and direct patient care

services within pharmacies and significant barriers still exist to fully implement and integrate. A

substantial opportunity for growth related to transforming pharmacies and integrating

pharmacists as providers to improve health conditions and outcomes, particularly among patients

with chronic disease conditions in low-provider areas, exists for the state. Internal changes to the

pharmacies (layout and workflow) to create a welcoming environment to patients may be a next

step in the advancement of these services. Education and promotion of MTM to patients is a

strategy to consider to better inform patients about the value of MTM to their self-management

and care.

A unique opportunity for the State of Nebraska to serve as a partner to dismantle these

barriers, better connect pharmacists to the patient healthcare continuum, and improve pharmacy

workflow operations is apparent.

Benefits Pharmacists have realized from offering MTM Services

Among Pharmacies of Interest, pharmacists in charge of the pharmacies providing

medication therapy management (MTM) services report that MTM delivers personal, health, and

economic benefits to both patients and pharmacists. Pharmacists generally view the service as a

mutually beneficial tool to improving health outcomes, particularly among patients with chronic

disease. A common viewpoint expressed by pharmacists is that MTM “is what we do” in basic

routine work as a pharmacist. In this sense, some pharmacists did not wish to recognize MTM as

a separate and distinct activity from their inherent professional role despite the economic policies

governing reimbursement for professional service provision.

Personal Benefits Realized by Patients from MTM Services

Pharmacists are “happy to help others feel better and live a meaningful life.” Patients

experience a closer and more trusted relationship with pharmacists as a healthcare provider

through receiving MTM services. The interaction opens up dialogue with the pharmacist.

Patients also build greater self-awareness regarding their own care. This is an essential gain,

improving patient self-efficacy.

Personal Benefits Realized by Pharmacists Who Provide MTM Services

Pharmacists providing MTM widely view the patient-centered service as a tool to

enhance personal buy-in from patients to optimize their drug therapy care.

“I feel my patients are more invested in their care plan after MTM is rendered.” In

addition to dispensing prescriptions, pharmacists collaborate with patients, educating them by

tailoring and optimizing the ways patients use their medications and answering questions they

and their family members and care takers have. Pharmacists engage by coaching patients to

better health management and outcomes.

“Patients trust and respect you more once [the patient has] done a complete medication

review.” Participation builds trust between pharmacists and patients developing stronger health

care based relationships. Pharmacists describe MTM as increasing patient interaction by

opening up lines of communication with patients. This increases patient loyalty and results in

patients returning for service.

MTM is “very enjoyable. I wish we could do them on a full-time basis!” Pharmacists

have an enhanced professional experience and reported greater satisfaction and perceived

credibility by interacting with patients through a more intimate relationship. The profession is

refocused on providing clinical care. Pharmacists report feeling part of a patient’s care team,

empowered to advise the patient as a trusted, reliable source of personal health management.

Pharmacists in community settings have particularly strong potential for influence. This setting

is “open access” to patients who walk in most anytime at their convenience, and regularly if

there is medication refill needed. For these reasons, pharmacists often see patients more

frequently than other members of a patient’s care team.

Health Benefits Realized by Patients from MTM Services

“After a complete medication review our patients have a better understanding of what

their medications are for, why they are important, and how to properly take them. This improves

patient outcomes.” Providing MTM, according to most pharmacists, allows the patient to benefit

from improved health status and outcomes in almost all cases.

“Resolve issues and increase medication adherence.” Pharmacists have observed

increased medication adherence and compliance to a drug regimen by providing MTM. Other

health- and medical-related benefits through MTM have are decreased patient hospitalizations

and improved chronic disease management.

“It catches therapy gaps; identifying problems that otherwise go undetected. It is a

service provided for patient safety.” Pharmacists have corrected potentially severe drug

interactions, eliminated unnecessary and outdated drug regimens, and improved patient drug

profile efficiency and effectiveness.

Health Benefits Realized by Pharmacists Who Provide MTM Services

By providing MTM, pharmacists are able to help the patient understand and manage

their medications to better improve their health.” Pharmacists have been able to view patient

care as a holistic endeavor, assessing complete drug therapies and patient conditions and

identifying specific problems for each individual patient. Through this approach, pharmacists

provide insight and advice to increase buy-in from patients to better manage their overall health

and lifestyle.

Financial Benefits Realized by Patients from MTM Services

“We save our patients money.” Providing MTM serves as a cost-saving measure for

patients by eliminating unnecessary drugs or other potential medical-related expenses such as

those from drug interactions or non-adherence.

Financial Benefits Realized by Pharmacists and Pharmacies Where MTM Services are

Provided

MTM is “a nice added source of income for services we already provide. Now we can

get paid for some of them.Pharmacists providing MTM have realized financial benefits to both

patients and pharmacies. Pharmacists view the provision of MTM services as a supplemental

source of income for the pharmacy. While a significant amount of pharmacists view

reimbursement rates for MTM services as inadequate, several are realizing a financial benefit to

the pharmacy. MTM, according to pharmacists, allows patients and insurance companies to save

money while bringing in an additional source of income to assist in the pharmacy’s bottom line.

The enhanced patient relationship realized as increased patient loyalty with patients returning for

service is also realized as repeat business.

Benefits Realized by Other Pharmacies

Among Other Pharmacies, there were a handful of pharmacies who reported providing

MTM. Benefits realized from providing MTM were virtually identical to the benefits realized in

the above category. Pharmacists have observed positive patient health outcomes, improved

pharmacist-patient relations, and improved patient care experiences. Multiple pharmacists

mentioned feeling appreciated by prescribers for MTM service products such as dosage

adjustments and health status monitoring, though the amount of pharmacists listing this benefit

was negligible. Overall, the provision of MTM, whether in a pharmacy likely or unlikely to

provide the service, is considered to improve patient and pharmacist experiences, enhance health

outcomes, and financially benefit all parties involved.

Implications. Pharmacists are able to recognize the many personal, health-related, and

financial benefits that result from the provision of MTM in their practices. For instance, MTM

allows pharmacists to feel like they are building stronger bonds of trust and loyalty with their

patients, and they also receive more appreciation from patients participating in the programs. The

low cost of most MTM sessions allows patients to enroll in the programs without having to

worry about financial strain, and reimbursement from MTM vendors can provide some extra

finances to providing pharmacists. Patient health benefits such as increased medication

adherence and increased self-efficacy have also been discovered through the delivery of MTM

services in pharmacies. The expanded provision of formal MTM services over the past five years

and the realized benefits of MTM by already-providing pharmacists in addition to an established

view of MTM as an inherent part of the profession create an atmosphere that is ideal for the

growth of a holistic, patient care-centered pharmacy model.

New Opportunities Realized Where MTM Services are Provided

As pharmacists reported their views about MTM service provision, they offered ways in

which they were considering or implementing new opportunities both for improved outcomes

and improved care. Here are new opportunities realized by some pharmacies in their

communities:

Value to patients resulted in pharmacists describing opportunities of approaching

businesses in the area to contract for expansion of MTM services.

Optimized drug therapy and reducing risk of harm and injury resulted in improved “star

ratings,” potentially important to patient-centered medical home participation and

accountable care organization contracting.

Improved adherence led to improved pharmacists services of quarterly chart review of

their patients to identify medication problems needing resolution, and introducing

medication compliance packaging, as opposed to bulk medication bottle dispensing only.

Trust relationship leads to patient referrals.

Personal buy-in from patients results in repeat business.

Implications. The provision of MTM leads to improved pharmacy ratings, stronger

customer bases, patient risk reduction, and the expansion of pharmacy services. These self-

reported benefits of MTM services could be used to generate greater interest in the

implementation of MTM in pharmacies that previously expressed little to no interest in doing so,

or felt like MTM was not applicable to their practice.

Pharmacies of Interest Getting Ready or Just Beginning MTM Provision

Overall, the tone of the pharmacist’s responses was that many are aware that the

provision of MTM services as a formal program is gaining momentum. While they did identify

barriers, most indicated they were preparing or getting ready in some way to provide MTM

services.

“I haven’t had time, but our situation is improved and we do plan to start.” While

pharmacists identified several challenges, many indicated they will be initiating MTM services

within the near future. These pharmacists wanted to be responsive to the ideas indicating that

MTM service provision is important and matters; there is intention.

“Just starting this service now.Several pharmacists explained that they are just starting

up MTM services, either for the first time or reinitiating after a period of inactivity. For some

pharmacies it has involved reworking workflow, constructing physical space needs, and learning

how to obtain reimbursement.

Business Model for MTM Does Not Include All Pharmacists

“Our company provides this service and has one pharmacist who goes from site-to-site.”

This business model was described in a couple of smaller chain pharmacies where the pharmacist

who had MTM expertise traveled between stores and performed these services.

Key Barriers to Implementation of Services in Pharmacies of Interest

Key barriers related to pharmacy workflow and workload, reimbursement for services,

pharmacy design, and patient relations were identified by pharmacists.

Workload and Time. MTM is considered to be too time consuming. I am one

pharmacist with one technician and we are very busy every minute just running the business.

Most pharmacists need uninterrupted time to complete MTM, and with a significant

amount of pharmacies running as single-pharmacist operations, the lack of additional staff

prevents pharmacists from providing the patient-centered service altogether. Pharmacists are

regularly pressed for time, and having to provide MTM services is seen as an additional burden,

preventing basic duties within the pharmacy being accomplished. Most pharmacists are focused

on filling prescriptions, dealing with insurance companies, dispensing medications, and assuring

basic safety with medication use. With understaffed locations, an inflexible workflow operation,

and other pharmacy operation obligations, pharmacists feel stretched to the maximum and cite a

lack of time as the reason for not providing MTM services.

Pharmacy Space. Several pharmacists consider their pharmacy design and lack of

physical space not conducive to providing MTM services. “We do not have a dedicated private

space” to provide MTM. “We are in the process of adding a private counseling room and

anticipate adding MTM services later this year.”

Pharmacists prefer a consultation area in which they can sit down and engage patients

regarding their drug regimens and health management in a confidential and private manner.

Without physical space to accommodate patients for MTM services, pharmacists do not feel they

are able to provide the service altogether.

Billing and Reimbursement.

Pharmacists largely consider the reimbursement amounts

for providing MTM to be dismally low. “The reimbursement does not justify the time involved.

For the amount of time required to complete an MTM session, pharmacists are not

realizing reimbursements consistent with the standard professional rate of pay. Several

pharmacists have attempted to provide MTM services, but have since discontinued the service

after receiving little to no compensation for the services provided. Another complicating factor

for pharmacists is the varying coverage of such services by insurance plans. Pharmacists have

difficulty billing and coding for MTM services, and consider these administrative issues, rejected

claims, and low reimbursement rates detrimental to their work, resulting in lost time and money.

The lack of coverage of MTM services, particularly by Nebraska Medicaid, was also identified

as a reason for not providing MTM. Pharmacy information technology and operation systems are

not set up to bill for MTM services and many pharmacists also do not feel adequately trained in

operating systems to bill and track MTM services provided to patients, resulting in a declination

to provide MTM altogether.

Patient Relations. Pharmacists often times experience difficulty in identifying patients

eligible for MTM services. When offering MTM services to patients, some pharmacists also feel

not enough patients are interested or utilize the service to justify offering the pharmacy service.

“Patients are unwilling to sit down and discuss their health issues—they think ‘their’ doctor

should do that.

Some patients are, at times, reluctant to discuss and allow their pharmacist to serve as a

member of the patient’s care team, discouraging pharmacists from providing MTM.

Implications. Many pharmacies are in the process of starting up MTM programs at their

pharmacies or plan to do so in the near future. Areas that need to be addressed in order for

successful implementation and sustainability from the viewpoints of pharmacists who are ready

to start but have been delayed are:

An absence of a workflow environment that accommodates for both the extra time and space

needed for the provision of MTM services to patients.

Low reimbursement given to pharmacists by MTM vendors like Mirixa and OutcomesMTM

in addition to confusion with billing and insuring hinders their progress.

Pharmacists cannot simultaneously conduct the prescription dispensing activities and MTM

because of inflexibility of time and staffing with current resources. Numerous participants

indicated that they do not have the ability and/or authority to hire new pharmacists in order to

free up time and therefore provide MTM in their pharmacies.

Some patients do not recognize the pharmacists as a part of their health care team, and this

disconnect makes patients reluctant to sign up for MTM services and discuss their health

issues with anyone other than their physician or doctor.

In order to create a sustainable model for the growth in provision of MTM services, these

issues must be addressed.

CONCLUSIONS FROM SURVEY OF PHARMACISTS ACROSS STATE

Pharmacists provide general services (medication adherence assistance,

immunizations/vaccinations, check person’s blood pressure to assess medication

effectiveness, offer to teach how to use blood pressure checking and blood glucose

testing products/devices). Pharmacists have a great opportunity to provide formal,

advanced disease-specific patient education (hypertension self-management education,

diabetes self-management education, comprehensive anti-coagulation management) with

a ‘ready audience’ in patients who access pharmacists in their local communities.

Early signs of collaborative practice agreements, bi-directional referral processes, and

awareness and involvement of community health workers (CHWs), while low, suggest a

beginning social infrastructure within the state, promising approaches to better

integrating pharmacists into the patient healthcare continuum.

Integration of pharmacists within Accountable Care Organizations (ACOs) and Patient-

Centered Medical Homes (PCMHs) has occurred in a few settings and could be used as

models for further development on a statewide basis.

The relatively recent uptake of MTM services within pharmacies and low average patient

loads suggest room for growth and improvements in promotion of MTM and direct care

services to patients.

While the majority of pharmacies utilize MTM vendors such as OutcomesMTM and

Mirixa, an opportunity for alternative systems to identify patient candidates for MTM

may expand the access patients have to the pharmacists’ services.

Pharmacists predominately view the provision of MTM and direct patient care services as

a responsibility in which the profession has always been engaged.

Overall, pharmacist-provided MTM and direct patient care services are delivered in an

understaffed environment and a fragmented and underdeveloped system. The workplace

settings have a role in developing better workflow systems and physical environments

that are inviting and supporting of MTM and chronic disease management clinical care

provision by pharmacists.

INTERVIEWS OF CORPORATE PHARMACY EMPLOYERS OF PHARMACISTS IN NEBRASKA

METHODS

Study sample. This study was designed to determine how corporate pharmacies are

positioning themselves to deliver MTM services and direct patient care services on the

community level throughout Nebraska. National and regional level corporate pharmacy

managers were identified through the community pharmacy database developed by integrating

the State Board of Health listing of community pharmacies and the Pharmacy Quality Assurance

Review (PQAR) data available through the State of Nebraska. The database was analyzed for all

of the employers in the state, and the top 20 employers identified for participation. These persons

were invited by email to participate in a telephone interview at a prearranged time.

Interview questions. The email invitation included a set of questions that matched key

aspects of the written survey sent to all pharmacists in charge of Nebraska community

pharmacies. This provides a baseline understanding of the corporations’ basic services that are

being provided.

PARTICIPATION

Corporate managers from nine pharmacy corporation employers participated in the

interview from the original 20 persons identified. Two additional corporations completed the

email survey without participating in the full interview for a total of 11 participating

corporations. One corporate manager declined participation; this corporation was involved in a

corporate takeover and was restricted from discussing any business strategies.

FINDINGS

This section of the report details the key themes representing the corporate manager

perspectives. Three thematic areas related to pharmacists providing MTM and direct patient care

services emerged: (a) financial and economic perspectives; (b) MTM and the healthcare

spectrum; and (c); MTM’s implications on pharmacy operations. Subthemes are identified within

each using rationale from the point of view of the corporate representative respondents to reflect

their perspectives.

Financial and Economic Perspectives

Subtheme 1: Pharmacist Compensation and Remuneration for MTM Services is an upside down

payment model.

From the pharmacy managers’ perspective, pharmacies are not getting a fair payment for

services provided by their pharmacists to encourage them to continue to invest in MTM and

direct patient care services on this financial component of business alone. Many corporate

representatives described reimbursement rates for MTM services as substantially lower than the

standard professional rate of pay for a pharmacist and do not consider the reimbursement

amounts those payers are providing for MTM to be competitive. Pharmacies providing MTM

and direct patient care services are realizing no or a very low reimbursement for services

provided. Many local corporations are offsetting this expense through other areas of successful

revenue generation in their businesses to keep afloat MTM and direct patient care services for

the other benefits that providing these services brings to the retail business side of the industry.

Generally, MTM is not viewed as a revenue-generating tool for pharmacies by the corporation

managers at this time.

Among corporate pharmacy managers, concern also exists about compensation to

pharmacists for providing of MTM and direct patient care services. Currently, a majority of

pharmacists are expected to provide these patient-centered services within their normal work

duties and are paid as part of their regular salary or wage, without a workload reduction in the

pharmacy. In nearly all cases, pharmacists are not provided additional or extra pay for provision

of MTM services to patients.

Implications. Corporate pharmacy managers are challenged by the inadequate financial

model for the current approaches to MTM service provision. Overall, pharmacy managers

support offering these services to patients; however, they are working through strategies to

improve the financing of these services. Without a stable financial model, it is unclear to the

pharmacy managers how much and when MTM and related services will expand from the

corporate point of view.

Subtheme 2: Uncertain about Impact of the Rise of Pay-for-Performance Models

Transition to pay-for-performance payment models means the pharmacy profession and

the pharmacy business corporations have to learn how to adapt to new systems of payment,

determine how to navigate payment processes and billing systems, and shift the compensation

for services focus more on patient outcomes rather than volume-based prescription drug

dispensing. This process, which is new for pharmacists, may prove to be particularly difficult as

workload demands on pharmacists have not lessened, and in many cases, have only increased.

This new payment model in health care has pharmacy corporate managers unsure how

payments will be generated and revenue will be realized for providing MTM services. Paired

with an increasing focus and expectation of additional pharmacist-provided clinical services, this

increases the uncertainty and apprehension about such developments related to payment models

and provision of services. In general, corporate pharmacies are unsure of the impact of the rise of

pay-for-performance models on pharmacist-provided care services at this time.

Implications. Pharmacists have expected themselves, and are often expected by patients

and other providers, to deliver services, including clinical-based services, at no charge to the

patient. These services typically take more time and detract the pharmacist from filling

prescriptions and meeting other pharmacy operation obligations. Within Nebraska, corporate

pharmacies are attempting to strike the right balance between providing patient-centered services

in accordance with a value-based care model and meeting traditional pharmacy-based operations

responsibilities such as filling and dispensing prescriptions.

Subtheme 3: MTM and Clinical Services Are a Tool for Patient Retention

These services are viewed as an additional benefit to patient care and an opportunity to

develop a more intimate pharmacist-patient relationship. Rather than viewing MTM and direct

patient care services as a solely revenue-generating and profit-driving tool, corporate pharmacies

view MTM and direct patient care services as a method by which to retain customers, develop

relationships, and prevent the loss or transferability of patients to other competing pharmacies.

Generally, MTM and direct patient care services are being utilized as a competitive patient

retention tool rather than a revenue-generating tool.

If pharmacies can offer services to better the relationship between pharmacists and

patients, pharmacies believe they will be able to retain patients and realize greater revenue from

continued business relationships with patients. Overwhelmingly, corporate pharmacies attempt to

view MTM and direct patient care services through a broader lens and as a tool to retain

customers, improve relationships, and realize financial gain over the long-term.

Implications. Corporate pharmacies have been challenged to look at provision of MTM

and direct patient care services through a longer-term financial lens. Noting that this has been a

challenge for particular corporate pharmacies within Nebraska, promotion of MTM financial

benefits over the long-term may be beneficial. If pharmacies within the state are able to become

aware of financial benefits and patient loyalty, more widespread adoption of MTM services may

be a result among Nebraska pharmacies.

MTM and the Healthcare Spectrum

Subtheme 1: An Uncertain Position We are Working with a Piecemeal System

Looking at the current healthcare landscape in regard to MTM and direct patient care

services, pharmacies are generally uncertain about the pharmacists’ position. Pharmacists realize

the increased focus placed on providing such services, but they are unsure how to provide these

services in an integrated, feasible, and beneficial manner. MTM is largely seen as just one

vehicle for improving patient care, and not the “end-all be-all” of services. Pharmacy managers

understand direct patient care services as a package, and MTM is only one of those services

offered. To fully improve patient care outcomes, pharmacy managers see the need for

collaboration among many entities and providers. However, they are generally unsure where to

position themselves in today’s healthcare landscape to best provide these services.

Implications. Pharmacy managers within Nebraska sense uneasiness about their position

within the healthcare landscape, expected during this time where there is a general lack of

guidance from the healthcare sector and State. Pharmacy managers are left to determine service

options and delivery methods on their own, which has proven to be particularly difficult for

smaller and more independent corporate pharmacies. Support from the State of Nebraska and

different areas of the healthcare sector may provide additional knowledge and assistance to

corporate pharmacy managers as they make decisions about MTM and direct patient care

services.

Subtheme 2: Expanding Care PortfoliosDirect Patient Care is the Wave of the Future

Corporate pharmacies have come to quickly realize the industry push to integrate

pharmacists into the patient care process and begin providing more clinical services. Generally,

pharmacies realize the need to considerably improve upon their services and delivery to patients,

more seamlessly integrate these services, and collaborate more frequently with other members of

patients’ care teams. Pharmacy managers are in the process and need to determine as quickly and

as smoothly as possible which direct patient care services are most feasible, generate the most

revenue, and best improve patient care outcomes. Pharmacies are rapidly becoming a new

vehicle by which to provide patient care, and corporate pharmacy managers are attempting to

determine how to most efficiently and effectively expand their patient care business portfolios.

Implications. Given the speed at which pharmacist-provided direct patient care services

have emerged within the healthcare landscape, pharmacies do not necessarily have precedent at

which to look. Best practices for direct patient care services among corporate pharmacies could

be developed and identified to empower corporate pharmacies within the state of Nebraska to

more successfully and seamlessly improve these clinical-based services. As many corporate

pharmacies have been experimenting with different services, a partnership between industry

leaders, healthcare professionals, and the State of Nebraska could be formed to share experiences

related to direct patient care services and identify best practices.

Subtheme 3: Team-Based Approach to CareThe Ultimate Say is with the Prescriber

With the rise in a team-based approach to patient care, corporate pharmacies are well-

aware of the increased drive to better integrate and utilize healthcare providers beyond

physicians to deliver patient care. However, corporate pharmacy managers generally feel

collaboration in regard to MTM and direct patient care services is not happening on the level

necessary to produce improved patient care outcomes. Pharmacist collaboration with other

members of patients’ care teams is not widely occurring, and pharmacists are uncertain how to

enter into and integrate themselves into a care team. This is often perpetuated by a sentiment

held by pharmacists that prescribers are not widely aware of the value of MTM and other

pharmacist-provided direct patient care services. Pharmacy managers describe that pharmacists

have also experienced prescribers unwilling to relinquish control and allow more team-based

approaches to patient care. Generally speaking, pharmacists experience a division with

prescribers in regard to what services pharmacists are capable of providing and what benefits

they may bring to a patient’s care process.

Implications. Given the perceived disconnect between pharmacists and providers, team-

based care faces significant challenges, particularly in areas of high need such as rural and

medically-underserved communities in Nebraska. Pharmacists have strong incentives to

continue to focus more on traditional pharmacy operations such as prescription filling and

dispensing in light of reluctant or low-knowledge providers. Increased emphasis on the need for

team-based patient care approaches, in which a pharmacist is an active participant, needs specific

strategy development and implementation.

MTM’s Implications on Pharmacy Operations

Subtheme 1: Staffing and WorkflowNeed to Better Integrate the Service into Our Work

Corporate pharmacy managers largely realize the potential benefit of MTM and direct

care services to their pharmacists’ patients, but they still see their pharmacists experiencing

staffing and workflow barriers within the pharmacy walls. To provide the most effective MTM

and direct patient care services, pharmacists need blocks of uninterrupted time to focus on their

patient and his or her needs. However, many corporate pharmacy locations operate single-

pharmacist stores, and uninterrupted time for MTM or other services is considered unrealistic.

Corporate pharmacy managers are working to provide resources, prepared paperwork,

toolkits, and technologies to allow pharmacists to better provide MTM services to patients.

However, MTM and direct patient care services are still currently not well-integrated into

pharmacy workflow operations. Full and seamless integration between pharmacists, prescribers,

payers, and patientsideally through electronic health records (EHRs) and health information

exchangewould be partial improvements in the workflow infrastructure.

Implications. Given that staffing challenges and inadequate time are the most significant

issues experienced by Nebraska pharmacists in providing MTM, additional pharmacy workforce

development (to include pharmacy technicians and support staff) may address this issue within

Nebraska. Without improvements pharmacists are likely continue to feel like they are unable to

provide additional services due to lack of time and capacity. Pharmacies will remain unable to

provide expanded patient care services such as MTM to the level necessary to widely improve

patient outcomes among Nebraskans.

Subtheme 2: Medical Providers and Care Referrals

Corporate pharmacy managers describe that collaborative practice agreements (CPAs)

and bi-directional referral processes with other providers of a patient’s care team are not

occurring on a network-wide level. Despite the lack of partnerships with other medical providers,

pharmacy managers support their pharmacists who stand interested and willing to partner with

other providers and prescribers. In the instances of success in partnering with other patient care

providers, practice agreements and referral processes are happening only on local levels in small

markets through grassroots endeavors. However, very few corporate representatives could point

to specific examples of CPAs or referral processes within the state of Nebraska.

Outside of occasional communication with prescribers about prescription questions or

verifications, little to no communication or collaboration between pharmacists and prescribers is

occurring. Pharmacists understand the potential benefit of partnerships with other members of a

patient’s care team, but establishing sustainable and mutually beneficial agreements at a broad

level in the current healthcare landscape is just beginning.

Implications. Within Nebraska, corporate pharmacies are unable to or have not yet tapped

into what could be a wide, integrated network of patient care options in which services could be

accessed by a physician in a clinic or a pharmacist at the nearest corporate pharmacy store

location. Corporate pharmacies within Nebraska are unsure how to connect and integrate with

other providers of a patient’s care team, revealing the unique possibility for the State of Nebraska

to facilitate agreement or referral processes among providers and pharmacists, perhaps through a

pilot program in select community settings to begin. Linking together various medical providers,

including pharmacists, has the potential to increase patient care access points and health

monitoring services, particularly for patients with chronic disease conditions, on a much greater

and more convenient scale within Nebraska.

Cross Theme Analysis

Within these key theme areas and subareas identified by corporate pharmacy managers,

several concepts are interrelated and offer additional insight into the perspective faced by

corporate pharmacies. These interrelated concepts are detailed below.

Tool for Patient Retention, Medical Providers and Care Referrals

By most corporate pharmacy managers, MTM and direct patient care services are viewed

as a tool for patient retention and continued business. If providing direct care services, such as

MTM, to patients makes the difference between the patients returning time-after-time for

prescriptions, this is considered to be a worthy endeavor by pharmacists. Corporate pharmacies

view collaborative practice agreements and referral processes as a similar tool for patient

retention. A diversified pharmacy portfolio with varied patient care services is ideal for corporate

pharmacies to maintain a strong customer base, and the State of Nebraska could uniquely

position itself to facilitate these agreements and processes among various providers, particularly

in rural and medically-underserved communities.

Paradox of Pharmacist Compensation, Staffing and Workflow

Pharmacy corporate managers like the services that are being provided and want to

continue to provide MTM services. With a compensation rate that is not competitive or

congruent with the standard professional rate of pay for a pharmacist, pharmacists are

experiencing difficulty in justifying provision of MTM and direct patient care services within

their normal workflow procedures. If pharmacists are having to provide MTM services and are

not able to dispense prescriptions and complete other required duties, the payment received for

MTM and compensation realized by the pharmacist is not currently a sustainable or adequate

model.

An Uncertain Position in Staffing and Workflow

Generally, corporate pharmacy managers express uncertainty about how to position

themselves as a provider of MTM and direct patient care services in a seamless, efficient, and

profitable manner. Difficulties are widely experienced by pharmacists in fully integrating these

types of services within their pharmacy staffing and workflow operations, perpetuating a sense of

uncertainty among corporate pharmacies. In pharmacies operating on a single-pharmacist basis,

MTM and direct patient care services are unlikely to reach the capacity and potential they have

without improvements in policies to incentivize and support the provision of such services.

Disconnect between Team-Based Approach, Medical Providers and Care Referrals

With an increased emphasis in team-based patient care, pharmacists are uncertain as to

where to position themselves in regard other medical providers and members of a patient’s care

team from the community pharmacy perspective. Currently, collaboration exists between

pharmacists and medical providers in limited situations (e.g. immunizations). Pharmacy

corporate managers see the pharmacist as a member of a patient’s care team, capable of

providing outcome-improving care services, and an active and necessary member of a team-

based approach to patient care.

Impact of Rise of Pay-for-Performance Models and Expanding Care Portfolios

With the rise of pay-for-performance models and value-based care, pharmacists are being

looked to for expanded clinical and direct patient care services. Corporate pharmacies are

attempting to offer different patient care services under an increasingly present value-based

payment model. Again, uncertainty by pharmacies surrounds this area in regard to how to realize

a profit from these types of services provided to patients under an emerging payment system.

CONCLUSION

Among corporate pharmacies, MTM and direct patient care services are largely viewed

both cautiously and optimistically.

The need for expanded clinical-based pharmacy services is widely understood by

corporate pharmacies, but lingering uncertainty about how to position pharmacists in the

rapidly-evolving healthcare sector persists.

MTM’s implications on pharmacy operations continue to challenge corporate pharmacies

with the need to more seamlessly incorporate MTM into pharmacists’ workflow

processes.

Financial and economic perspectives of corporate pharmacies must be considered as

MTM and direct patient care services are marked by inadequate reimbursement, but

understood to be a diverse tool in increasing patient loyalty and continued business in the

larger, long term context of success.

Pharmacist-provided MTM services within the healthcare spectrum remain largely

uncertain territory to corporate pharmacy managers, but their recognition of the need for

pharmacists to be integrated and active participants of team-based patient care is clear.

OVERALL INTERPRETATION WHEN PHARMACISTS SURVEY AND CORPORATE

PHARMACY INTERVIEW FINDINGS ARE COMPARED

Pharmacists are engaging at a growing pace in the delivery of MTM and direct care

services to patients. The last 5 years has shown substantial growth in the adoption of MTM

service provision in locales across Nebraska. While many pharmacists provide or will be

providing MTM and direct patient care services within the near future, these services remain

underutilized by patients, resulting in substantial loss of opportunity for improvements in patient

outcomes. Teaching other community-based resources, such as Community Health Workers,

about how and when to refer patients to pharmacists to receive these services could substantially

increase patient access to these services in many communities where pharmacists are offering

MTM and other services and are ready to receive more patient involvement now.

Pharmacy corporate managers are actively pursuing options to best position themselves

to continue offering pharmacist-provided direct patient care services, and leverage these

offerings to team-based approaches with other health care entities/providers. Collaborative

practice agreements are in place in near half of the pharmacies in the state, demonstrating a

model of integration of pharmacists’ services into the delivery of care to patients that extends

provider care plans (chronic disease management) and public health priorities (immunization).

Other models of integration that have some examples include contributing to patient care in

Accountable Care Organizations (ACO) and Patient Centered Medical Homes (PCMHs) through

pharmacists-delivered MTM services, as an example. These models need further advancement

and dissemination within the pharmacy corporations and profession.

Corporate pharmacy managers are generally unsure about how to implement such

arrangements. Concurrently, pharmacists current work and practice conditions, which are already

efficient based upon the needs of dispensing and counseling of patients, are often impeding

pharmacists from promoting these services to patients beyond their current level of engagement.

Workload and traditional workflow and organization within pharmacies make it difficult for

pharmacists to “add work” in many of the pharmacies that responded to the survey. This, despite

the fact that most pharmacies indicated their intention to try to improve the conditions so that

they could offer/or expand their offering of these services. Many are reporting they are near

ready and intend to offer these services soon.

Recent changes in the policy and healthcare landscape have ushered in a sense of urgency

expressed by the pharmacy corporate managers, to determine compensation/reimbursement,

patient care integration, and pharmacy operations improvements so pharmacist can provide these

services. Corporate pharmacy managers recognize that MTM and direct patient care services

exist in an overwhelmingly piecemeal and fractured system; for MTM to be truly successful

within the state of Nebraska, full integration, both of pharmacists within the healthcare spectrum

and of MTM within the pharmacists’ workflow and pharmacy operations, is needed.

Limitations

Much knowledge about the current state of pharmacists’ services and capacity in the

community pharmacy environment has been learned through this work. The viewpoints of both

pharmacists and pharmacy managers at the corporate decision making level have contributed to

this knowledge. This study does reveal how pharmacists perceive their patients’ views about

these services. Obtaining the viewpoints of patients directly could help further inform us about

the strategies that are worthwhile to implement from their point of view those that would have

the impact of engaging more patients to participate in pharmacists provided care designed to

optimize medication therapy management outcomes through local community based pharmacies.

Recommendations

Strategies should be considered in advancing these services:

A large portion of pharmacists could charge for MTM services who are not. This is an

important growth area for improving access to services.

Corporate pharmacy managers view MTM as a tool to retain customers, improve

relationships, and realize financial gain long-term. Managers should consider methods to

enhance pharmacists’ performance of these services.

Improvement in pharmacy workflow, work organization, and performance recognition of

pharmacists who work hard to provide services with corporate pharmacy managers is needed.

Pharmacies are rapidly becoming a new vehicle by which to provide patient care, and

corporate pharmacy managers should support expanding their patient care business models.

Pharmacy managers understand direct patient care services as a package, with MTM as one

service offered within it. Pharmacy managers see the need for collaboration among many

entities and providers to improve patient outcomes, but are unsure how to position within the

health care landscape. Help with making good decisions would be beneficial.

A partnership between industry leaders, healthcare professionals, and the State of Nebraska

could be formed to share experiences related to direct patient care services and identify

potential successful business practices that support high quality patient care services.

Pharmacists’ promotion of MTM service provision directly to patients would potentially

increase access rapidly to patients whose local pharmacists presently offer this.

Conducting state wide training of pharmacists for chronic disease management/MTM. A

standardized training process could be provided to pharmacists in the state of Nebraska.

Conducting state wide training of Community Health Workers about how to refer patients to

MTM services and direct patient care services from pharmacists would increase patient

access to these services.

A majority of pharmacists in community pharmacy practices provide blood pressure checks,

offer to teach how to use blood pressure checking products/devices, offer to teach how to use

blood glucose products/devices, offer medication adherence assistance, provide home

delivery of medications and supplies, and give immunizations. It makes sense for

pharmacists to extend their clinical expertise in these areas and promote their advancement to

be providers of chronic disease self-management, hypertension and diabetes self-

management education to the corporate pharmacy managers and professional association

leadership of pharmacy.

Offer educational opportunities and training to pharmacists to become educators of patients

in self-management areas of chronic disease management, hypertension and diabetes.

Almost half of the pharmacists in community practices have collaborative practice

agreements in place, primarily for immunization and vaccination services. Transforming

pharmacy practice to provide immunization and vaccine services have displayed the ability

of pharmacists to offer expanded clinical services, and a significant opportunity for growth

exist for pharmacists in establishing practice agreements with providers to offer additional

services related to medication therapy monitoring and management within pharmacy walls.

Types of Pharmacies of Interest

Total

Subtotal Other Types of Pharmacies

LTC Facility/Pharmacy Other

Mass Merchandise Chain

Traditional Chain

Independent

Hospital Outpatient

Home Care

Health System/Clinic Pharmacy

Grocery Chain

Subtotal

Specialty

Nebraska Pharmacies by License Type and Response Rate

Table 1

Number Licensed in Nebraska

419

501

165

82

95

28

61

83

11

19

15

15

n

9

100%

84%

16%

33%

19%

12%

17%

4%

2%

2%

3%

3%

6%

%

Response Rate by Type of Pharmacy

343

287

113

44

56

55

63

12

19

15

10

n

6

6

68%

68%

68%

72%

76%

79%

58%

55%

67%

67%

68%

68%

80%

%

30%Medication

5%Point-of-care

4%Point-of-care

11%Diabetes

18%Immunizations

43%Home

0%Hypertension

11%Comprehensive

34%Comprehensive

20%Offer

14%Offer

9%Smoking/tobacco

to teach how to use blood glucose testing products/devices

to teach how to use blood pressure checking products/devices

delivery of medications and supplies

Table 2 Services Provided through Corporations at the Local Community Level

self-management education

adherence assistance

blood glucose testing or hemoglobin A1C testing

INR testing for monitoring anticoagulation

self-management education

drug therapy review

anticoagulation management

cessation education

All Pharmacies

229

236

231

240

218

175

38

22

48

43

n

2

8

70%

51%

69%

67%

67%

64%

14%

11%

13%

2%

6%

1%

%

Pharmacies of

220

221

223

226

156

194

32

22

40

43

n

2

0

Interest

77%

79%

77%

78%

54%

68%

11%

14%

15%

0%

8%

1%

%

Pharmacies

24

10

17

11

19

n

3

2

5

0

6

8

6

Other

%

20%Other 34 10% 23 8% 11
20%Other
34
10%
23
8%
11
11%Blood pressure checks 215 63% 209 73% 6
11%Blood
pressure checks
215
63%
209
73%
6

pressure

hemoglobin

67%Medication

testing

Comprehensive anticoagulation management

monitoring

11%Diabetes

Point-of-care A1C

Point-of-care anticoagulation

79%Immunizations

Home delivery of medications and supplies

Hypertension self-management education

54%Comprehensive

Offer to products/devices

Offer to teach

8%Other

15%Smoking/tobacco

Services Provided through Corporations at the Local Community Level [Settings where MTM services are likely to occur]

Table 3

teach how to use blood glucose

checking

self-management education

adherence assistance

blood

INR testing for

how products/devices

drug therapy review

testing

cessation education

to use blood

glucose testing or

Pharmacies

226

220

221

223

156

194

32

23

22

40

43

n

2

0

Interest of

77%

78%

77%

68%

14%

0%

8%

1%

%

Independent

Pharmacies

98

58

61

89

81

88

14

n

7

7

0

9

5

1

72%

79%

78%

51%

54%

87%

12%

4%

0%

6%

6%

8%

1%

%

Merchandise

45

45

53

35

61

15

4

n

0

0

2

3

3

1

Mass

71%

71%

24%

97%

56%

84%

0%

0%

2%

5%

5%

3%

6%

%

Traditional

46

42

48

26

53

33

10

12

4

n

0

0

9

5

Chains

47%

76%

96%

22%

60%

87%

84%

18%

16%

7%

0%

0%

9%

%

Grocery Chain

43

41

33

31

33

34

15

11

18

n

0

0

3

6

41%

75%

75%

77%

70%

93%

25%

98%

34%

14%

7%

0%

0%

%

Health System/Clinic

10

n

7

0

2

9

3

3

3

6

8

8

1

1

75%

25%

25%

25%

50%

58%

67%

83%

17%

0%

8%

8%

%

33%Blood pressure checks 209 73% 67 59% 44 70% 54 98% 40 91% 4
33%Blood
pressure checks
209
73%
67
59%
44
70%
54
98%
40
91%
4
50% 5 8 % 67% 8 3 % 17% 0 % 8 % 8 % %

pressure

hemoglobin

33%Medication

testing

Comprehensive anticoagulation management

self-management education 6 11%Diabetes

monitoring

Point-of-care A1C

Point-of-care anticoagulation

10 18%Immunizations

Hypertension self-management education

Home delivery of medications and supplies

34%Comprehensive

Offer to teach

11 20%Other

Offer to products/devices

cessation education 5 9%Smoking/tobacco

Services Provided through Corporations at the Local Community Level [Settings where MTM services are not likely to occur]

Table 4

teach how to use blood glucose

checking

adherence assistance

blood

INR testing for

how products/devices

drug therapy review

testing

to use blood

glucose testing or

Pharmacies

24

19

11

17

n

3

2

0

6

8

Other

30%

20%

43%

14%

11%

4%

5%

0%

%

Outpatient

4

4

4

n

0

0

0

2

2

2

3

3

1

1

Hospital

21%

21%

21%

11%

11%

16%

16%

11%

0%

0%

0%

5%

5%

%

Home Care

n

0

0

0

0

0

0

0

0

0

0

6

1

1

100%

17%

17%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

%

n

0

0

0

2

2

2

2

2

Specialty

3

6

6

1

1

20%

20%

20%

20%

20%

30%

60%

60%

10%

10%

0%

0%

0%

%

LTC Facility

10

10

4

4

n

7

7

0

0

0

6

1

1

1

40%

47%

47%

27%

27%

67%

67%

7%

7%

7%

0%

0%

0%

%

n

0

0

0

0

0

0

0

2

2

2

2

1

1

Other

33%

33%

33%

17%

17%

0%

0%

0%

0%

0%

0%

0%

%

17%Blood pressure checks 6 11% 1 5% 0 0% 1 10% 3 20% 1
17%Blood
pressure checks
6
11%
1
5%
0
0%
1
10%
3
20%
1
3 % 33% 1 7 % 17% 0 % 0% 0% 0% 0 % 0 %

55%Yes

13%Yes

Table 7

Table 5

Table 6

Collaborative Practice Agreements with Providers [Settings where MTM services are not likely to occur]

Collaborative Practice Agreements with Providers

Collaborative Practice Agreements with Providers [Settings where MTM services are likely to occur]

Pharmacies

Pharmacies

158

n

n

7

Interest of

Other

%

%

Independent

Outpatient

52

n

n

1

Hospital

46%

5%

%

%

Merchandise

Home Care

38

n

n

0

Mass

60%

0%

%

%

Pharmacies

Chain

Specialty

n

Traditional

33

n

n

2

All

%

20%

60%

%

%

Pharmacies of

Chain

LTC Facility

n

30

Interest

n

n

3