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Promising Results Revealed in Mississippi Disease Management Program

Donna Young

Preliminary data from a Mississippi disease management program show that patients with diabetes mellitus lowered their hemoglobin (Hb) A1c level, and emergency department (ED) visits and hospitalizations decreased for patients with asthma, said Leigh Ann Ramsey, assistant professor of pharmacy practice at the University of Mississippi (UM) School of Pharmacy at Jackson.

Mississippi was the first state that paid pharmacists for providing drug therapy management services to Medicaid beneficiaries after the federal government approved an amendment to the state’s plan in 1998.

Under the Mississippi Medicaid program, pharmacists who enter into a collaborative practice agreement, or protocol, with a physician are paid $20 per patient visit for up to 12 visits per patient per year to manage medication regimens for persons with diabetes mellitus, asthma, hyperlipidemia, or a coagulation disorder.

Pharmacists must be credentialed by the National Institute for Standards in Pharmacist Credentialing (NISPC) and have a state-issued Medicaid provider number to participate in the program, Ramsey said.

Low pharmacist participation. About 200 of Mississippi’s 2200 pharmacists have received the NISPC credentialing, 45 have applied for a Medicaid provider number, and 25 are filing Medicaid claims, said H. Joseph Byrd, UM’s associate dean for clinical affairs and chairman of pharmacy practice.

“There are not as many pharmacists engaged as I would like,” he said. “Most pharmacists would give their firstborn to be where we are with [the Medicaid] amendment and provider path. We have it and are struggling.”

More pharmacists would participate in providing disease management if they could “make a living” at it, Byrd said.

But, he added, Congress must first pass the Medication Therapy Management Act of 2003, a bill that will amend the Social Security Act to cover drug therapy management services provided by pharmacists to high-risk Medicare beneficiaries.

“If Congress is going to spend $400 billion restructuring Medicare and providing a prescription drug benefit, the government should commit to spending at least 1% of that amount to ensure safe and effective outcomes,” Byrd said.

Some of Mississippi’s pharmacists are hesitant to participate in the Medicaid program because they fear that physicians will not accept drug therapy management as a role that pharmacists should play, he noted.

“Not true, according to our experience,” Byrd said. “When physicians understand the service and see that it makes their practice more efficient and improves the quality of care, they accept it with open arms. It is always easier to find an excuse not to do something, especially if it is new and different, than to just do it. We, the pharmacist, are still our own worst enemy. We fuss about what we are doing, don’t want to change, and want to blame someone else for our woes.”

Other pharmacists justify not participating in the state’s program by saying they lack the time necessary to provide services because they are already engaged in dispensing up to 300 prescriptions per day, he added.

“It will require that they reengineer their practices, utilize techs and automation, [and] look at what they are doing and why they are doing it,” Byrd said.

Most of the claims submitted to Mississippi’s Medicaid program for drug therapy management, Byrd said, are from pharmacists providing services as part of a joint project of UM’s School of Pharmacy and the University of Mississippi Medical Center (UMMC) at the Jackson Medical Mall—a once-vacant shopping mall that was renovated to serve as an ambulatory care center and UMMC’s teaching clinics.

The medical mall’s Pharmaceutical Care Clinic first provided drug therapy management services in the summer of 1998 to patients with coagulation disorders, said Ramsey, who is the clinic’s director.

A few months later, pharmacists at the clinic began managing drug therapies under protocol for patients with asthma, she noted.

The following year, UM’s pharmacy practice department teamed with the university’s internal medicine department to provide physician-supervised diabetes management services to patients, she added. The diabetes management clinic is now part of a metabolic disorders clinic, which has expanded to include lipid monitoring services, Ramsey said.

Pharmacists at the Pharmaceutical Care Clinic provide drug therapy management to Medicaid beneficiaries and patients who self-pay or have insurance, but pharmacists can only bill Medicaid for their services, she noted.

If a Medicaid beneficiary has used all of his or her 12 billable visits, she added, pharmacists at the clinic will continue to provide drug therapy management services at no cost to the patient or the state. Pharmacy residents in UMMC’s primary care residency program spend three months in an experiential rotation providing diabetes, asthma, and lipid monitoring services to patients at the clinic, Ramsey said.

As part of the program, residents spend one day each week away from their regular rotation in internal medicine, hypertension, family medicine, or pharmaceutical care, in a longitudinal care experience providing anticoagulation services to patients at the Jackson Medical Mall, she added.

Preliminary findings. Records of 80 adults with diabetes mellitus who received drug therapy management from pharmacists were evaluated for visits between August 1, 2000, and July 31, 2001. The average HbA1c level was 9.9%. Most of the patients were female (65%) and African-American (62.5%). Researchers noted an average decrease in HbA1c value of 2.2 percentage points from the initial to the final visit observed, Ramsey said.

Most notable, she added, was that the patients with diabetes mellitus had had the diagnosis for an average of 9.6 years.

“Their therapy had failed under traditional or conventional management before receiving care under this innovative team approach utilizing pharmacists,” she said.

Forty-two patients, or 53%, had achieved an HbA1c value of <8% and 38% had achieved a value of <7%, the target range set by the American Diabetes Association.

Documentation of microalbuminuria (92.5%), lipid panel (83.3%), fundoscopic examination or referral to an ophthalmologist (91.3%), and aspirin use (47.5%) was observed, Ramsey noted.

Of the patients with diabetes mellitus who had been diagnosed with dyslipidemia (65%), low-density-lipoprotein cholesterol concentrations also improved, with 42.9% of patients achieving a level of <100 mg/dL.

About three fourths of the patients with diabetes mellitus had hypertension at their initial visit. Of those, 31.7% attained a systolic blood pressure of <130 mm Hg and 60.7% achieved a diastolic blood pressure of <80 mm Hg.

An outcomes analysis of patients with asthma revealed “significant” cost savings for Medicaid due to fewer ED visits and hospitalizations for beneficiaries who received services at the clinic, Ramsey said.

UMMC’s billing records of 75 adult patients with asthma were evaluated for visits between September 1998 and December 2001. Patient data collected 12 months before and after drug therapy were compared. The mean age was 36.5 years, with 60% male and 75% African-American.

ED visits for the group fell from 170 to 104 after disease management, yielding a cost saving of $13,960, researchers found.

The number of hospitalizations decreased by nearly half—from 34 to 18—yielding a cost saving of $85,325.

The annualized rate of cost savings per study participant was $1,324.

In a similar analysis of 21 Medicaid beneficiaries with asthma whose care at UMMC and other hospitals could be tracked, the number of ED visits decreased by 28% after patients received disease management.

Although the number of hospitalizations did not decrease, costs associated with those hospitalizations decreased by 48%, according to Ramsey.

The overall cost savings to Medicaid for the 21 patients was $55,755, and the annualized rate of cost savings per Medicaid beneficiary was $2,655.

Mississippi has required Ramsey and UM to include a disclaimer on their evaluations of the Medicaid beneficiaries that the analysis includes a small portion of the state’s Medicaid population and cannot be extrapolated to all Mississippi Medicaid beneficiaries.