Positioning patient counselling as a measurable cornerstone of medication therapy management

Advancing patient care is a systems issue. All stakeholders – practitioners, patients, and payers – have integrated roles in creating more effective, safe, efficient, participatory and responsible models of care to contain costs, improve access and ensure quality. Practitioner roles are dramatically changing – a result of a quality improvement cycle characterized by early pilot projects, curricular changes, larger demonstration projects, publication of emerging evidence and the piloting of new innovations in various practice settings. For pharmacists, the trend has been for less emphasis on product delivery and more on patient counselling for medication therapy management (MTM). Systems improve through continuous feedback – a critical step in the quality improvement cycle. To this point, two questions arise. What kind of feedback is the system receiving regarding pharmacist counselling? And, do the system's larger payers, self-insured employers and the government understand the importance of high-quality patient counselling as the bedrock for evidence-based MTM programmes? Studies have demonstrated the value of pharmacist care services (PCS) for medication therapy and chronic disease management (CDM), including programmes for diabetes, hypertension, hyperlipidaemia and asthma.[1–5] In a review of three 5-year cohorts of published studies on PCS programme assessments, Perez et al. recently reported the median return on investment (ROI) was about 4.8 to 1 (i.e. for every dollar spent on PCS, $4.80 was saved in total health costs).[6] Yet, the ROIs from these studies varied widely, such that the size of the ROIs for PCS programmes is dependent on the type of service, setting and an assumption that the quality of the counselling provided by the pharmacist was of high quality. Before continuing, it is important to state that this assumption underlies physician- and nurse-provided patient care as well. The assumption for all published medication therapy and CDM programmes is that high-quality effective patient counselling is being delivered by all of the participating practitioners. This may be, but how do we know? Assuming regression to the mean is not contributing to successful health-care cost savings, a favourable ROI does not necessarily mean that high-quality patient care was delivered by qualified and effective practitioners. Indeed, the cost–benefit PCS publications cited by Perez et al. provide no information that would bear directly on the quality of the PCS for the MTM programmes studied. Varying ROIs reported in these studies could be explained by variable quality of the counselling. This issue is highlighted by the 2010 Call Letter of US Center for Medicare and Medicaid Services. A Call Letter is issued annually to help US providers plan MTM and CDM programmes for the upcoming year. MTM was identified in the 2003 Medicare Modernization Act as a required drug benefit for seniors under Part D. The 2010 Call Letter expanded the scope of MTM services with the directive: Offer a minimum level of MTM services including interventions for both beneficiaries and prescribers, an annual comprehensive medication review for the beneficiary, which includes a review of medications, interactive person-to-person consultation, and an individualized, written summary of interactive consultation, and quarterly targeted medication reviews.[7] While payers are expected to field programmes with interactive person-to-person consultations with patients, guidance on how such interactions are done, optimized and/or reported is not given. Currently, the assumption is that if the programmes show improved outcomes, the practitioner–patient interaction was probably successful. But, was it optimal? Are we willing to settle for at best a rough estimate? It is generally accepted that effective counselling encompasses: acquisition and use of knowledge relating to information gathering, problem solving and prioritizing; and motivational interviewing techniques of empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy tied to communication skills of listening (active, passive, acknowledgement and encouragement), probing (timing, open-ended, organization, phrasing), paraphrasing, summarizing, transition and repeating (e.g. teach-back).[8] The literature supports motivational interviewing as a foundation for patient behaviour change.[9,10] With behaviour change come sustained habits of self-care supporting risk- reduction approaches to chronic disease self-management. Hence, optimal returns on investment for payers are likely to be associated with programmes in which serious attention is paid to the quality and nature of the person-to-person consultation For health professionals on the front line of patient counselling, these counselling skills for transformative learning are an essential element to achieving behavioural change by patients. Hence, it is also important for health professionals (e.g. those in pharmacy or medical services for larger payers) to understand the essentials of effective patient–pharmacist interactions for ensuring success of its contracted MTM/CDM programmes. By enhancing the patient–practitioner relationship, patients are more likely to be engaged and more likely to maximize their own self-care efforts to achieve disease-related goals of therapy. All this would help to optimize the ROI for the payer. As a practical matter, managers in payer organizations may give only passing attention to the importance of effective counselling in maximizing the success of medication therapy and CDM programmes contracted by large insurers and self-insured employer plans. It is our experience in California with a large insurer, a self-insured employer, a community clinic and a union trust benefits manager that this issue has never been addressed or considered formally by them in determining who they choose as clients for their CDM programmes (Soller B, personal communication). In systems management, solutions are often multifactorial and doable. We favour at least two approaches to emphasizing high-quality patient counselling in MTM and CDM programmes. First, programmes contracted or offered by larger payers, self-insured employers and governments should require the clinical service vendor to report on: (1) training (including that related to patient interviewing and counselling) and qualifications of its participating practitioners; (2) patient and physician recommendations made by pharmacists (and other CDM practitioners); (3) an assessment of the nature and number of recommendations made to patients' physicians that are accepted and acted on by physicians; and (4) internal physician audits of PCS and associated recommendations to patients and physicians. For example, in a study we recently completed assessing pharmacists' key recommendations to physicians and/or patients, over 40% relate to medication therapy in the initial and 30-day visit, of a five-visit per annum model of care. We know from SOAP (subjective–objective–assessment–plan) note reviews of follow-up visits post recommendations that a high percentage of pharmacists' recommendations are carried out by physicians. Coupled with a physician audit of the programme and practitioner MTM training, there is a reasonably strong indication that a high quality of counselling is being delivered. Second, professional organizations have a key role. For example, the American Pharmacist Association defines MTM as a process of care with three essential components: (1) improving collaboration among pharmacists, physicians and other health-care professionals; (2) enhancing communication between patients and their health-care team; and (3) optimizing medication use for improved patient outcomes (emphasis supplied).[11] Implementation of the three MTM components has largely focused on the content aspects of medication therapy reviews through a personal medication record and a medication action plan, interventions/referrals and follow-up.[11] Less or no emphasis has been made in relation to optimizing how MTM-related information is conveyed and in a manner most likely to be used by patients in their own self-care. This requires pharmacists having counselling skills grounded in established principles of clear health communication, education and motivational interviewing. Expanding the definition of MTM to incorporate the definition of quality counselling and how it should be measured would help move the field in the right direction. In summary, the literature supports motivational interviewing and transformative learning as a foundation for patient behaviour change. With behaviour change come sustained habits of self-care supporting risk reduction approaches to chronic disease self-management. Hence, optimal returns on investment for payers are likely to be associated with programmes in which serious attention is paid to the quality and nature of the person-to-person consultation. To raise the quality bar we recommend that managers in payer groups require evidence that the programmes for which they use outside contractors or internal professional staff have a strong foundation (i.e. established criteria) and training programmes in motivational interviewing and transformative learning for their counsellors.