- Email: [email protected]
Evaluation of pharmacists' barriers to the implementation of medication therapy management services
Research
Evaluation of pharmacists’ barriers to the implementation of medication therapy management services Jody L. Lounsbery, Christopher G. Green, Marialice S. Bennett, and Craig A. Pedersen
Received December 10, 2007, and in revised form April 27, 2008. Accepted for publication May 23, 2008.
Abstract Objectives: To assess pharmacists’ actual and perceived barriers to implementing medication therapy management (MTM) services in the outpatient setting and to assess demographic and other factors associated with identified barriers. Design: Cross-sectional study. Setting: United States in 2007. Participants: 970 pharmacists practicing in an outpatient setting. Intervention: E-mail invitation to participate in an Internet-based survey. Main outcome measures: Barriers to implementing MTM, practice characteristic influences on barriers, and personal characteristic influences on barriers. Results: 776 of the 970 respondents (80.0%) were providing MTM or direct patient care services. Of respondents, 35% were compensated and 45% were not compensated for providing MTM services they provided to patients. The most common barriers identified for pharmacists providing MTM services with or without compensation were related to compensation. The most common barriers identified for those interested in providing MTM services were lack of additional staffing (89.6%) and poor access to medical information (84.0%). Pharmacists providing MTM with compensation were significantly less likely to agree with barriers relating to management, documentation, and compensation compared with those providing MTM without compensation. Those providing MTM with compensation were less likely to agree with most barriers compared with pharmacists who were interested in providing MTM services. Pharmacists practicing in a noncommunity setting were less likely to agree with barriers related to interprofessional relationships and documentation. Conclusion: These results show that the most important barriers to implementing MTM services in the outpatient setting identified by pharmacist survey respondents were related to interprofessional relationships, documentation, and compensation. Despite the resources available to pharmacists, barriers continue to hinder the expansion of MTM and direct patient care services. Keywords: Medication therapy management, patient care, barriers, community and ambulatory pharmacy, outpatient setting, pharmaceutical care. J Am Pharm Assoc. 2009;49:51–58. doi: 10.1331/JAPhA.2009.07158
Jody L. Lounsbery, PharmD, BCPS, was Ambulatory and Community Care Pharmacy Practice Resident, College of Pharmacy, Ohio State University, Columbus, at the time of this study was conducted; she is currently Assistant Professor, College of Pharmacy, University of Minnesota, Minneapolis. Christopher G. Green, PharmD, is Clinical Pharmacist, University Health Connection, Ohio State University, Columbus. Marialice S. Bennett, BPharm, FAPhA, is Community and Ambulatory Care Pharmacy Practice Residency Director and Professor, and Craig A. Pedersen, BPharm, PhD, FAPhA, is Associate Professor, College of Pharmacy, Ohio State University, Columbus. Correspondence: Jody L. Lounsbery, PharmD, BCPS, College of Pharmacy, University of Minnesota, 420 Delaware St SE, C-205 Mayo, Minneapolis, MN 55455. Fax: 612-626-4613. E-mail: [email protected] Disclosure: Prof. Bennett was a member of the Core Elements of an MTM Service Model Version 2.0 Advisory Panel. The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To the American Association of Colleges of Pharmacy; the American College of Clinical Pharmacy; Marcie Bough, PharmD, and Anne Burns, BPharm, at the American Pharmacists Association; David Chen, BPharm, MBA, at the American Society for Health-System Pharmacists; and Carla Saxton McSpadden, BPharm, CGP, at the American Society of Consultant Pharmacists for support of this project and to Maria C. Pruchnicki, PharmD, BCPS, for ongoing support. Funding: Supported by an American Pharmacists Association Foundation Incentive Grant for Practitioner Innovation in Pharmaceutical Care. Previous presentations: Poster (research in progress) at the American Pharmacists Association Annual Meeting, Atlanta, GA, March 16–19, 2007, and podium presentation (research in progress) at the Great Lakes Pharmacy Resident Conference, West Lafayette, IN, April 26, 2007.
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T
he Medicare Modernization Act of 2003 created a Medicare Part D prescription drug benefit and included a provision that required a medication therapy management (MTM) program. MTM was defined as “services that optimize therapeutic outcomes for individual patients.” Essential concepts of MTM were outlined and included a wide range of distinct professional services and responsibilities that can be independent of or combined with a medication product, as well as recommendations of the core criteria for MTM programs.1 Several pharmaceutical care programs have yielded valuable clinical and economic outcomes through medication therapy reviews.2–6 If pharmacists embrace the opportunity to provide MTM services in the Medicare population, the profession has the potential to translate MTM to other patient populations. The ability of pharmacists to obtain compensation for these services is crucial for the further development and expansion of the profession. Despite evidence of successful programs, barriers to implementing services that optimize medication outcomes and pharmacist compensation may be hindering expansion. Identifying actual and perceived barriers to implementing MTM ser-
At a Glance
Synopsis: The most important barriers to implementing medication therapy management (MTM) services in the outpatient setting, according to 970 U.S. pharmacists, centered around interprofessional relationships, documentation, and compensation. The most common barriers for pharmacists providing MTM with compensation were lack of sufficient compensation (70.8%), lack of ability to obtain compensation (67.3%), and lack of recognition as a provider (62.2%). Pharmacists interested in providing MTM cited lack of additional staffing (89.6%), poor access to medical information (84.0%), and lack of collaborative practice agreements (82.5%) as barriers. In all cases, the barriers were greater for those interested in providing MTM services compared with those currently providing MTM services. Analysis: Interprofessional relationship barriers to implementing MTM likely hinder the ability of those interested in providing MTM services to facilitate continuity of care. More than 56% of those providing MTM or direct patient care services were not receiving compensation. Previous research has provided approaches for addressing the need for compensation, including developing fee structures and the process of billing. Although resources designed to assist pharmacists in implementing MTM services are readily available, lack of specific MTM practice standards and understanding of the components of MTM services were considered barriers in the current study. Increasing awareness of existing resources and discovering why they are not being used may be beneficial to expanding MTM uptake.
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vices and gaining pharmacists’ perceptions of these barriers could be critical in the further expansion of MTM services in the outpatient setting.
Objectives The primary objective of this study was to assess pharmacists’ actual and perceived barriers to implementing MTM services in the outpatient setting. The secondary objective was to assess demographic and other factors associated with identified barriers.
Methods This project was deemed exempt by the institutional review board of Ohio State University. Participation in the survey indicated consent to participate in the project. A survey with questions regarding barriers to implementing MTM services specific to a pharmacist’s practice was developed and distributed to pharmacists in the outpatient setting who were providing patient care services or who had interest in providing these services. Pharmacists not practicing in an outpatient setting were excluded. Screening questions assessed whether the pharmacist practiced in an eligible setting and verified whether the pharmacist provided MTM or direct patient care services. Definitions of MTM and direct patient care were provided.1,7 Pharmacist respondents self-categorized into one of two groups: (1) those who were providing MTM services and (2) those who were interested in providing MTM or direct patient care services. Questions regarding barriers to implementing MTM were asked of both groups. Extensive literature reviews on implementing MTM, pharmaceutical care, and direct patient care services were performed in the process of identifying and developing the barrier questions.1,8–13 The survey consisted of 30 questions on seven topic areas of potential barriers to implementing MTM services. The areas included components of MTM, pharmacist concerns, interprofessional relationships, patient care, management, documentation, and compensation. For each of the barriers to implementing MTM, a 5-point Likerttype scale was used to assess pharmacist responses, with the scale ranging from 1 (strongly disagree) to 5 (strongly agree). Information on demographics, years in practice, years at current practice site, primary position, primary practice setting, training, and certification was collected. Practice characteristics, including information regarding collaborative practice agreements and compensation, were also collected. Before the project was implemented, the survey was pilot tested on 12 outpatient pharmacists to ensure readability and relevance of questions. Based on this feedback, the survey questions were modified before distribution to the study participants. In an attempt to reach a large number of pharmacists practicing in an outpatient setting, the survey was distributed to the American Association of Colleges of Pharmacy’s Pharmacy Practice roster, members of the American College of Clinical Pharmacy Ambulatory Care Practice and Research Network, members of the American Pharmacists Association Community and Ambulatory Practice and Clinical/Pharmacotherapeutic
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Practice Academy Sections, members of the American Society of Consultant Pharmacists Senior Care Pharmacist Forum Internet mailing list (listserv), and selected members of the American Society of Health-System Pharmacists who indicated a primary focus in ambulatory care. The survey (Appendix 1 in the electronic version of this article, available online at www.japha.org) was delivered to participants via an Internet-based survey tool in March 2007. Pharmacists were sent an e-mail announcement and a link to the survey. Reminder e-mails were sent to nonresponders after 4 days, with data collection concluding 2 weeks after initial distribution. Statistical analysis was performed using SPSS version 14.0 (SPSS, Chicago) and Stata version 7 (Stata, College Station, TX). The a priori level of significance for all statistical computations was P < 0.05. Demographic information was compared by the chi-square test for categorical variables and analysis of variance for continuous variables. Comparisons among providers of MTM services with compensation, providers of MTM services without compensation, and those interested in providing MTM services were assessed by the chi-square test for each barrier. For the most relevant barriers (interprofessional relationships, management, documentation, and compensation), logistic regression was used to describe the relationship between each barrier and the set of practice and personal characteristics. For the logistic models, the dependent variable was dichotomous; those agreeing with the barrier (strongly agree and agree) were compared with those who neither disagreed
nor agreed, those who disagreed, and those who strongly dis agreed. Most independent variables for practice characteristics were dichotomous (i.e., MTM status, position, practice setting, collaborative practice agreement), and age was included as a continuous variable. For the personal characteristic independent variables, postgraduate training, gender, and region were dichotomous and age was a continuous variable. Odds ratios and 95% CIs are reported. The goal of the logistic regression analysis was to isolate the effects of each independent variable on the barrier (dependent variable) while controlling for the other independent variables in the model. Hence, if MTM status was significant in the model, that result was independent of all other personal and practice characteristics of that respondent.
Results The total population consisted of 14,419 e-mail addresses. Of the 14,419 e-mails sent, only 1,019 pharmacists were eligible for the study as a result of undeliverable e-mails (n = 13), not practicing in an outpatient setting (n = 480), and nonresponse (n = 12,907). Of those eligible, 49 did not provide MTM or direct patient care services and were not interested in providing those services. The usable surveys for the purpose of analysis were those in which pharmacists answered the questions assessing barriers to implementing MTM services (n = 970). The final usable response rate for analysis in this study was 6.7%.
Table 1. Demographics of pharmacist respondents to survey assessing barriers to the implementation of MTM services Variable n Age (y), mean ± SD Gender, no. (%) Men Women Region, no. (%) West Midwest South Northeast Practice duration (y) (mean ± SD) Duration at current site (SD), y Postgraduate training (yes), no. (%) Position, no. (%) Manager Staff Clinical Faculty Postgraduate Practice setting, no. (%) Clinic College Hospital Community Other CPA in practice (yes), no. (%)
Interested in providing MTM 194 43.3 ± 12.6
Provide MTM without compensation 440 39.2 ± 11.3
Provide MTM with compensation 336 39.7 ± 12.0
160 (36.4) 280 (63.6)
139 (41.4) 197 (58.6)
77 (17.7) 141 (32.5) 136 (31.3) 80 (18.4) 13.8 ± 11.4 6.4 ± 7.0 309 (70.2)
55 (16.4) 118 (35.2) 133 (39.7) 29 (8.7) 14.9 ± 12.1 7.9 ± 8.7 259 (77.1)
77 (39.7) 101 (52.1) 7 (3.6) 8 (4.1) 1 (0.5)
131 (29.8) 68 (15.5) 101 (23.0) 121 (27.5) 19 (4.3)
140 (41.7) 38 (11.3) 81 (24.1) 56 (16.7) 21 (6.3)
10 (5.2) 8 (4.1) 12 (6.2) 154 (79.4) 10 (5.2) 23 (11.9)
169 (38.4) 35 (8.0) 63 (14.3) 136 (30.9) 37 (8.4) 178 (40.5)
93 (27.7) 11 (3.3) 24 (7.1) 180 (53.6) 28 (8.3) 191 (56.8)
106 (54.6) 88 (45.4) 30 (15.5) 73 (37.6) 48 (24.7) 43 (22.2) 18.2 ± 13.5 6.3 ± 7.2 68 (35.1)
P <0.001 <0.001 <0.001
<0.001 0.012 <0.001 <0.001
<0.001
<0.001
Total 970 40.2 ± 11.9 405 (41.8) 565 (58.2) 162 (16.8) 332 (34.5) 317 (32.9) 152 (15.8) 15.1 ± 12.2 6.9 ± 7.7 636 (65.6) 348 (35.9) 207 (21.3) 189 (19.5) 185 (19.1) 41 (4.2) 272 (28.0) 54 (5.6) 99 (10.2) 470 (48.5) 75 (7.7) 392 (40.4)
Abbreviations used: CPA, collaborative practice agreement; MTM, medication therapy management.
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Demographics
The demographic characteristics of respondents are reported in Table 1. The majority of respondents were women (58.2%) and had underwent postgraduate training (65.6%). The mean (± SD) age of respondents was 40.2 ± 11.9 years. The most common position was manager (35.9%), followed by staff (21.3%) and clinical (19.5%). The most common practice setting was community (48.5%), followed by clinic (28.0%) and
hospital (10.2%). Respondents had been in practice for 15.1 ± 12.2 years and were at their current practice site for 6.9 ± 7.7 years. Respondents primarily lived in the midwest (34.5%) and south (32.9%). Barriers to implementing MTM
Table 2 describes the responses to barriers of those providing MTM services with or without compensation (actual
Table 2. Proportion of pharmacist agreement with barriers to providing MTM Barrier n Components of MTM Lack of specific MTM services practice standards Lack of understanding of the components of MTM services Lack of knowledge of where to locate educational MTM resources Lack of adequate educational MTM resources available Pharmacist concerns Lack of time needed to stay current on clinical knowledge Lack of training on clinical problem solving skills Concerns of civil litigation or professional discipline Lack of training on therapeutic knowledge Interprofessional relationships Lack of recognition as a provider Poor access to medical information, including the patient chart, labs, past medical history, and/or medication lists Lack of CPAs in your practice Poor access to primary care provider Lack of trusted professional relationships with providers Patient care Lack of ability to initiate or modify therapy for patients Lack of ability to monitor patients and their responses to drug therapy Lack of ability to select therapy for patients Lack of ability to deliver MTM to patients with cultural diversity, health literacy, and/or language barriers Lack of ability to develop patient care programs Lack of ability to perform MTM services through face-to-face interactions Lack of ability to establish and build professional relationships with patients Management Lack of additional staffing (pharmacist, technician, or support staff) Lack of ability to market MTM services Lack of physical space to perform MTM services Lack of support from upper management Documentation Lack of an efficient documentation system Lack of standardized documentation system Lack of time to document appropriately Compensation Lack of sufficient compensation to cover costs Lack of ability to obtain compensation for providing MTM services Lack of understanding on billing for MTM services
Interested in Provide MTM without Provide MTM with providing MTM compensation compensation Agreement, no. (%) Agreement, no. (%) Agreement, no. (%) 194 440 336
P
120 (61.9) 129 (66.5) 108 (55.7)
282 (64.1) 261 (59.3) 243 (55.2)
178 (53.0) 134 (39.9) 101 (30.1)
0.006 <0.001 <0.001
103 (53.1)
200 (45.5)
93 (27.7)
<0.001
97 (50.0) 75 (38.7) 59 (30.4) 57 (29.4)
154 (35.0) 88 (20.0) 102 (23.2) 77 (17.5)
100 (29.8) 47 (14.0) 43 (12.8) 38 (11.3)
<0.001 <0.001 <0.001 <0.001
140 (72.2) 163 (84.0)
256 (58.2) 218 (49.5)
209 (62.2) 196 (58.2)
0.004 <0.001
160 (82.5) 138 (71.1) 93 (47.9)
224 (50.9) 179 (40.7) 120 (27.3)
148 (44.0) 144 (42.9) 95 (28.3)
<0.001 <0.001 <0.001
94 (48.5) 98 (50.5)
150 (34.1) 145 (33.0)
95 (28.3) 86 (25.6)
<0.001 <0.001
78 (40.2) 71 (36.6)
125 (28.4) 118 (26.8)
75 (22.3) 70 (20.8)
<0.001 <0.001
93 (47.9) 56 (28.9)
112 (25.5) 79 (18.0)
61 (18.2) 49 (14.6)
<0.001 <0.001
29 (14.9)
46 (10.5)
28 (8.3)
0.058
173 (89.6)
297 (67.5)
185 (55.1)
<0.001
108 (56.0) 155 (80.3) 117 (60.6)
222 (50.5) 246 (55.9) 186 (42.3)
147 (43.8) 127 (37.8) 86 (25.6)
0.020 <0.001 <0.001
150 (77.7) 142 (73.6) 144 (74.6)
255 (58.0) 253 (57.5) 239 (54.3)
168 (50.0) 167 (49.7) 151 (44.9)
<0.001 <0.001 <0.001
135 (69.9) 154 (79.8)
333 (75.7) 366 (83.2)
238 (70.8) 226 (67.3)
0.192 <0.001
154 (79.8)
357 (81.1)
178 (53.0)
<0.001
Abbreviations used: CPA, collaborative practice agreement; MTM, medication therapy management. Strongly agree and agree responses were combined.
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barriers) and those interested in providing MTM or direct patient care services (perceived barriers). The most common barriers for those providing MTM with compensation were lack of sufficient compensation (70.8%), lack of ability to obtain compensation (67.3%), and lack of recognition as a provider (62.2%). The most common barriers for those providing MTM without compensation were related to compensation. The most common barriers for those interested in providing MTM were lack of additional staffing (89.6%), poor access to medical information (84.0%), and lack of collaborative practice agreements (82.5%). Conversely, the least agreed upon barrier for those providing MTM with compensation, providing MTM without compensation, and interested in providing MTM was lack of ability to establish and build relationships with patients (8.3%, 10.5%, and 14.9%, respectively). In all cases, the barriers were greater for those interested in providing MTM services compared with those currently providing MTM services. In most cases, barriers were greater for those providing MTM services without compensation compared with those providing MTM with compensation. Practice and personal characteristics influences on barriers
Table 3 presents results from the logistic regression analyses that examined the relationship between barriers to implementing MTM services and the set of practice and personal characteristics. Pharmacists providing MTM with compensation were significantly less likely to agree with management-, documentation-, and compensation-related barriers compared with those providing MTM without compensation. Those providing MTM services with compensation were significantly less likely to agree with most barriers compared with those interested in providing MTM services. Pharmacists practicing in a noncommunity setting were less likely to agree with interprofessional relationships and documentation-related barriers.
Discussion Key features of an MTM service stress a patient-centered approach and collaboration with physicians and other health care providers.8,9 However, this study found that limited access to a patient’s medical information and primary care provider were important barriers to those interested in providing MTM services and those in the community setting. Building a trusted professional relationship with providers also presented a barrier to those practicing in the community. Variables that influence building trusted collaborative working relationships between pharmacists and physicians have been reported. Influential characteristics of collaborative relationships identified include relationship initiation by pharmacists, showing added value to the physicians’ practice, trustworthiness, and defined roles and responsibilities.14 Professional interaction between pharmacists and physicians has also been identified as a factor affecting collaborative working relationships.15 Convenience to the physician and improvement in the physicians’ workflow, as well as caring for mutual patients and open communication, were variables influencing development of collaboration. On
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the other hand, proximity of the pharmacist and physician, focus on a narrow patient segment, and presence of a formal collaborative practice agreement were identified to be nondiscriminating variables.16 The barriers to implementing MTM associated with interprofessional relationships likely hinder the ability to facilitate continuity of care of those interested in providing MTM services. Pharmacists interested in providing MTM, those providing MTM without compensation, and those practicing in the community reported important barriers for all documentationrelated survey items. Appropriate documentation systems are key features of an MTM service.8,9 Community pharmacists have identified the most important characteristics of a documentation system. Those characteristics included a comprehensive documentation system permitting documentation of all patient care services in one system, cost, time efficiency, ease of use, and the ability to generate patient reports.17 Panels of pharmacist practitioners and experts developed documentation guidelines on pharmacist-provided care in any practice setting. The panels identified key elements required for documenting patient encounters and patient records.18 Documentation guides describing requirements for practices in a clinic setting are also available resources.19 In this survey, more than 40% of those providing MTM services were receiving compensation. Despite the common assumption that compensation will result in the expansion of patient care services, all three groups of pharmacists agreed that barriers existed for survey statements related to compensation. Interestingly, the highest level of agreement was observed for compensation-related barriers, even among pharmacists providing MTM services with compensation. The three mostagreed-upon barriers for those providing MTM services without compensation were compensation related. However, the compensation-related barriers were not the most agreed upon barriers for those interested in providing MTM services. Not surprisingly, those providing MTM services with compensation were significantly less likely to agree that lack of understanding on how to bill and lack of ability to obtain compensation were barriers compared with those providing MTM without compensation and those interested in providing MTM services. Survey results showed that more than 56% of those providing MTM or direct patient care services were not receiving compensation. Snella et al.20 outlined the steps involved in receiving compensation, including the development of fee structures and the process of billing. Scenarios focusing on both the physician office and the community setting were described. Steps for establishing collaboration with physicians and receiving compensation for patient care services in a clinic setting have also been discussed.16 Nutescu and Klotz21 defined key terms important for receiving compensation for cognitive services and provided examples of useful resources in the process of billing and obtaining compensation. Additional resources have described the implementation process of MTM services and the appropriate level of pharmacist compensation for providing these services.8,22,23 Despite the resources available discussing compensation for patient care services in the past, the majority
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Table 3. Results from logistic regression analyses examining relationship between barriers to implementing MTM services and practice and personal characteristics
Provide MTM without compensationa Years at site Nonstaff position Noncommunity practice setting CPA in practice Personal characteristics Postgraduate training Women Age West regiond South regiond Northeast regiond
Lack of support from upper management OR (95% CI)
Lack of CPA in your practice OR (95% CI)
Lack of recognition as a provider OR (95% CI)
Lack of trusted professional relationships with providers OR (95% CI)
Poor access to primary care provider OR (95% CI)
Barrier Practice characteristics Interested in providing MTMa
Poor access to medical information OR (95% CI)
Interprofessional relationships
1.72 (1.00–2.94)b 0.93 (0.66–1.32) 0.96 (0.93–0.98)c 0.86 (0.53– 1.39) 0.13 (0.09–0.19)c 0.78 (0.56–1.08)
2.06 (1.31–3.24)c 1.15 (0.83–1.60) 0.98 (0.96–1.01) 1.09 (0.73–1.63) 0.26 (0.19–0.36)c 0.84 (0.61–1.14)
1.67 (1.08–2.58)b 0.92 (0.64–1.30) 0.99 (0.97–1.02) 0.83 (0.56–1.22) 0.54 (0.38–0.76)c 0.62 (0.45–0.87)c
1.49 (0.96–2.32) 0.81 (0.59–1.11) 0.98 (0.96–1.01) 1.16 (0.78–1.71) 0.80 (0.58–1.10) 0.81 (0.60–1.10)
2.97 (1.81–4.88)c 1.30 (0.93–1.83) 0.97 (0.95–1.00)b 0.86 (0.56–1.33) 0.38 (0.27–0.53)c 0.37 (0.27–0.50)c
3.61 (2.34–5.56)c 1.82 (1.31–2.54)c 0.97 (0.95–0.99)c 0.73 (0.50–1.08) 1.12 (0.81–1.56) 0.94 (0.69–1.82)
0.80 (0.55–1.16) 0.97 (0.70–1.36) 1.02 (1.00–1.04) 1.25 (0.80–1.97) 1.16 (0.80–1.67) 1.63 (1.01–2.63)b
0.75 (0.54–1.04) 1.04 (0.76–1.42) 1.00 (0.99–1.02) 1.16 (0.76–1.77) 1.44 (1.02–2.01)b 1.59 (1.04–2.44)b
1.01 (0.72–1.43) 1.33 (0.96–1.83) 0.99 (0.97–1.00) 2.01 (1.30–3.11)c 1.71 (1.20–2.45)c 2.12 (1.38–3.25)c
0.95 (0.69–1.32) 1.27 (0.94–1.70) 0.99 (0.97–1.00) 0.83 (0.56–1.23) 1.14 (0.82–1.58) 1.10 (0.73–1.67)
0.90 (0.64–1.28) 1.31 (0.95–1.81) 1.00 (0.99–1.02) 0.71 (0.46–1.10) 1.12 (0.79–1.58) 1.94 (1.22–3.08)c
0.98 (0.70–1.36) 0.98 (0.73–1.33) 1.00 (0.99–1.02) 1.07 (0.71–1.62) 1.21 (0.86–1.69) 1.68 (1.12–2.54)b
Abbreviations used: CPA, collaborative practice agreement; MTM, medication therapy management. a Provide MTM and receive compensation is referent group. b P < 0.05. c P < 0.01. d Midwest region is referent group.
of those providing MTM services indicated that they were not receiving compensation for those services. Resources designed to assist pharmacists in implementing MTM services exist and are readily available.1,8,9,15–23 However, lack of specific MTM practice standards and understanding the components of MTM services were considered barriers by pharmacists providing MTM with or without compensation
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and those interested in providing MTM services. For those interested in providing MTM and those providing MTM without compensation, lack of adequate educational resources and lack of knowledge regarding where to locate resources were significant barriers compared with those providing MTM with compensation. If resources are indeed available, increasing awareness of their existence and discovering why they are not
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Lack of sufficient compensation to cover costs OR (95% CI)
Lack of ability to obtain compensation for providing MTM services OR (95% CI)
Lack of understanding how to bill for MTM services OR (95% CI)
Compensation
Lack of an efficient documentation system OR (95% CI)
Lack of time to document appropriately OR (95% CI)
Lack of standardized documentation system OR (95% CI)
Lack of ability to market MTM services OR (95% CI)
Documentation
Lack of physical space to perform MTM services OR (95% CI)
Lack of additional staffing OR (95% CI)
Management
5.34 (3.05–9.33)c 1.74 (1.26–2.40)c 1.00 (0.97–1.02) 0.62 (0.39–0.98)b 0.68 (0.48–0.95)b 0.95 (0.69–1.29)
4.91 (3.09–7.82)c 1.85 (1.35–2.53)c 0.98 (0.96–1.00) 0.72 (0.48–1.08) 1.09 (0.79–1.51) 0.84 (0.62–1.14)
1.24 (0.82–1.87) 1.29 (0.95–1.75) 1.00 (0.98–1.02) 0.87 (0.60–1.26) 0.75 (0.55–1.02) 0.80 (0.60–1.07)
1.87 (1.20–2.92) 1.49 (1.08–2.04)b 1.00 (0.98–1.02) 0.81 (0.54–1.20) 0.50 (0.36–0.69)c 0.77 (0.57–1.04)
2.61 (1.67–4.07)c 1.59 (1.16–2.18)c 1.01 (0.99–1.04) 0.79 (0.53–1.17) 0.59 (0.43–0.80)c 0.90 (0.67–1.21)
2.35 (1.48–3.72)c 1.54 (1.13–2.13)c 0.98 (0.96–1.00) 0.98 (0.65–1.47) 0.44 (0.32–0.61)c 0.81 (0.60–1.10)
3.41 (2.12–5.47) c 3.37 (2.39–4.76)c 0.99 (0.97–1.01) 0.85 (0.55–1.31) 1.32 (0.94–1.86) 1.14 (0.82–1.58)
1.99 (1.23–3.24) c 2.22 (1.54–3.19)c 0.99 (0.97–1.01) 1.08 (0.70–1.64) 1.14 (0.80–1.64) 1.24 (0.88–1.76)
1.08 (0.69–1.70) 1.33 (0.94–1.89) 0.99 (0.97–1.01) 1.32 (0.88–1.98) 0.91 (0.64–1.28) 1.18 (0.85–1.65)
0.77 (0.54–1.09) 1.12 (0.81–1.53) 0.99 (0.97–1.00) 1.26 (0.82–1.94) 1.26 (0.89–1.78) 1.10 (0.70–1.72)
0.69 (0.50–0.96)b 1.36 (1.01–1.84b 1.01 (0.99–1.02) 1.44 (0.95–2.16) 1.19 (0.85–1.65) 1.32 (0.87–2.01)
0.90 (0.66–1.23) 1.03 (0.77–1.37) 1.00 (0.98–1.01) 1.24 (0.84–1.82) 1.22 (0.89–1.67) 1.32 (0.89–1.95)
0.91 (0.66–1.26) 1.36 (1.01–1.84)b 1.01 (0.99–1.02) 1.03 (0.69–1.53) 1.05 (0.76–1.45) 1.59 (1.04–2.44)b
0.69 (0.50–0.95)b 1.41 (1.05–1.90)b 1.01 (0.99–1.02) 1.04 (0.70–1.56) 1.36 (0.98–1.89) 1.16 (0.77–1.76)
0.94 (0.68–1.31) 1.32 (0.98–1.79) 1.02 (1.01–1.04)c 0.96 (0.64–1.44) 1.07 (0.77–1.48) 1.41 (0.92–2.17)
0.83 (0.58–1.19) 1.10 (0.80–1.53) 0.99 (0.98–1.01) 1.02 (0.66–1.60) 0.84 (0.60–1.20) 1.18 (0.73–1.90)
0.88 (0.61–1.28) 1.05 (0.75–1.48) 1.00 (0.98–1.01) 1.03 (0.64–1.63) 0.78 (0.54–1.12) 1.50 (0.89–2.54)
1.16 (0.82–1.64) 0.96 (0.69–1.32) 1.01 (0.99–1.02) 1.15 (0.75–1.78) 1.09 (0.77–1.53) 1.65 (1.04–2.64)b
being used may be beneficial. Assessing pharmacists’ level of agreement with the value and usefulness of existing MTM resources may also help expand services. Future studies focusing on uncovering solutions to the identified barriers are necessary. In addition, other barriers to implementing MTM services may exist apart from the ones addressed by this survey.
Journal of the American Pharmacists Association
Limitations Limitations should be considered when interpreting the results of the current study. Participants who received the survey were identified by section membership or listservs within five national pharmacy organizations. These groups were selected to reach a large number of pharmacists practicing in an outpatient setting. The potential exists for a smaller overall
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population because of the inability to account for all undeliverable e-mails and the probable overlap of e-mail addresses, as respondents could be members of multiple organizations. A large number of pharmacists were likely practicing in an outpatient setting and not included in the sections or listservs within the organizations; therefore, they did not receive the survey. In addition, participants may have received the survey more than once and potentially responded more than one time. In the survey’s introduction, pharmacists were instructed to respond only once if they received the survey more than one time (online Appendix 1). The potential for response bias also exists. The population was targeted at those providing patient care services in the outpatient setting. As a potential consequence, those who were providing services were more likely to respond.
Conclusion Identifying actual and perceived barriers to implementing MTM services and gaining pharmacists’ perceptions of these barriers is critical to encouraging the expansion of patient care services in the outpatient setting. Results of this survey show the most significant barriers identified were related to interprofessional relationships, documentation, and compensation. Pharmacists in a noncommunity setting were less likely to agree with barriers related to interprofessional relationships and documentation. Despite the resources available to pharmacists, barriers continue to be identified that are hindering the expansion of MTM and direct patient care services. Assessment of pharmacists’ level of agreement with the available resources may be valuable in expanding MTM services. References 1. Bluml B. Definition of medication therapy management: development of professionwide consensus. J Am Pharm Assoc. 2005;45:566–72. 2. Chrischilles EA, Carter BL, Lund BC, et al. Evaluation of the Iowa Medicaid Pharmaceutical Case Management Program. J Am Pharm Assoc. 2004;44:337–49. 3. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy care program. J Am Pharm Assoc. 2003;43:173–84. 4. Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc. 2006;46:133–47. 5. Garrett DG, Bluml BM. Patient self-management program for diabetes: first-year clinical, humanistic, and economic outcomes. J Am Pharm Assoc. 2005;45:130–7. 6. Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and health care costs. Arch Intern Med. 1998;158:1641–7. 7. Murphy JE, Nappi JM, Bosso JA, et al. American College of Clinical Pharmacy’s vision of the future: postgraduate pharmacy resi-
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dency training as a prerequisite for direct patient care practice. Pharmacotherapy. 2006;26:722–33. 8. American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in community pharmacy practice: core elements of an MTM service (version 1.0). J Am Pharm Assoc. 2005;45:573–9. 9. Academy of Managed Care Pharmacy. Sound medication therapy management programs: 2006 consensus document. J Manag Care Pharm. 2006;12:S1–15. 10. Berenguer B, La Casa C, de la Matta MJ, Martin-Calero MJ. Pharmaceutical care: past, present and future. Curr Pharm Des. 2004;10:3931–46. 11. Martin-Calero MJ, Machuca M, Murillo MD, et al. Structural process and implementation programs of pharmaceutical care in different countries. Curr Pharm Des. 2004;10:3969–85. 12. Dunlop JA, Shaw JP. Community pharmacists’ perspectives on pharmaceutical care implementation in New Zealand. Pharm World Sci. 2002;24:224–30. 13. Doucette WR, Kreling DH, Schommer JC, et al. Evaluation of community pharmacy service mix: evidence from the 2004 national pharmacist workforce study. J Am Pharm Assoc. 2006;46:348 –55. 14. Zillich AJ, McDonough RP, Carter BL, Doucette WR. Influential characteristics of physician/pharmacist collaborative relationships. Ann Pharmacother. 2004;38:764–70. 15. Doucette WR, Nevins J, McDonough RP. Factors affecting collaborative care between pharmacists and physicians. Res Social Adm Pharm. 2005;1:565–78. 16. Brock KA, Doucette WR. Collaborative working relationships between pharmacists and physicians: an exploratory study. J Am Pharm Assoc. 2004;44:358–65. 17. Brock KA, Casper KA, Green TR, Pedersen CA. Documentation of patient care services in a community pharmacy setting. J Am Pharm Assoc. 2006;46:378–84. 18. Currie JD, Doucette WR, Kuhle J, et al. Identification of essential elements in the documentation of pharmacist-provided care. J Am Pharm Assoc. 2003;43:41–9. 19. Kuo GM, Buckley TE, Fitzsimmons DS, Steinbauer JR. Collaborative drug therapy management services and reimbursement in a family medicine clinic. Am J Health Syst Pharm. 2004;61:343–54. 20. Snella KA, Trewyn RR, Hansen LB, Bradberry JC. Pharmacist compensation for cognitive services: focus on the physician office and community pharmacy. Pharmacotherapy. 2004;24:372– 88. 21. Nutescu EA, Klotz RS. Basic terminology in obtaining reimbursement for pharmacists’ cognitive services. Am J Health Syst Pharm. 2007;64:186–92. 22. The Lewin Group. Medication therapy management services: a critical review. J Am Pharm Assoc. 2005;45:580–7. 23. Minnesota Department of Human Services. Provider update PRX06-02R: medication therapy management services (MTMS). Accessed at www.dhs.state.mn.us/main/idcplg?IdcService=GET_ DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestRel eased&dDocName=id_055325, July 11, 2006.
Journal of the American Pharmacists Association
Evaluation of pharmacists’ barriers to the implementation of medication therapy management services Jody L. Lounsbery, Christopher G. Green, Marialice S. Bennett, and Craig A. Pedersen
Received December 10, 2007, and in revised form April 27, 2008. Accepted for publication May 23, 2008.
Abstract Objectives: To assess pharmacists’ actual and perceived barriers to implementing medication therapy management (MTM) services in the outpatient setting and to assess demographic and other factors associated with identified barriers. Design: Cross-sectional study. Setting: United States in 2007. Participants: 970 pharmacists practicing in an outpatient setting. Intervention: E-mail invitation to participate in an Internet-based survey. Main outcome measures: Barriers to implementing MTM, practice characteristic influences on barriers, and personal characteristic influences on barriers. Results: 776 of the 970 respondents (80.0%) were providing MTM or direct patient care services. Of respondents, 35% were compensated and 45% were not compensated for providing MTM services they provided to patients. The most common barriers identified for pharmacists providing MTM services with or without compensation were related to compensation. The most common barriers identified for those interested in providing MTM services were lack of additional staffing (89.6%) and poor access to medical information (84.0%). Pharmacists providing MTM with compensation were significantly less likely to agree with barriers relating to management, documentation, and compensation compared with those providing MTM without compensation. Those providing MTM with compensation were less likely to agree with most barriers compared with pharmacists who were interested in providing MTM services. Pharmacists practicing in a noncommunity setting were less likely to agree with barriers related to interprofessional relationships and documentation. Conclusion: These results show that the most important barriers to implementing MTM services in the outpatient setting identified by pharmacist survey respondents were related to interprofessional relationships, documentation, and compensation. Despite the resources available to pharmacists, barriers continue to hinder the expansion of MTM and direct patient care services. Keywords: Medication therapy management, patient care, barriers, community and ambulatory pharmacy, outpatient setting, pharmaceutical care. J Am Pharm Assoc. 2009;49:51–58. doi: 10.1331/JAPhA.2009.07158
Jody L. Lounsbery, PharmD, BCPS, was Ambulatory and Community Care Pharmacy Practice Resident, College of Pharmacy, Ohio State University, Columbus, at the time of this study was conducted; she is currently Assistant Professor, College of Pharmacy, University of Minnesota, Minneapolis. Christopher G. Green, PharmD, is Clinical Pharmacist, University Health Connection, Ohio State University, Columbus. Marialice S. Bennett, BPharm, FAPhA, is Community and Ambulatory Care Pharmacy Practice Residency Director and Professor, and Craig A. Pedersen, BPharm, PhD, FAPhA, is Associate Professor, College of Pharmacy, Ohio State University, Columbus. Correspondence: Jody L. Lounsbery, PharmD, BCPS, College of Pharmacy, University of Minnesota, 420 Delaware St SE, C-205 Mayo, Minneapolis, MN 55455. Fax: 612-626-4613. E-mail: [email protected] Disclosure: Prof. Bennett was a member of the Core Elements of an MTM Service Model Version 2.0 Advisory Panel. The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To the American Association of Colleges of Pharmacy; the American College of Clinical Pharmacy; Marcie Bough, PharmD, and Anne Burns, BPharm, at the American Pharmacists Association; David Chen, BPharm, MBA, at the American Society for Health-System Pharmacists; and Carla Saxton McSpadden, BPharm, CGP, at the American Society of Consultant Pharmacists for support of this project and to Maria C. Pruchnicki, PharmD, BCPS, for ongoing support. Funding: Supported by an American Pharmacists Association Foundation Incentive Grant for Practitioner Innovation in Pharmaceutical Care. Previous presentations: Poster (research in progress) at the American Pharmacists Association Annual Meeting, Atlanta, GA, March 16–19, 2007, and podium presentation (research in progress) at the Great Lakes Pharmacy Resident Conference, West Lafayette, IN, April 26, 2007.
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T
he Medicare Modernization Act of 2003 created a Medicare Part D prescription drug benefit and included a provision that required a medication therapy management (MTM) program. MTM was defined as “services that optimize therapeutic outcomes for individual patients.” Essential concepts of MTM were outlined and included a wide range of distinct professional services and responsibilities that can be independent of or combined with a medication product, as well as recommendations of the core criteria for MTM programs.1 Several pharmaceutical care programs have yielded valuable clinical and economic outcomes through medication therapy reviews.2–6 If pharmacists embrace the opportunity to provide MTM services in the Medicare population, the profession has the potential to translate MTM to other patient populations. The ability of pharmacists to obtain compensation for these services is crucial for the further development and expansion of the profession. Despite evidence of successful programs, barriers to implementing services that optimize medication outcomes and pharmacist compensation may be hindering expansion. Identifying actual and perceived barriers to implementing MTM ser-
At a Glance
Synopsis: The most important barriers to implementing medication therapy management (MTM) services in the outpatient setting, according to 970 U.S. pharmacists, centered around interprofessional relationships, documentation, and compensation. The most common barriers for pharmacists providing MTM with compensation were lack of sufficient compensation (70.8%), lack of ability to obtain compensation (67.3%), and lack of recognition as a provider (62.2%). Pharmacists interested in providing MTM cited lack of additional staffing (89.6%), poor access to medical information (84.0%), and lack of collaborative practice agreements (82.5%) as barriers. In all cases, the barriers were greater for those interested in providing MTM services compared with those currently providing MTM services. Analysis: Interprofessional relationship barriers to implementing MTM likely hinder the ability of those interested in providing MTM services to facilitate continuity of care. More than 56% of those providing MTM or direct patient care services were not receiving compensation. Previous research has provided approaches for addressing the need for compensation, including developing fee structures and the process of billing. Although resources designed to assist pharmacists in implementing MTM services are readily available, lack of specific MTM practice standards and understanding of the components of MTM services were considered barriers in the current study. Increasing awareness of existing resources and discovering why they are not being used may be beneficial to expanding MTM uptake.
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vices and gaining pharmacists’ perceptions of these barriers could be critical in the further expansion of MTM services in the outpatient setting.
Objectives The primary objective of this study was to assess pharmacists’ actual and perceived barriers to implementing MTM services in the outpatient setting. The secondary objective was to assess demographic and other factors associated with identified barriers.
Methods This project was deemed exempt by the institutional review board of Ohio State University. Participation in the survey indicated consent to participate in the project. A survey with questions regarding barriers to implementing MTM services specific to a pharmacist’s practice was developed and distributed to pharmacists in the outpatient setting who were providing patient care services or who had interest in providing these services. Pharmacists not practicing in an outpatient setting were excluded. Screening questions assessed whether the pharmacist practiced in an eligible setting and verified whether the pharmacist provided MTM or direct patient care services. Definitions of MTM and direct patient care were provided.1,7 Pharmacist respondents self-categorized into one of two groups: (1) those who were providing MTM services and (2) those who were interested in providing MTM or direct patient care services. Questions regarding barriers to implementing MTM were asked of both groups. Extensive literature reviews on implementing MTM, pharmaceutical care, and direct patient care services were performed in the process of identifying and developing the barrier questions.1,8–13 The survey consisted of 30 questions on seven topic areas of potential barriers to implementing MTM services. The areas included components of MTM, pharmacist concerns, interprofessional relationships, patient care, management, documentation, and compensation. For each of the barriers to implementing MTM, a 5-point Likerttype scale was used to assess pharmacist responses, with the scale ranging from 1 (strongly disagree) to 5 (strongly agree). Information on demographics, years in practice, years at current practice site, primary position, primary practice setting, training, and certification was collected. Practice characteristics, including information regarding collaborative practice agreements and compensation, were also collected. Before the project was implemented, the survey was pilot tested on 12 outpatient pharmacists to ensure readability and relevance of questions. Based on this feedback, the survey questions were modified before distribution to the study participants. In an attempt to reach a large number of pharmacists practicing in an outpatient setting, the survey was distributed to the American Association of Colleges of Pharmacy’s Pharmacy Practice roster, members of the American College of Clinical Pharmacy Ambulatory Care Practice and Research Network, members of the American Pharmacists Association Community and Ambulatory Practice and Clinical/Pharmacotherapeutic
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Practice Academy Sections, members of the American Society of Consultant Pharmacists Senior Care Pharmacist Forum Internet mailing list (listserv), and selected members of the American Society of Health-System Pharmacists who indicated a primary focus in ambulatory care. The survey (Appendix 1 in the electronic version of this article, available online at www.japha.org) was delivered to participants via an Internet-based survey tool in March 2007. Pharmacists were sent an e-mail announcement and a link to the survey. Reminder e-mails were sent to nonresponders after 4 days, with data collection concluding 2 weeks after initial distribution. Statistical analysis was performed using SPSS version 14.0 (SPSS, Chicago) and Stata version 7 (Stata, College Station, TX). The a priori level of significance for all statistical computations was P < 0.05. Demographic information was compared by the chi-square test for categorical variables and analysis of variance for continuous variables. Comparisons among providers of MTM services with compensation, providers of MTM services without compensation, and those interested in providing MTM services were assessed by the chi-square test for each barrier. For the most relevant barriers (interprofessional relationships, management, documentation, and compensation), logistic regression was used to describe the relationship between each barrier and the set of practice and personal characteristics. For the logistic models, the dependent variable was dichotomous; those agreeing with the barrier (strongly agree and agree) were compared with those who neither disagreed
nor agreed, those who disagreed, and those who strongly dis agreed. Most independent variables for practice characteristics were dichotomous (i.e., MTM status, position, practice setting, collaborative practice agreement), and age was included as a continuous variable. For the personal characteristic independent variables, postgraduate training, gender, and region were dichotomous and age was a continuous variable. Odds ratios and 95% CIs are reported. The goal of the logistic regression analysis was to isolate the effects of each independent variable on the barrier (dependent variable) while controlling for the other independent variables in the model. Hence, if MTM status was significant in the model, that result was independent of all other personal and practice characteristics of that respondent.
Results The total population consisted of 14,419 e-mail addresses. Of the 14,419 e-mails sent, only 1,019 pharmacists were eligible for the study as a result of undeliverable e-mails (n = 13), not practicing in an outpatient setting (n = 480), and nonresponse (n = 12,907). Of those eligible, 49 did not provide MTM or direct patient care services and were not interested in providing those services. The usable surveys for the purpose of analysis were those in which pharmacists answered the questions assessing barriers to implementing MTM services (n = 970). The final usable response rate for analysis in this study was 6.7%.
Table 1. Demographics of pharmacist respondents to survey assessing barriers to the implementation of MTM services Variable n Age (y), mean ± SD Gender, no. (%) Men Women Region, no. (%) West Midwest South Northeast Practice duration (y) (mean ± SD) Duration at current site (SD), y Postgraduate training (yes), no. (%) Position, no. (%) Manager Staff Clinical Faculty Postgraduate Practice setting, no. (%) Clinic College Hospital Community Other CPA in practice (yes), no. (%)
Interested in providing MTM 194 43.3 ± 12.6
Provide MTM without compensation 440 39.2 ± 11.3
Provide MTM with compensation 336 39.7 ± 12.0
160 (36.4) 280 (63.6)
139 (41.4) 197 (58.6)
77 (17.7) 141 (32.5) 136 (31.3) 80 (18.4) 13.8 ± 11.4 6.4 ± 7.0 309 (70.2)
55 (16.4) 118 (35.2) 133 (39.7) 29 (8.7) 14.9 ± 12.1 7.9 ± 8.7 259 (77.1)
77 (39.7) 101 (52.1) 7 (3.6) 8 (4.1) 1 (0.5)
131 (29.8) 68 (15.5) 101 (23.0) 121 (27.5) 19 (4.3)
140 (41.7) 38 (11.3) 81 (24.1) 56 (16.7) 21 (6.3)
10 (5.2) 8 (4.1) 12 (6.2) 154 (79.4) 10 (5.2) 23 (11.9)
169 (38.4) 35 (8.0) 63 (14.3) 136 (30.9) 37 (8.4) 178 (40.5)
93 (27.7) 11 (3.3) 24 (7.1) 180 (53.6) 28 (8.3) 191 (56.8)
106 (54.6) 88 (45.4) 30 (15.5) 73 (37.6) 48 (24.7) 43 (22.2) 18.2 ± 13.5 6.3 ± 7.2 68 (35.1)
P <0.001 <0.001 <0.001
<0.001 0.012 <0.001 <0.001
<0.001
<0.001
Total 970 40.2 ± 11.9 405 (41.8) 565 (58.2) 162 (16.8) 332 (34.5) 317 (32.9) 152 (15.8) 15.1 ± 12.2 6.9 ± 7.7 636 (65.6) 348 (35.9) 207 (21.3) 189 (19.5) 185 (19.1) 41 (4.2) 272 (28.0) 54 (5.6) 99 (10.2) 470 (48.5) 75 (7.7) 392 (40.4)
Abbreviations used: CPA, collaborative practice agreement; MTM, medication therapy management.
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Demographics
The demographic characteristics of respondents are reported in Table 1. The majority of respondents were women (58.2%) and had underwent postgraduate training (65.6%). The mean (± SD) age of respondents was 40.2 ± 11.9 years. The most common position was manager (35.9%), followed by staff (21.3%) and clinical (19.5%). The most common practice setting was community (48.5%), followed by clinic (28.0%) and
hospital (10.2%). Respondents had been in practice for 15.1 ± 12.2 years and were at their current practice site for 6.9 ± 7.7 years. Respondents primarily lived in the midwest (34.5%) and south (32.9%). Barriers to implementing MTM
Table 2 describes the responses to barriers of those providing MTM services with or without compensation (actual
Table 2. Proportion of pharmacist agreement with barriers to providing MTM Barrier n Components of MTM Lack of specific MTM services practice standards Lack of understanding of the components of MTM services Lack of knowledge of where to locate educational MTM resources Lack of adequate educational MTM resources available Pharmacist concerns Lack of time needed to stay current on clinical knowledge Lack of training on clinical problem solving skills Concerns of civil litigation or professional discipline Lack of training on therapeutic knowledge Interprofessional relationships Lack of recognition as a provider Poor access to medical information, including the patient chart, labs, past medical history, and/or medication lists Lack of CPAs in your practice Poor access to primary care provider Lack of trusted professional relationships with providers Patient care Lack of ability to initiate or modify therapy for patients Lack of ability to monitor patients and their responses to drug therapy Lack of ability to select therapy for patients Lack of ability to deliver MTM to patients with cultural diversity, health literacy, and/or language barriers Lack of ability to develop patient care programs Lack of ability to perform MTM services through face-to-face interactions Lack of ability to establish and build professional relationships with patients Management Lack of additional staffing (pharmacist, technician, or support staff) Lack of ability to market MTM services Lack of physical space to perform MTM services Lack of support from upper management Documentation Lack of an efficient documentation system Lack of standardized documentation system Lack of time to document appropriately Compensation Lack of sufficient compensation to cover costs Lack of ability to obtain compensation for providing MTM services Lack of understanding on billing for MTM services
Interested in Provide MTM without Provide MTM with providing MTM compensation compensation Agreement, no. (%) Agreement, no. (%) Agreement, no. (%) 194 440 336
P
120 (61.9) 129 (66.5) 108 (55.7)
282 (64.1) 261 (59.3) 243 (55.2)
178 (53.0) 134 (39.9) 101 (30.1)
0.006 <0.001 <0.001
103 (53.1)
200 (45.5)
93 (27.7)
<0.001
97 (50.0) 75 (38.7) 59 (30.4) 57 (29.4)
154 (35.0) 88 (20.0) 102 (23.2) 77 (17.5)
100 (29.8) 47 (14.0) 43 (12.8) 38 (11.3)
<0.001 <0.001 <0.001 <0.001
140 (72.2) 163 (84.0)
256 (58.2) 218 (49.5)
209 (62.2) 196 (58.2)
0.004 <0.001
160 (82.5) 138 (71.1) 93 (47.9)
224 (50.9) 179 (40.7) 120 (27.3)
148 (44.0) 144 (42.9) 95 (28.3)
<0.001 <0.001 <0.001
94 (48.5) 98 (50.5)
150 (34.1) 145 (33.0)
95 (28.3) 86 (25.6)
<0.001 <0.001
78 (40.2) 71 (36.6)
125 (28.4) 118 (26.8)
75 (22.3) 70 (20.8)
<0.001 <0.001
93 (47.9) 56 (28.9)
112 (25.5) 79 (18.0)
61 (18.2) 49 (14.6)
<0.001 <0.001
29 (14.9)
46 (10.5)
28 (8.3)
0.058
173 (89.6)
297 (67.5)
185 (55.1)
<0.001
108 (56.0) 155 (80.3) 117 (60.6)
222 (50.5) 246 (55.9) 186 (42.3)
147 (43.8) 127 (37.8) 86 (25.6)
0.020 <0.001 <0.001
150 (77.7) 142 (73.6) 144 (74.6)
255 (58.0) 253 (57.5) 239 (54.3)
168 (50.0) 167 (49.7) 151 (44.9)
<0.001 <0.001 <0.001
135 (69.9) 154 (79.8)
333 (75.7) 366 (83.2)
238 (70.8) 226 (67.3)
0.192 <0.001
154 (79.8)
357 (81.1)
178 (53.0)
<0.001
Abbreviations used: CPA, collaborative practice agreement; MTM, medication therapy management. Strongly agree and agree responses were combined.
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barriers) and those interested in providing MTM or direct patient care services (perceived barriers). The most common barriers for those providing MTM with compensation were lack of sufficient compensation (70.8%), lack of ability to obtain compensation (67.3%), and lack of recognition as a provider (62.2%). The most common barriers for those providing MTM without compensation were related to compensation. The most common barriers for those interested in providing MTM were lack of additional staffing (89.6%), poor access to medical information (84.0%), and lack of collaborative practice agreements (82.5%). Conversely, the least agreed upon barrier for those providing MTM with compensation, providing MTM without compensation, and interested in providing MTM was lack of ability to establish and build relationships with patients (8.3%, 10.5%, and 14.9%, respectively). In all cases, the barriers were greater for those interested in providing MTM services compared with those currently providing MTM services. In most cases, barriers were greater for those providing MTM services without compensation compared with those providing MTM with compensation. Practice and personal characteristics influences on barriers
Table 3 presents results from the logistic regression analyses that examined the relationship between barriers to implementing MTM services and the set of practice and personal characteristics. Pharmacists providing MTM with compensation were significantly less likely to agree with management-, documentation-, and compensation-related barriers compared with those providing MTM without compensation. Those providing MTM services with compensation were significantly less likely to agree with most barriers compared with those interested in providing MTM services. Pharmacists practicing in a noncommunity setting were less likely to agree with interprofessional relationships and documentation-related barriers.
Discussion Key features of an MTM service stress a patient-centered approach and collaboration with physicians and other health care providers.8,9 However, this study found that limited access to a patient’s medical information and primary care provider were important barriers to those interested in providing MTM services and those in the community setting. Building a trusted professional relationship with providers also presented a barrier to those practicing in the community. Variables that influence building trusted collaborative working relationships between pharmacists and physicians have been reported. Influential characteristics of collaborative relationships identified include relationship initiation by pharmacists, showing added value to the physicians’ practice, trustworthiness, and defined roles and responsibilities.14 Professional interaction between pharmacists and physicians has also been identified as a factor affecting collaborative working relationships.15 Convenience to the physician and improvement in the physicians’ workflow, as well as caring for mutual patients and open communication, were variables influencing development of collaboration. On
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the other hand, proximity of the pharmacist and physician, focus on a narrow patient segment, and presence of a formal collaborative practice agreement were identified to be nondiscriminating variables.16 The barriers to implementing MTM associated with interprofessional relationships likely hinder the ability to facilitate continuity of care of those interested in providing MTM services. Pharmacists interested in providing MTM, those providing MTM without compensation, and those practicing in the community reported important barriers for all documentationrelated survey items. Appropriate documentation systems are key features of an MTM service.8,9 Community pharmacists have identified the most important characteristics of a documentation system. Those characteristics included a comprehensive documentation system permitting documentation of all patient care services in one system, cost, time efficiency, ease of use, and the ability to generate patient reports.17 Panels of pharmacist practitioners and experts developed documentation guidelines on pharmacist-provided care in any practice setting. The panels identified key elements required for documenting patient encounters and patient records.18 Documentation guides describing requirements for practices in a clinic setting are also available resources.19 In this survey, more than 40% of those providing MTM services were receiving compensation. Despite the common assumption that compensation will result in the expansion of patient care services, all three groups of pharmacists agreed that barriers existed for survey statements related to compensation. Interestingly, the highest level of agreement was observed for compensation-related barriers, even among pharmacists providing MTM services with compensation. The three mostagreed-upon barriers for those providing MTM services without compensation were compensation related. However, the compensation-related barriers were not the most agreed upon barriers for those interested in providing MTM services. Not surprisingly, those providing MTM services with compensation were significantly less likely to agree that lack of understanding on how to bill and lack of ability to obtain compensation were barriers compared with those providing MTM without compensation and those interested in providing MTM services. Survey results showed that more than 56% of those providing MTM or direct patient care services were not receiving compensation. Snella et al.20 outlined the steps involved in receiving compensation, including the development of fee structures and the process of billing. Scenarios focusing on both the physician office and the community setting were described. Steps for establishing collaboration with physicians and receiving compensation for patient care services in a clinic setting have also been discussed.16 Nutescu and Klotz21 defined key terms important for receiving compensation for cognitive services and provided examples of useful resources in the process of billing and obtaining compensation. Additional resources have described the implementation process of MTM services and the appropriate level of pharmacist compensation for providing these services.8,22,23 Despite the resources available discussing compensation for patient care services in the past, the majority
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Table 3. Results from logistic regression analyses examining relationship between barriers to implementing MTM services and practice and personal characteristics
Provide MTM without compensationa Years at site Nonstaff position Noncommunity practice setting CPA in practice Personal characteristics Postgraduate training Women Age West regiond South regiond Northeast regiond
Lack of support from upper management OR (95% CI)
Lack of CPA in your practice OR (95% CI)
Lack of recognition as a provider OR (95% CI)
Lack of trusted professional relationships with providers OR (95% CI)
Poor access to primary care provider OR (95% CI)
Barrier Practice characteristics Interested in providing MTMa
Poor access to medical information OR (95% CI)
Interprofessional relationships
1.72 (1.00–2.94)b 0.93 (0.66–1.32) 0.96 (0.93–0.98)c 0.86 (0.53– 1.39) 0.13 (0.09–0.19)c 0.78 (0.56–1.08)
2.06 (1.31–3.24)c 1.15 (0.83–1.60) 0.98 (0.96–1.01) 1.09 (0.73–1.63) 0.26 (0.19–0.36)c 0.84 (0.61–1.14)
1.67 (1.08–2.58)b 0.92 (0.64–1.30) 0.99 (0.97–1.02) 0.83 (0.56–1.22) 0.54 (0.38–0.76)c 0.62 (0.45–0.87)c
1.49 (0.96–2.32) 0.81 (0.59–1.11) 0.98 (0.96–1.01) 1.16 (0.78–1.71) 0.80 (0.58–1.10) 0.81 (0.60–1.10)
2.97 (1.81–4.88)c 1.30 (0.93–1.83) 0.97 (0.95–1.00)b 0.86 (0.56–1.33) 0.38 (0.27–0.53)c 0.37 (0.27–0.50)c
3.61 (2.34–5.56)c 1.82 (1.31–2.54)c 0.97 (0.95–0.99)c 0.73 (0.50–1.08) 1.12 (0.81–1.56) 0.94 (0.69–1.82)
0.80 (0.55–1.16) 0.97 (0.70–1.36) 1.02 (1.00–1.04) 1.25 (0.80–1.97) 1.16 (0.80–1.67) 1.63 (1.01–2.63)b
0.75 (0.54–1.04) 1.04 (0.76–1.42) 1.00 (0.99–1.02) 1.16 (0.76–1.77) 1.44 (1.02–2.01)b 1.59 (1.04–2.44)b
1.01 (0.72–1.43) 1.33 (0.96–1.83) 0.99 (0.97–1.00) 2.01 (1.30–3.11)c 1.71 (1.20–2.45)c 2.12 (1.38–3.25)c
0.95 (0.69–1.32) 1.27 (0.94–1.70) 0.99 (0.97–1.00) 0.83 (0.56–1.23) 1.14 (0.82–1.58) 1.10 (0.73–1.67)
0.90 (0.64–1.28) 1.31 (0.95–1.81) 1.00 (0.99–1.02) 0.71 (0.46–1.10) 1.12 (0.79–1.58) 1.94 (1.22–3.08)c
0.98 (0.70–1.36) 0.98 (0.73–1.33) 1.00 (0.99–1.02) 1.07 (0.71–1.62) 1.21 (0.86–1.69) 1.68 (1.12–2.54)b
Abbreviations used: CPA, collaborative practice agreement; MTM, medication therapy management. a Provide MTM and receive compensation is referent group. b P < 0.05. c P < 0.01. d Midwest region is referent group.
of those providing MTM services indicated that they were not receiving compensation for those services. Resources designed to assist pharmacists in implementing MTM services exist and are readily available.1,8,9,15–23 However, lack of specific MTM practice standards and understanding the components of MTM services were considered barriers by pharmacists providing MTM with or without compensation
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and those interested in providing MTM services. For those interested in providing MTM and those providing MTM without compensation, lack of adequate educational resources and lack of knowledge regarding where to locate resources were significant barriers compared with those providing MTM with compensation. If resources are indeed available, increasing awareness of their existence and discovering why they are not
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Evaluation of barriers to implementation of MTM Research
Lack of sufficient compensation to cover costs OR (95% CI)
Lack of ability to obtain compensation for providing MTM services OR (95% CI)
Lack of understanding how to bill for MTM services OR (95% CI)
Compensation
Lack of an efficient documentation system OR (95% CI)
Lack of time to document appropriately OR (95% CI)
Lack of standardized documentation system OR (95% CI)
Lack of ability to market MTM services OR (95% CI)
Documentation
Lack of physical space to perform MTM services OR (95% CI)
Lack of additional staffing OR (95% CI)
Management
5.34 (3.05–9.33)c 1.74 (1.26–2.40)c 1.00 (0.97–1.02) 0.62 (0.39–0.98)b 0.68 (0.48–0.95)b 0.95 (0.69–1.29)
4.91 (3.09–7.82)c 1.85 (1.35–2.53)c 0.98 (0.96–1.00) 0.72 (0.48–1.08) 1.09 (0.79–1.51) 0.84 (0.62–1.14)
1.24 (0.82–1.87) 1.29 (0.95–1.75) 1.00 (0.98–1.02) 0.87 (0.60–1.26) 0.75 (0.55–1.02) 0.80 (0.60–1.07)
1.87 (1.20–2.92) 1.49 (1.08–2.04)b 1.00 (0.98–1.02) 0.81 (0.54–1.20) 0.50 (0.36–0.69)c 0.77 (0.57–1.04)
2.61 (1.67–4.07)c 1.59 (1.16–2.18)c 1.01 (0.99–1.04) 0.79 (0.53–1.17) 0.59 (0.43–0.80)c 0.90 (0.67–1.21)
2.35 (1.48–3.72)c 1.54 (1.13–2.13)c 0.98 (0.96–1.00) 0.98 (0.65–1.47) 0.44 (0.32–0.61)c 0.81 (0.60–1.10)
3.41 (2.12–5.47) c 3.37 (2.39–4.76)c 0.99 (0.97–1.01) 0.85 (0.55–1.31) 1.32 (0.94–1.86) 1.14 (0.82–1.58)
1.99 (1.23–3.24) c 2.22 (1.54–3.19)c 0.99 (0.97–1.01) 1.08 (0.70–1.64) 1.14 (0.80–1.64) 1.24 (0.88–1.76)
1.08 (0.69–1.70) 1.33 (0.94–1.89) 0.99 (0.97–1.01) 1.32 (0.88–1.98) 0.91 (0.64–1.28) 1.18 (0.85–1.65)
0.77 (0.54–1.09) 1.12 (0.81–1.53) 0.99 (0.97–1.00) 1.26 (0.82–1.94) 1.26 (0.89–1.78) 1.10 (0.70–1.72)
0.69 (0.50–0.96)b 1.36 (1.01–1.84b 1.01 (0.99–1.02) 1.44 (0.95–2.16) 1.19 (0.85–1.65) 1.32 (0.87–2.01)
0.90 (0.66–1.23) 1.03 (0.77–1.37) 1.00 (0.98–1.01) 1.24 (0.84–1.82) 1.22 (0.89–1.67) 1.32 (0.89–1.95)
0.91 (0.66–1.26) 1.36 (1.01–1.84)b 1.01 (0.99–1.02) 1.03 (0.69–1.53) 1.05 (0.76–1.45) 1.59 (1.04–2.44)b
0.69 (0.50–0.95)b 1.41 (1.05–1.90)b 1.01 (0.99–1.02) 1.04 (0.70–1.56) 1.36 (0.98–1.89) 1.16 (0.77–1.76)
0.94 (0.68–1.31) 1.32 (0.98–1.79) 1.02 (1.01–1.04)c 0.96 (0.64–1.44) 1.07 (0.77–1.48) 1.41 (0.92–2.17)
0.83 (0.58–1.19) 1.10 (0.80–1.53) 0.99 (0.98–1.01) 1.02 (0.66–1.60) 0.84 (0.60–1.20) 1.18 (0.73–1.90)
0.88 (0.61–1.28) 1.05 (0.75–1.48) 1.00 (0.98–1.01) 1.03 (0.64–1.63) 0.78 (0.54–1.12) 1.50 (0.89–2.54)
1.16 (0.82–1.64) 0.96 (0.69–1.32) 1.01 (0.99–1.02) 1.15 (0.75–1.78) 1.09 (0.77–1.53) 1.65 (1.04–2.64)b
being used may be beneficial. Assessing pharmacists’ level of agreement with the value and usefulness of existing MTM resources may also help expand services. Future studies focusing on uncovering solutions to the identified barriers are necessary. In addition, other barriers to implementing MTM services may exist apart from the ones addressed by this survey.
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Limitations Limitations should be considered when interpreting the results of the current study. Participants who received the survey were identified by section membership or listservs within five national pharmacy organizations. These groups were selected to reach a large number of pharmacists practicing in an outpatient setting. The potential exists for a smaller overall
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population because of the inability to account for all undeliverable e-mails and the probable overlap of e-mail addresses, as respondents could be members of multiple organizations. A large number of pharmacists were likely practicing in an outpatient setting and not included in the sections or listservs within the organizations; therefore, they did not receive the survey. In addition, participants may have received the survey more than once and potentially responded more than one time. In the survey’s introduction, pharmacists were instructed to respond only once if they received the survey more than one time (online Appendix 1). The potential for response bias also exists. The population was targeted at those providing patient care services in the outpatient setting. As a potential consequence, those who were providing services were more likely to respond.
Conclusion Identifying actual and perceived barriers to implementing MTM services and gaining pharmacists’ perceptions of these barriers is critical to encouraging the expansion of patient care services in the outpatient setting. Results of this survey show the most significant barriers identified were related to interprofessional relationships, documentation, and compensation. Pharmacists in a noncommunity setting were less likely to agree with barriers related to interprofessional relationships and documentation. Despite the resources available to pharmacists, barriers continue to be identified that are hindering the expansion of MTM and direct patient care services. Assessment of pharmacists’ level of agreement with the available resources may be valuable in expanding MTM services. References 1. Bluml B. Definition of medication therapy management: development of professionwide consensus. J Am Pharm Assoc. 2005;45:566–72. 2. Chrischilles EA, Carter BL, Lund BC, et al. Evaluation of the Iowa Medicaid Pharmaceutical Case Management Program. J Am Pharm Assoc. 2004;44:337–49. 3. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy care program. J Am Pharm Assoc. 2003;43:173–84. 4. Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc. 2006;46:133–47. 5. Garrett DG, Bluml BM. Patient self-management program for diabetes: first-year clinical, humanistic, and economic outcomes. J Am Pharm Assoc. 2005;45:130–7. 6. Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and health care costs. Arch Intern Med. 1998;158:1641–7. 7. Murphy JE, Nappi JM, Bosso JA, et al. American College of Clinical Pharmacy’s vision of the future: postgraduate pharmacy resi-
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dency training as a prerequisite for direct patient care practice. Pharmacotherapy. 2006;26:722–33. 8. American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in community pharmacy practice: core elements of an MTM service (version 1.0). J Am Pharm Assoc. 2005;45:573–9. 9. Academy of Managed Care Pharmacy. Sound medication therapy management programs: 2006 consensus document. J Manag Care Pharm. 2006;12:S1–15. 10. Berenguer B, La Casa C, de la Matta MJ, Martin-Calero MJ. Pharmaceutical care: past, present and future. Curr Pharm Des. 2004;10:3931–46. 11. Martin-Calero MJ, Machuca M, Murillo MD, et al. Structural process and implementation programs of pharmaceutical care in different countries. Curr Pharm Des. 2004;10:3969–85. 12. Dunlop JA, Shaw JP. Community pharmacists’ perspectives on pharmaceutical care implementation in New Zealand. Pharm World Sci. 2002;24:224–30. 13. Doucette WR, Kreling DH, Schommer JC, et al. Evaluation of community pharmacy service mix: evidence from the 2004 national pharmacist workforce study. J Am Pharm Assoc. 2006;46:348 –55. 14. Zillich AJ, McDonough RP, Carter BL, Doucette WR. Influential characteristics of physician/pharmacist collaborative relationships. Ann Pharmacother. 2004;38:764–70. 15. Doucette WR, Nevins J, McDonough RP. Factors affecting collaborative care between pharmacists and physicians. Res Social Adm Pharm. 2005;1:565–78. 16. Brock KA, Doucette WR. Collaborative working relationships between pharmacists and physicians: an exploratory study. J Am Pharm Assoc. 2004;44:358–65. 17. Brock KA, Casper KA, Green TR, Pedersen CA. Documentation of patient care services in a community pharmacy setting. J Am Pharm Assoc. 2006;46:378–84. 18. Currie JD, Doucette WR, Kuhle J, et al. Identification of essential elements in the documentation of pharmacist-provided care. J Am Pharm Assoc. 2003;43:41–9. 19. Kuo GM, Buckley TE, Fitzsimmons DS, Steinbauer JR. Collaborative drug therapy management services and reimbursement in a family medicine clinic. Am J Health Syst Pharm. 2004;61:343–54. 20. Snella KA, Trewyn RR, Hansen LB, Bradberry JC. Pharmacist compensation for cognitive services: focus on the physician office and community pharmacy. Pharmacotherapy. 2004;24:372– 88. 21. Nutescu EA, Klotz RS. Basic terminology in obtaining reimbursement for pharmacists’ cognitive services. Am J Health Syst Pharm. 2007;64:186–92. 22. The Lewin Group. Medication therapy management services: a critical review. J Am Pharm Assoc. 2005;45:580–7. 23. Minnesota Department of Human Services. Provider update PRX06-02R: medication therapy management services (MTMS). Accessed at www.dhs.state.mn.us/main/idcplg?IdcService=GET_ DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestRel eased&dDocName=id_055325, July 11, 2006.
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