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Prediction of pharmacist intention to provide Medicare medication therapy management services using the theory of planned behavior
Research in Social and Administrative Pharmacy 2 (2006) 299–314
Original research
Prediction of pharmacist intention to provide Medicare medication therapy management services using the theory of planned behavior Kathleen E. Herbert, Pharm.D.a, Julie M. Urmie, Ph.D.a,*, Brand A. Newland, Pharm.D.b,1, Karen B. Farris, Ph.D.a a
University of Iowa College of Pharmacy, Iowa City, IA 52242-1112, USA b Outcomes Pharmaceutical Healthcare, Des Moines, IA, USA
Abstract Background: Medicare Part D is a voluntary prescription drug benefit for Medicare beneficiaries. As part of the coverage, medication therapy management services (MTMS) are mandated for beneficiaries with chronic diseases who take multiple medications covered under part D and who are likely to incur annual costs that exceed a specified level. Objective: To predict the behavioral intention of pharmacists to provide Medicare medication therapy management services (MTMS) using the theory of planned behavior (TPB) and to determine the relationship between pharmacists’ characteristics and intention to provide MTMS. Methods: The population for this cross-sectional descriptive study consisted of all community pharmacists in Iowa. Data collection occurred through a self-administered
* Corresponding author. S519 Pharmacy Building, 115 S Grand Avenue, Iowa City, IA 52242-1112, USA. Tel.: þ1 319 335 8616; fax: þ1 319 353 5646. E-mail address: [email protected] (J.M. Urmie). 1 Dr Newland was a PharmD student at the University of Iowa when he participated in the research. 1551-7411/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2006.02.008
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anonymous mail survey. Two surveys each were mailed to 500 pharmacies selected through a stratified random sample, 1 survey for the pharmacy manager and 1 survey for a staff pharmacist if applicable. Descriptive statistics and scale reliability were calculated for each of the 4 TPB scales (attitude, subjective norm, perceived behavioral control, and intention). Linear regression was used to predict intent as a function of the other 3 TPB factors, demographic factors, experience, and type of pharmacy. Results: Out of 212 surveys received, 203 had usable data. The usable response rate ranged from 21% to 41%. Pharmacists’ intent to provide MTMS was generally positive but varied in strength with a mean score of 22.47 (4.00) and a range of 7-30. Pharmacists mostly agreed that they had appropriate training to provide MTMS but lacked time and support. The linear regression analysis found the constructs of attitude, subjective norm, and perceived behavioral control to be significant predictors of intent (P < .05). Pharmacists with stronger intent to provide MTMS were those who felt they had more control over providing MTMS, felt their peers approved of the provision of MTMS, and had a positive attitude about providing MTMS. Type of pharmacy and pharmacist demographic variables were not significant predictors of intent to provide MTMS. Conclusion: Pharmacists showed generally positive intent to provide MTMS. Perceived behavioral control, subjective norm, and attitude were significant predictors of intent (P < .05). Strategies to help pharmacists provide MTMS should focus on finding time and support to provide MTMS rather than individual educational needs. Ó 2006 Elsevier Inc. All rights reserved. Keywords: Medicare Part D; Medication therapy management services (MTMS); The theory of planned behavior (TPB)
1. Introduction The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 will potentially have a significant impact on the profession of pharmacy. The MMA of 2003 was signed into law on December 8, 2003, creating Medicare Part D. Under Medicare Part D, enrolled beneficiaries will receive coverage for outpatient prescription medications. In addition, the law requires that medication therapy management services (MTMS) be provided for beneficiaries with chronic diseases who take multiple medications covered under part D and who are likely to incur annual costs that exceed a specified level. Although the law does not mandate specific MTMS to be covered, MTMS may include using patient education to decrease misuse of medications, increasing detection of both adverse drug reactions and the overuse or underuse of medication therapy, and also working to improve the adherence of beneficiaries to their medication therapy.1
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The inclusion of the provision of MTMS in the Medicare law was a positive move forward for the profession of pharmacy. Pharmacy organizations had been lobbying Congress to include such a provision in the MMA of 2003. The law does not require pharmacists to be the only providers of MTMS, but pharmacists are the only health care professionals specifically mentioned in the law.1 The final Medicare drug benefit rules allow the Medicare prescription drug plans (PDPs) considerable freedom in determining the providers and types of services for MTMS, but there should be some opportunities for pharmacists to participate and these opportunities may increase over time if pharmacists are proactive about working with insurers. This eventually could further the transition from pharmacists as dispensers of medication to recognized providers of health care. For this change to take place, pharmacists need to overcome barriers to providing care-based services. Previous studies have looked at barriers to the provision of pharmaceutical services, but never before has there been a national plan on the horizon, which may consistently reimburse pharmacies for their services. The objectives of this study were to (1) predict the behavioral intention of pharmacists to provide Medicare MTMS using the theory of planned behavior (TPB) and (2) determine the relationship between pharmacists’ characteristics and intention to provide Medicare MTMS. This study uses the TPB as its theoretical framework. The TPB is an extension of the theory of reasoned action developed by Fishbein in 1967. The TPB uses the constructs of attitude (individual’s positive or negative feelings about performing a behavior), subjective norm (individual’s perception of whether people important to the individual think the behavior should be performed), perceived behavioral control (individual’s perception of the difficulty of performing a behavior),2 and behavioral intention (individual’s plan to perform behavior) to determine the likelihood of the occurrence of a specific behavior.3 The TPB has been used in a wide range of contexts to predict behavior, including predicting sexual intercourse and condom use intentions among Spanish-dominant Latino youth,4 explaining hormone replacement therapy use decisions in women,5 and identifying factors that influence regular soda intake among females aged 13 to 18 years.6 Godin and Kok conducted a review of the efficiency of the TPB to explain and predict health-related behaviors. Fifty-six studies were included in the review. The TPB was found to explain intention well, with the variation in intention most often significantly explained by attitude and perceived behavioral control. The review found the TPB to be a good framework to measure intention across health-related behaviors.7 In the pharmacy area, TPB was included in a model to measure pharmacists’ implementation of pharmaceutical care. In a study based on this model, community pharmacists were found to have high behavioral intention to provide pharmaceutical care, but a low amount of pharmaceutical care was actually performed. Factors which may explain the inconsistency between intention and behavior were found to include low perceived social
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norm (akin to subjective norm defined above) by physicians, low perceived behavioral control, low self-efficacy (an indication of how confident a pharmacist is that he/she will successfully carry out pharmaceutical care), and low affect (an indication of how much the pharmacist likes carrying out pharmaceutical care processes).8 A different study found that community pharmacists expressed positive attitudes and high intentions to try to prevent and correct drug-therapy problems.9 Attitude and social norm toward trying were both significant predictors of intention to try. Other studies have found additional barriers to implementing pharmaceutical care in the community practice setting. With regard to counseling, perceived barriers were found to include lack of privacy, store layout, and patient attitudes. With regard to interacting with physicians, perceived barriers were found to include difficulty in making contact because of interactions usually occurring indirectly through messages transferred by prescribers’ employees or coworkers rather than directly between prescribers and pharmacists, negative physicians’ attitudes toward pharmacists’ drug-therapy recommendations, whether perceived or actual, that may lead to pharmacists avoiding these interactions, and inadequate patient information. Information available to community pharmacists is usually obtained directly from patients and refill histories. If a patient uses multiple pharmacies, this information may be incomplete. In addition, community pharmacists typically do not have access to laboratory data or diagnostic results.10 Pharmacists were found to have an overall positive attitude toward providing pharmaceutical care services, but some pharmacists working for chain pharmacies felt that pharmacists should receive part of the reimbursement that chain pharmacies receive for their interventions.11 These barriers identified in past studies were examined to define areas for further exploration in this study. Identifying barriers specific to providing MTMS is the first step to overcoming these obstacles and increasing care-based services provided by pharmacists. Along with the overall positive attitude of pharmacists toward providing pharmaceutical care services, a systematic review of 21 randomized control trials assessing the effect of pharmaceutical care intervention found evidence that pharmaceutical care improves patient care. This evidence included improvement in medication use and improvement of the signs and symptoms for people with asthma along with surrogate end points such as blood pressure and cholesterol and glycosylated hemoglobin levels.12 In addition, many programs that were begun to test the effects of providing pharmaceutical care services have found positive outcomes.13-16 The findings have demonstrated pharmacists’ ability to effectively educate, manage, and refer patients to physicians for further care13 as well as improve patient care and lower total mean direct medical costs.14 When looking at reimbursement for care-based services, it was found that patients are willing to pay for bone mineral density screenings and third-party payers are willing to reimburse pharmacists for collaborative community services.13 Patients have been found to be receptive to the newly
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offered community pharmacy services. A phone survey conducted with 20 randomly selected patients at an independent community pharmacy found that patients responded favorably to the idea of blood glucose monitoring (65%), vaccine administration (50%), dietary counseling (50%), cholesterol screening (70%), blood pressure monitoring (95%), and parenteral medication administration (65%) in the community pharmacy setting. Willingness to pay for services of interest was expressed by 68% of patients, but no patients were able to give specific monetary amounts for each service.17 The findings of these and other studies suggest a need to probe further into the barriers preventing the implementation of pharmaceutical care services where patients and third-party payers have shown a willingness to pay. This study seeks to identify barriers to providing the new Medicare MTMS beginning in 2006 within the constructs of pharmacists’ attitudes, perceived behavioral control, subjective norms, and intentions and to determine the relationship between pharmacists’ characteristics and intention to provide MTMS.
2. Methods 2.1. Design, population, and sample The University of Iowa’s Institutional Review Board approved this crosssectional, descriptive study. The study population consisted of all community pharmacists in Iowa. A listing of Iowa pharmacists by practice setting was not available, so an electronic database of Iowa pharmacies was obtained from the Iowa Pharmacy Association (IPA). The usable information obtained from the IPA electronic database included names of pharmacies, pharmacy managers’ names, and pharmacy addresses. The sample was generated by stratifying the database by zip code and then randomly selecting the pharmacy managers at 500 pharmacies. Data collection occurred through a self-administered anonymous mail survey. 2.2. Survey development and administration The framework for the survey was the TPB. Items were generated on the basis of the 4 main constructs of the TPB including the attitude of pharmacists (4 items), subjective norms (4 items), pharmacists’ perceived behavioral control (5 items), and behavioral intention to provide MTMS (8 items). All items in the intent scale were worded globally ie, they asked about intent to provide MTMS, rather than intent to provide specific components of MTMS. Also, no definition of MTMS was provided. This was done because the Center for Medicare and Medicaid Services rules regarding MTMS did not mandate specific components; so at the time the survey was conducted, the specific components were unknown and also likely to vary across
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Medicare PDPs. All items were scored on a 5-point Likert scale with possible answers being strongly disagree, disagree, neutral, agree, and strongly agree. The following demographic, practice setting, and experience data were collected: gender, practice setting, years of practice in pharmacy, pharmacy degree, pharmacy residency experience, board certifications held, payment received from cash-paying customers for care-based services, time spent on care-based services for which reimbursement is received, and third-party reimbursed care-based program participation in the past and present. Information on past and present participation in care-based programs was collected for 4 care-based pharmacist reimbursement programs: Outcomes Pharmaceutical Health Care, the Iowa Priority Brown Bag Medication Review, Iowa Medicaid pharmaceutical case management, and other. The survey was pilot tested on a convenience sample of Iowa pharmacists in attendance at 4 regional pharmacy association meetings in September and October 2004. A total of 40 surveys were completed in the pilot study. Alterations were made to the original pilot survey to improve Cronbach’s alpha. Five questions were discarded, and 11 new statements were added to the final survey. The final survey consisted of 7 items measuring attitude, 6 items measuring subjective norms, 9 items measuring perceived behavioral control, and 6 items measuring intent to provide. Please refer to Table 2 for the complete listing of statements by construct. One question was added to the demographic/practice setting section to measure specialized board certifications held by the pharmacists. Two surveys were mailed to each of the 500 pharmacy managers selected in June 2005. The pharmacy manager was asked to give the second survey to a staff pharmacist. A survey was given to both the pharmacy manager and staff pharmacist, when applicable, to account for perceived barriers to the implementation of MTMS across roles. The surveys were addressed to the manager of the pharmacy by name in an attempt to improve response rate. Surveys were not sent directly to staff pharmacists because of the limited information obtained from the IPA database. Each survey packet included a cover letter explaining the study and an informed consent form. The surveys were returned in the supplied postage paid, addressed envelope. There was no identifying subject information present on the survey or the return envelope. A reminder postcard was mailed out to the 500 pharmacies 1 week following the initial survey packet mailing.
2.3. Data analysis Data analysis was done using SPSS version 11.5 (SPSS Inc., Chicago, IL). Likert scale data were coded as strongly disagree ¼ 1, disagree ¼ 2, neutral ¼ 3, agree ¼ 4, and strongly agree ¼ 5. Surveys completed by pharmacy managers and staff pharmacists were treated equally in the analysis. The number of missing entries was calculated for each question, and if
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1 subject missed multiple entries, categories of statements missed were examined. If 2 or less entries were missed in any one category (attitude, intention, subjective norm, or perceived behavioral control), the subject data were included and the missing entries were replaced with the median value for each question. One survey was not used because 3 perceived behavioral control questions were missed. Three questions were reverse coded before analysis to account for negative phrasing. For example, the following statement measuring attitude, ‘‘Providing Medicare MTMS is not likely to be profitable for my pharmacy,’’ was reverse coded with strongly disagree ¼ 5, disagree ¼ 4, neutral ¼ 3, agree ¼ 2, and strongly agree ¼ 1. Table 2 shows the remaining 2 statements that were reverse coded. Summated scales were created for attitude, subjective norm, perceived behavioral control, and intention. Higher scores signified more positive attitude toward Medicare MTMS, more favorable attitudes of others toward MTMS, more control over providing MTMS, and stronger intention to provide MTMS. Two dummy variables were created for practice setting. In addition to the ‘‘independent pharmacy site’’ variable, 1 variable accounting for the ‘‘chain pharmacy’’ practice setting and 1 variable accounting for all ‘‘other practice sites’’ were created. One dummy variable was also created for the amount of time spent per day on care-based services that are reimbursed: zero hours ¼ 0, and 1 or more hours ¼ 1. A new variable titled ‘‘advanced degree’’ was created to encompass those holding a PharmD, PhD, or other higher degree beyond a Bachelor’s. Dichotomous variables were created for both past and current participation in care-based services to account for participation in any type of care-based service in either the past or the present. Descriptive statistics including frequencies, mean, median, standard deviation, range, and maximum and minimum values were calculated. Scale reliability was measured for each of the 4 scales (attitude, subjective norm, perceived behavioral control, and intention) using Cronbach’s alpha. Linear regression was used with the dependent variable intent to provide MTMS and the following independent variables: attitude, subjective norm, perceived behavioral control, gender, years of practice, degree, practice setting, past participation in care-based pharmacy programs, the amount of time spent providing care-based services that are reimbursed, and payment received from cash-paying customers for care-based services. Both past and current participation in care-based pharmacy programs were not included in the regression analysis because of their high correlation. Past participation was chosen because it captures a larger field of participation. Pharmacists who have participated in a care-based program at any time in the past have gained some experience in the provision of care-based services and therefore would be expected to have a stronger intent to participate in MTMS. Very few respondents had completed a residency or certification so these variables were not included in the analysis.
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3. Results Five survey packets were returned unopened because of changes of address. Out of 212 surveys received, 203 had usable data. The usable response rate ranged from 21% to 41%. A range was calculated because the number of pharmacies that had a second pharmacist was not known. The lower rate assumes that every pharmacy had at least 2 pharmacists, and the higher rate assumes that every pharmacy had only the manager pharmacist. Those who completed the survey generally held a Bachelor’s degree, had not completed a residency, had participated in the Iowa Priority program in the past or are currently participating, spent an average of zero hours per week providing care-based services for which they are reimbursed, and were not currently receiving payment from cash-paying customers for pharmaceutical care services (Table 1). Table 2 lists descriptive statistics for individual items including the percentage of respondents answering positively (either agree or strongly agree) versus negatively (disagree or strongly disagree) for each statement. In terms of attitudes toward MTMS, pharmacists tended to agree that pharmacist participation in providing Medicare MTMS is an important step in moving the profession of pharmacy forward and would allow them to provide better care to their patients. They were less likely to agree that providing MTMS would be profitable for their pharmacy and that it would attract more patients to their pharmacy. While slightly over half of the pharmacists surveyed agreed that involvement in Medicare MTMS will improve their job satisfaction, almost 70% agreed that participation in Medicare MTMS will increase their stress level at work. For subjective norm, pharmacists were somewhat more likely to agree that patients and store managers would approve of them providing MTMS than they were to agree that physicians would approve of them providing MTMS. However, 68.1% still agreed that physicians would approve of them providing MTMS services. Fewer respondents agreed that other pharmacists they knew intended to provide MTMS or that patients would be disappointed if they did not provide MTMS. For the construct perceived behavioral control, more pharmacists agreed that they had the necessary knowledge and skills to provide MTMS to Medicare beneficiaries than agreed that they had the necessary support staff, computer support, or time to provide MTMS. Respondents tended to agree that pharmacists would be the main professional providers of MTMS but did not agree that it would be entirely up to them whether MTMS was provided at their pharmacy. Pharmacists generally showed strong intent to provide MTMS, with 72% agreeing or positively agreeing that they intended to provide MTMS at their pharmacy and 75% agreeing or strongly agreeing that they planned to actively enroll eligible patients at their pharmacy in MTMS programs. Pharmacists showed more willingness to speak with store management about
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K.E. Herbert et al. / Research in Social and Administrative Pharmacy 2 (2006) 299–314 Table 1 Sample demographics and descriptive statistics, N ¼ 203 Characteristic
n (%)a
Gender Male Female
117 (57.6) 86 (42.4)
Pharmacy practice setting Independent Chain Mass merchandiser Grocery store Hospital Clinic Other
102 52 2 24 4 11 8
(50.2) (25.6) (1.0) (11.8) (2.0) (5.4) (3.9)
58 41 59 45
(28.6) (20.2) (29.1) (22.2)
Degree Bachelor’s PharmD Master’s PhD Other
154 46 0 1 2
(75.9) (22.7) (0.0) (0.5) (1.0)
Residency completion Yes No Unanswered
9 (4.4) 193 (95.1) 1 (0.5)
Current participation in care-based services Outcomesb Iowa priorityc Iowa Medicaid pharmaceutical case managementd Other
70 110 62 8
(34.5) (54.2) (30.5) (3.9)
Past participation in care-based services Outcomesb Iowa priorityc Iowa Medicaid pharmaceutical case managementd Other
87 120 74 7
(42.9) (59.1) (36.5) (3.4)
Currently receive payment from cash-paying patients for any care-based services Yes No Unanswered
30 (14.8) 169 (83.3) 4 (2.0)
Experience (y) 0-10 11-20 21-30 31 or more
Average time spent each day providing care-based services that are reimbursed (hrs) Zero 142 (70.0) 1-2 48 (23.6) 3-4 2 (1.0) (Continued)
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Table 1 (Continued) Characteristic More than 4 Unanswered
n (%)a 3 (1.5) 8 (3.9)
a
Percents do not all sum to 100 because of rounding. An Iowa-based company that provides reimbursement for selected pharmacist services. c A nonprofit discount card for Medicare beneficiaries that provides reimbursement for medication reviews and other selected pharmacist services. d The Iowa Medicaid program pays pharmacists to provide pharmaceutical case management services to targeted patients. b
offering MTMS than to contact insurance companies to arrange for MTMS to be provided at their pharmacy. There was considerable variability in pharmacists’ scores on each of the 4 TPB scales, showing that pharmacists have very different opinions related to MTMS and vary in the strength of their intent to provide these services to their patients (Table 3). Cronbach’s alpha was above 0.70 for all 4 scales, with the intent scale having the best reliability. This level of reliability meets the generally accepted criteria for internal consistency and supports the use of summated scales for each of the constructs.18 The linear regression analysis (Table 4) found only the constructs of attitude, subjective norm, and perceived behavioral control to be significant predictors of pharmacists’ intention to provide MTMS (P < .05). For each 1-point increase in the attitude score, there was a 0.19 increase in the intent score, and for each 1-point increase in the subjective norm score, there was a 0.41-point increase in intention. For each 1-point increase in the perceived behavioral control score, there was a 0.27-point increase in the intent to provide MTMS score. The adjusted R2 value was equal to 0.632, which means that 63.2% of the variation in intent was explained by the independent variables. None of the demographic or practice setting variables was significant at P < .05, but past participation in care-based services approached significance (P ¼ .06), with people who had participated in care-based service programs showing stronger intent to provide MTMS.
4. Discussion The TPB effectively predicted pharmacists’ intention to provide Medicare MTMS. As shown in Table 3, the attitude, subjective norm, and perceived behavioral control scores all averaged around 70% (24/35, 22/30, and 30/45, respectively). These findings demonstrate positive attitudes, favorable subjective norms, and substantial perceived behavioral control toward the provision of Medicare MTMS. The constructs of attitude, subjective norms, and perceived behavioral control were all significant, and the model
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explained 63.2% of the variation in intent to provide. Subjective norm was the most important predictor of intention to provide MTMS. This is different from many health-related TBP studies where attitude and perceived behavioral control were most important7 but is consistent with past TBP research in pharmacy.9 Interestingly, practice setting, defined as independent, chain, and ‘‘other’’ community pharmacy settings, and demographic variables such as ‘‘advanced degree,’’ which essentially compared those holding a PharmD versus those holding a Bachelor’s degree, were not significant predictors of intent to provide Medicare MTMS. Past experience with care-based service programs approached significance, and past experiences also may have influenced pharmacist opinions reflected in the attitude, subjective norm, and perceived behavioral control items. For example, pharmacists who had a good experience with the Iowa Medicaid pharmaceutical case management program may have had a more positive attitude toward Medicare MTMS, while pharmacists who had a negative experience with the Medicaid program may have had a more negative attitude toward Medicare MTMS. The survey results show that while pharmacists think that MTMS is beneficial for the profession and for patients, there still remain substantial barriers to implementation. Major perceived barriers seemed to be lack of support staff (21.4%), computer support (13.9%), and time (30.0%), while lack of skills and knowledge was less of a concern (10.4%). This implies that MTMS training should be focused on managing the pharmacy environment to provide MTMS rather than on the clinical skills necessary for MTMS. However, it is important to note that these results are from self-reported surveys and may not be an objective representation of the pharmacists’ knowledge and skills. Pharmacists were split on whether providing MTMS would be profitable, likely due to the lack of information available on MTMS reimbursement at the time the survey was conducted. In spite of the perceived barriers, pharmacists generally showed strong intention to provide MTMS. The high level of intention to speak to store management about providing MTMS (68.0%) and actively enroll eligible patients in MTMS programs (74.8%) is encouraging. However, the lower levels of agreement with statements about contacting insurance companies to arrange for MTMS to be provided (54.2%) and actively working to ensure a role for pharmacists (59.5%) show some unwillingness to be proactive in providing MTMS. This finding is of concern because Medicare PDPs’ tendency likely will be to keep MTMS in-house. MTMS are an administrative cost for the PDPs since they do not receive additional funding from the government for providing them. This gives them an incentive to minimize the cost of their MTMS programs. Therefore, obtaining the opportunity to provide MTMS may require some effort and persistence on the part of community pharmacists. Although this study provides useful information in the prediction of pharmacists’ intention to provide MTMS, there are some limitations. There
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Table 2 Survey statements and descriptive statistics by construct Survey statement
Mean (SD)a
Nb
Percent agreec,f
Attitude
Pharmacist participation in providing Medicare MTMS is an important step in moving the profession of pharmacy forward. My Medicare patients will trust me more if I provide MTMS. Providing Medicare MTMS is not likely to be profitable for my pharmacy.e Participation in Medicare MTMS will allow me to provide a higher level of care to Medicare beneficiaries. Participation in Medicare MTMS will increase my stress level at work.e Participation in Medicare MTMS will attract more patients to my pharmacy. Involvement in Medicare MTMS will improve my job satisfaction.
4.33 (0.73)
203
90.1
2.0
3.57 (0.93) 2.99 (0.91)
203 203
54.2 28.0
12.8 28.1
4.05 (0.76)
203
86.2
4.9
3.67 (0.86)
203
69.4
10.9
3.38 (0.87)
202
49.5
15.9
3.50 (1.00)
203
54.2
15.7
3.98 (0.71)
203
77.9
2.0
3.78 (0.81)
201
68.1
4.9
4.20 (0.77)
203
82.7
1.5
3.25 (0.67)
202
31.7
8.9
3.17 (0.81)
203
33.4
18.3
3.41 (0.81)
203
44.8
9.4
Subjective norm
Patients in my community would like to see me provide Medicare MTMS. Physicians in my community would approve of me providing MTMS to Medicare beneficiaries. My pharmacy/store manager(s) would support me providing MTMS to Medicare beneficiaries. Other pharmacists I know intend to provide MTMS to Medicare beneficiaries. Patients at my pharmacy will be disappointed if we do not provide Medicare MTMS. Physicians in my community would approve of pharmacists having their own provider numbers.
Percent disagreed,f
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Construct
Perceived behavioral control
I will actively work to ensure that adequate reimbursement is established for the provision of Medicare MTMS. I plan to speak with pharmacy/store management about offering Medicare MTMS. I plan to actively enroll eligible Medicare patients at my pharmacy in MTMS programs. If necessary, I will contact insurance companies to arrange for Medicare MTMS to be provided at my pharmacy. I intend to provide MTMS to Medicare beneficiaries. I will actively work to ensure a role for pharmacists in the provision of MTMS to Medicare beneficiaries.
3.23 (1.08)
202
47.0
29.3
3.45 (1.01) 2.76 (0.94)
201 203
55.2 22.7
21.4 42.9
3.21 (1.27)
203
46.3
37.4
3.64 (0.88)
203
61.1
9.9
3.08 (1.02) 3.38 (0.84)
203 203
39.9 48.7
30.0 14.8
3.43 (0.90)
202
49.0
13.9
3.72 (0.89)
203
66.5
10.4
3.78 (0.81)
203
71.9
7.4
3.83 (0.84)
200
68.0
6.5
3.94 (0.77)
202
74.8
3.0
3.39 (1.04)
201
54.2
21.9
3.86 (0.77) 3.66 (0.81)
203 200
71.9 59.5
3.9 7.0
311
MTMS, medication therapy management services. a Coded as 1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neutral, 4 ¼ agree, 5 ¼ strongly agree. b Total number of usable surveys returned ¼ 203. c Percent stating they agreed or strongly agreed. d Percent stating they disagreed or strongly disagreed. e The statement was reverse coded in the relevant summated scale to account for negative phrasing. Information in this table is based on raw data. f Percents were calculated using the number of surveys with valid responses (listed in the N column) as the denominator.
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Intent
Pharmacists will have some role in deciding the specific provisions of the Medicare MTMS program. I will have the necessary support staff to provide Medicare MTMS. For me, providing MTMS to Medicare beneficiaries would be difficult.e It is entirely up to me whether or not Medicare MTMS will be provided at my pharmacy. Pharmacists will be the main professional providers of Medicare MTMS. I will have the necessary time to provide Medicare MTMS. I will have to provide Medicare MTMS in order for my pharmacy to stay competitive. I have the necessary computer support to provide Medicare MTMS. I have the necessary knowledge and skills to provide MTMS to Medicare beneficiaries.
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was a low response rate, which may be due to lack of knowledge about the Medicare MTMS. Approximately 3.8% of surveys returned were not completed by the respondents because of lack of adequate education about MTMS. The surveys were anonymous, so it was not possible to compare respondents and nonrespondents. The results cannot be accurately generalized to non-Iowa pharmacists because of the sample studied. It also may not be possible to generalize to all Iowa community pharmacists. Although the pharmacy managers were selected randomly, participation of staff pharmacists was decided by the pharmacy manager. This may have created bias if pharmacy managers selectively chose to give the surveys to staff pharmacists who shared their opinions. It also is likely that more pharmacy managers than staff pharmacists completed a survey. This further limits the generalizability, although store managers may have more influence in deciding whether a pharmacy participates in MTMS programs and thus are more important to survey. Some information that would have been helpful in the analysis was not included in the survey. For example, the survey did not obtain information on whether respondents were managers or staff pharmacists. When measuring barriers to the provision of MTMS, information was not collected pertaining to the volume of prescriptions each pharmacy filled per day. This information would have been helpful to provide a more specific measurement of practice setting instead of using only pharmacy type (independent versus chain versus ‘‘other’’). There also was poor variability in the time spent per day providing care-based services that are reimbursed. It may have been better to measure time spent per week rather than per day. A final limitation is that validity was not assessed, other than a content or ‘‘face’’ validity check during the survey development process. Future research opportunities include readministering the same survey after the Medicare drug benefit takes effect on January 1, 2006. Pharmacists’ attitudes and intent to provide Medicare MTMS may change significantly once they learn more about what opportunities to provide MTMS will be available in their region. It also will be important to use the TPB to examine pharmacists’ actual provision of MTMS.
5. Conclusions Pharmacists generally showed positive attitude, favorable subjective norms, substantial perceived behavioral control, and positive intent to provide MTMS, but these feelings varied in strength as shown by the ranges for these constructs in Table 3. The TPB was shown to be a good model to measure and predict pharmacists’ behavioral intention to provide MTMS. The linear regression analysis showed perceived attitude, subjective norm, and behavioral control to be significant predictors of intent (P < .05), while demographic and practice setting characteristics were not significant. This
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Table 3 Theory of planned behavior scale constructs used to measure pharmacists’ characteristics and intent to provide Medicare MTMS Scale
Items
Mean (SD)a,b
Min
Max
Cronbach’s alpha
Attitude Subjective norm Perceived behavioral control Intent
7 6 9 6
24.16 21.79 30.38 22.47
9 14 18 7
35 29 45 30
0.812 0.770 0.721 0.881
(4.18) (3.13) (4.94) (4.00)
MTMS, medication therapy management services. a N ¼ 203. b Individual items were measured on a Likert scale (1 ¼ strongly disagree through 5 ¼ strongly agree). Higher scores signify more positive attitudes, more favorable subjective norms, more perceived behavioral control, and stronger intent to provide Medicare MTMS.
survey provides some insight into pharmacists’ potential participation in MTMS as well as challenges, including time and staffing constraints, pharmacist perception of increased stress with the provision of MTMS, and some lack of willingness to actively pursue MTMS opportunities. Strategies to help pharmacists provide MTMS should focus on organizational factors to find time and support to provide MTMS rather than individual educational or training needs.
Table 4 Multivariate linear regression analysis predicting intent to provide Medicare medication therapy management services Variable
b
Standard error
t statistic
P value
Constant Attitude Subjective norm Perceived behavioral control Gendera Years of practiceb Advanced degreec Chain settingd ‘‘Other’’ settingd Past participation in care-based services 1 h spent each day providing reimbursed care-based services Payment received from cash-paying customers for care-based services
0.186 0.191 0.408 0.268 0.683 0.086 0.098 0.202 0.503 0.734 0.284
1.493 0.062 0.081 0.058 0.432 0.217 0.514 0.436 0.438 0.390 0.485
0.125 3.098 5.022 4.606 1.582 0.394 0.191 0.463 1.149 1.883 0.586
.901 .002 .000 .000 .115 .694 .848 .644 .252 .061 .558
0.224
0.597
0.375
.708
N ¼ 203. Adjusted R2 ¼ 0.632. a Gender coded, 1 ¼ male, 0 ¼ female. b Years of practice coded, 1 ¼ 0-10 y, 2 ¼ 11-20 y, 3 ¼ 21-30 y, 4 ¼ 31 or more years. c Summated variable, where 1 ¼ respondents holding a PharmD, PhD, or other beyond Master’s degree, ¼ 0 otherwise. d Dummy variables created for practice setting. Reference variable is independent pharmacy.
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References 1. American Pharmacists Association Understanding Medicare Reform: What Pharmacists Need to KnowdMonograph 2: Medication Therapy Management Services and Chronic Care Improvement Programs. American Pharmacists Association.. [Select ‘‘Education,’’ ‘‘Get CE Now,’’ then ‘‘Medicare’’]. Accessed 20.05.05. 2. Furneaux B. Theories Used in IS Research: The Theory of Planned Behavior. York University and Appalachian State University. . Accessed 6.02.05. 3. Montan˜o DE, Kasprzyk D. The theory of reasoned action and the theory of planned behavior. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education. 3rd ed. San Francisco, CA: Jossey-Bass; 2002, p. 67–98. 4. Villarruel AM, Jemmott 3rd JB, Jemmott LS, Ronis DL. Predictors of sexual intercourse and condom use intentions among Spanish-dominant Latino youth: a test of the planned behavior theory. Nurs Res. 2004;53(3):172–181. 5. Spatz BA, Thombs DL, Byrne TJ, Page BJ. Use of the theory of planned behavior to explain HRT decisions. Am J Health Behav. 2003;27(4):445–455. 6. Kassem NO, Lee JW, Modeste NN, Johnston PK. Understanding soft drink consumption among female adolescents using the theory of planned behavior. Health Educ Res. 2003;18(3):278–291. 7. Godin G, Kok G. The theory of planned behavior: a review of its applications to healthrelated behaviors. Am J Health Promotion. 1996;11(2):87–98. 8. Odedina FT, Segal R, Hepler CD, Lipowski E, Kimberlin C. Changing pharmacists’ practice pattern: pharmacists’ implementation of pharmaceutical care factors. J Soc Administrative Pharm. 1996;13(2):74–88. 9. Farris KB, Kirking DM. Predicting community pharmacists’ intention to try to prevent and correct drug therapy problems. J Soc Administrative Pharm. 1995;12(2):64–78. 10. Raisch DW. Barriers to providing cognitive services. Am Pharm. 1993;NS33(Dec):54–58. 11. Rochester CD, Currey CE. Chain-community pharmacists’ view of practice in a reimbursement-based pharmaceutical care environment (Abstract of meeting presentation Journal article). ASHP Midyear Clinical Meeting. 1999;34(Dec). P-236E. 12. Roughead EE, Semple SJ, Vitry AI. Pharmaceutical care services: a systematic review of published studies, 1990 to 2003, examining effectiveness in improving patient outcomes. Int J Pharm Pract. 2005;13(1):53–70. 13. Goode JV, Swiger K, Bluml BM. Regional osteoporosis screening, referral, and monitoring program in community pharmacies: findings from project ImPACT: Osteoporosis. J Am Pharm Assoc. 2004;44(2):152–160. 14. Cranor CW, Bunting BA, Christensen DB. The Asheville project: long-term clinical and economic outcomes of community-pharmacy diabetes care program. J Am Pharm Assoc. 2003;43(2):173–184. 15. Knowlton CH, Voltis TO, Williamson A, et al. Establishing community pharmacy-based anticoagulation education and monitoring programs. J Am Pharm Assoc. 1999;39(MayJun):368–374. 16. Shibley MC, Pugh CB. Implementation of pharmaceutical care services for patients with hyperlipidemias by independent community pharmacy practitioners. Ann Pharmacother. 1997;31(Jun):713–719. 17. Whitley CW, Jones HA, Peal GW. Patients’ acceptance of fee-for-service pharmaceutical care in a community pharmacy (Abstract of meeting presentation. Journal article). J Am Pharm Assoc. 1996;143(Mar):40. 18. Nunnally JC, Bernstein IH. Psychometric Theory. New York: McGraw-Hill; 1994.
Original research
Prediction of pharmacist intention to provide Medicare medication therapy management services using the theory of planned behavior Kathleen E. Herbert, Pharm.D.a, Julie M. Urmie, Ph.D.a,*, Brand A. Newland, Pharm.D.b,1, Karen B. Farris, Ph.D.a a
University of Iowa College of Pharmacy, Iowa City, IA 52242-1112, USA b Outcomes Pharmaceutical Healthcare, Des Moines, IA, USA
Abstract Background: Medicare Part D is a voluntary prescription drug benefit for Medicare beneficiaries. As part of the coverage, medication therapy management services (MTMS) are mandated for beneficiaries with chronic diseases who take multiple medications covered under part D and who are likely to incur annual costs that exceed a specified level. Objective: To predict the behavioral intention of pharmacists to provide Medicare medication therapy management services (MTMS) using the theory of planned behavior (TPB) and to determine the relationship between pharmacists’ characteristics and intention to provide MTMS. Methods: The population for this cross-sectional descriptive study consisted of all community pharmacists in Iowa. Data collection occurred through a self-administered
* Corresponding author. S519 Pharmacy Building, 115 S Grand Avenue, Iowa City, IA 52242-1112, USA. Tel.: þ1 319 335 8616; fax: þ1 319 353 5646. E-mail address: [email protected] (J.M. Urmie). 1 Dr Newland was a PharmD student at the University of Iowa when he participated in the research. 1551-7411/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.sapharm.2006.02.008
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anonymous mail survey. Two surveys each were mailed to 500 pharmacies selected through a stratified random sample, 1 survey for the pharmacy manager and 1 survey for a staff pharmacist if applicable. Descriptive statistics and scale reliability were calculated for each of the 4 TPB scales (attitude, subjective norm, perceived behavioral control, and intention). Linear regression was used to predict intent as a function of the other 3 TPB factors, demographic factors, experience, and type of pharmacy. Results: Out of 212 surveys received, 203 had usable data. The usable response rate ranged from 21% to 41%. Pharmacists’ intent to provide MTMS was generally positive but varied in strength with a mean score of 22.47 (4.00) and a range of 7-30. Pharmacists mostly agreed that they had appropriate training to provide MTMS but lacked time and support. The linear regression analysis found the constructs of attitude, subjective norm, and perceived behavioral control to be significant predictors of intent (P < .05). Pharmacists with stronger intent to provide MTMS were those who felt they had more control over providing MTMS, felt their peers approved of the provision of MTMS, and had a positive attitude about providing MTMS. Type of pharmacy and pharmacist demographic variables were not significant predictors of intent to provide MTMS. Conclusion: Pharmacists showed generally positive intent to provide MTMS. Perceived behavioral control, subjective norm, and attitude were significant predictors of intent (P < .05). Strategies to help pharmacists provide MTMS should focus on finding time and support to provide MTMS rather than individual educational needs. Ó 2006 Elsevier Inc. All rights reserved. Keywords: Medicare Part D; Medication therapy management services (MTMS); The theory of planned behavior (TPB)
1. Introduction The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 will potentially have a significant impact on the profession of pharmacy. The MMA of 2003 was signed into law on December 8, 2003, creating Medicare Part D. Under Medicare Part D, enrolled beneficiaries will receive coverage for outpatient prescription medications. In addition, the law requires that medication therapy management services (MTMS) be provided for beneficiaries with chronic diseases who take multiple medications covered under part D and who are likely to incur annual costs that exceed a specified level. Although the law does not mandate specific MTMS to be covered, MTMS may include using patient education to decrease misuse of medications, increasing detection of both adverse drug reactions and the overuse or underuse of medication therapy, and also working to improve the adherence of beneficiaries to their medication therapy.1
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The inclusion of the provision of MTMS in the Medicare law was a positive move forward for the profession of pharmacy. Pharmacy organizations had been lobbying Congress to include such a provision in the MMA of 2003. The law does not require pharmacists to be the only providers of MTMS, but pharmacists are the only health care professionals specifically mentioned in the law.1 The final Medicare drug benefit rules allow the Medicare prescription drug plans (PDPs) considerable freedom in determining the providers and types of services for MTMS, but there should be some opportunities for pharmacists to participate and these opportunities may increase over time if pharmacists are proactive about working with insurers. This eventually could further the transition from pharmacists as dispensers of medication to recognized providers of health care. For this change to take place, pharmacists need to overcome barriers to providing care-based services. Previous studies have looked at barriers to the provision of pharmaceutical services, but never before has there been a national plan on the horizon, which may consistently reimburse pharmacies for their services. The objectives of this study were to (1) predict the behavioral intention of pharmacists to provide Medicare MTMS using the theory of planned behavior (TPB) and (2) determine the relationship between pharmacists’ characteristics and intention to provide Medicare MTMS. This study uses the TPB as its theoretical framework. The TPB is an extension of the theory of reasoned action developed by Fishbein in 1967. The TPB uses the constructs of attitude (individual’s positive or negative feelings about performing a behavior), subjective norm (individual’s perception of whether people important to the individual think the behavior should be performed), perceived behavioral control (individual’s perception of the difficulty of performing a behavior),2 and behavioral intention (individual’s plan to perform behavior) to determine the likelihood of the occurrence of a specific behavior.3 The TPB has been used in a wide range of contexts to predict behavior, including predicting sexual intercourse and condom use intentions among Spanish-dominant Latino youth,4 explaining hormone replacement therapy use decisions in women,5 and identifying factors that influence regular soda intake among females aged 13 to 18 years.6 Godin and Kok conducted a review of the efficiency of the TPB to explain and predict health-related behaviors. Fifty-six studies were included in the review. The TPB was found to explain intention well, with the variation in intention most often significantly explained by attitude and perceived behavioral control. The review found the TPB to be a good framework to measure intention across health-related behaviors.7 In the pharmacy area, TPB was included in a model to measure pharmacists’ implementation of pharmaceutical care. In a study based on this model, community pharmacists were found to have high behavioral intention to provide pharmaceutical care, but a low amount of pharmaceutical care was actually performed. Factors which may explain the inconsistency between intention and behavior were found to include low perceived social
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norm (akin to subjective norm defined above) by physicians, low perceived behavioral control, low self-efficacy (an indication of how confident a pharmacist is that he/she will successfully carry out pharmaceutical care), and low affect (an indication of how much the pharmacist likes carrying out pharmaceutical care processes).8 A different study found that community pharmacists expressed positive attitudes and high intentions to try to prevent and correct drug-therapy problems.9 Attitude and social norm toward trying were both significant predictors of intention to try. Other studies have found additional barriers to implementing pharmaceutical care in the community practice setting. With regard to counseling, perceived barriers were found to include lack of privacy, store layout, and patient attitudes. With regard to interacting with physicians, perceived barriers were found to include difficulty in making contact because of interactions usually occurring indirectly through messages transferred by prescribers’ employees or coworkers rather than directly between prescribers and pharmacists, negative physicians’ attitudes toward pharmacists’ drug-therapy recommendations, whether perceived or actual, that may lead to pharmacists avoiding these interactions, and inadequate patient information. Information available to community pharmacists is usually obtained directly from patients and refill histories. If a patient uses multiple pharmacies, this information may be incomplete. In addition, community pharmacists typically do not have access to laboratory data or diagnostic results.10 Pharmacists were found to have an overall positive attitude toward providing pharmaceutical care services, but some pharmacists working for chain pharmacies felt that pharmacists should receive part of the reimbursement that chain pharmacies receive for their interventions.11 These barriers identified in past studies were examined to define areas for further exploration in this study. Identifying barriers specific to providing MTMS is the first step to overcoming these obstacles and increasing care-based services provided by pharmacists. Along with the overall positive attitude of pharmacists toward providing pharmaceutical care services, a systematic review of 21 randomized control trials assessing the effect of pharmaceutical care intervention found evidence that pharmaceutical care improves patient care. This evidence included improvement in medication use and improvement of the signs and symptoms for people with asthma along with surrogate end points such as blood pressure and cholesterol and glycosylated hemoglobin levels.12 In addition, many programs that were begun to test the effects of providing pharmaceutical care services have found positive outcomes.13-16 The findings have demonstrated pharmacists’ ability to effectively educate, manage, and refer patients to physicians for further care13 as well as improve patient care and lower total mean direct medical costs.14 When looking at reimbursement for care-based services, it was found that patients are willing to pay for bone mineral density screenings and third-party payers are willing to reimburse pharmacists for collaborative community services.13 Patients have been found to be receptive to the newly
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offered community pharmacy services. A phone survey conducted with 20 randomly selected patients at an independent community pharmacy found that patients responded favorably to the idea of blood glucose monitoring (65%), vaccine administration (50%), dietary counseling (50%), cholesterol screening (70%), blood pressure monitoring (95%), and parenteral medication administration (65%) in the community pharmacy setting. Willingness to pay for services of interest was expressed by 68% of patients, but no patients were able to give specific monetary amounts for each service.17 The findings of these and other studies suggest a need to probe further into the barriers preventing the implementation of pharmaceutical care services where patients and third-party payers have shown a willingness to pay. This study seeks to identify barriers to providing the new Medicare MTMS beginning in 2006 within the constructs of pharmacists’ attitudes, perceived behavioral control, subjective norms, and intentions and to determine the relationship between pharmacists’ characteristics and intention to provide MTMS.
2. Methods 2.1. Design, population, and sample The University of Iowa’s Institutional Review Board approved this crosssectional, descriptive study. The study population consisted of all community pharmacists in Iowa. A listing of Iowa pharmacists by practice setting was not available, so an electronic database of Iowa pharmacies was obtained from the Iowa Pharmacy Association (IPA). The usable information obtained from the IPA electronic database included names of pharmacies, pharmacy managers’ names, and pharmacy addresses. The sample was generated by stratifying the database by zip code and then randomly selecting the pharmacy managers at 500 pharmacies. Data collection occurred through a self-administered anonymous mail survey. 2.2. Survey development and administration The framework for the survey was the TPB. Items were generated on the basis of the 4 main constructs of the TPB including the attitude of pharmacists (4 items), subjective norms (4 items), pharmacists’ perceived behavioral control (5 items), and behavioral intention to provide MTMS (8 items). All items in the intent scale were worded globally ie, they asked about intent to provide MTMS, rather than intent to provide specific components of MTMS. Also, no definition of MTMS was provided. This was done because the Center for Medicare and Medicaid Services rules regarding MTMS did not mandate specific components; so at the time the survey was conducted, the specific components were unknown and also likely to vary across
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Medicare PDPs. All items were scored on a 5-point Likert scale with possible answers being strongly disagree, disagree, neutral, agree, and strongly agree. The following demographic, practice setting, and experience data were collected: gender, practice setting, years of practice in pharmacy, pharmacy degree, pharmacy residency experience, board certifications held, payment received from cash-paying customers for care-based services, time spent on care-based services for which reimbursement is received, and third-party reimbursed care-based program participation in the past and present. Information on past and present participation in care-based programs was collected for 4 care-based pharmacist reimbursement programs: Outcomes Pharmaceutical Health Care, the Iowa Priority Brown Bag Medication Review, Iowa Medicaid pharmaceutical case management, and other. The survey was pilot tested on a convenience sample of Iowa pharmacists in attendance at 4 regional pharmacy association meetings in September and October 2004. A total of 40 surveys were completed in the pilot study. Alterations were made to the original pilot survey to improve Cronbach’s alpha. Five questions were discarded, and 11 new statements were added to the final survey. The final survey consisted of 7 items measuring attitude, 6 items measuring subjective norms, 9 items measuring perceived behavioral control, and 6 items measuring intent to provide. Please refer to Table 2 for the complete listing of statements by construct. One question was added to the demographic/practice setting section to measure specialized board certifications held by the pharmacists. Two surveys were mailed to each of the 500 pharmacy managers selected in June 2005. The pharmacy manager was asked to give the second survey to a staff pharmacist. A survey was given to both the pharmacy manager and staff pharmacist, when applicable, to account for perceived barriers to the implementation of MTMS across roles. The surveys were addressed to the manager of the pharmacy by name in an attempt to improve response rate. Surveys were not sent directly to staff pharmacists because of the limited information obtained from the IPA database. Each survey packet included a cover letter explaining the study and an informed consent form. The surveys were returned in the supplied postage paid, addressed envelope. There was no identifying subject information present on the survey or the return envelope. A reminder postcard was mailed out to the 500 pharmacies 1 week following the initial survey packet mailing.
2.3. Data analysis Data analysis was done using SPSS version 11.5 (SPSS Inc., Chicago, IL). Likert scale data were coded as strongly disagree ¼ 1, disagree ¼ 2, neutral ¼ 3, agree ¼ 4, and strongly agree ¼ 5. Surveys completed by pharmacy managers and staff pharmacists were treated equally in the analysis. The number of missing entries was calculated for each question, and if
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1 subject missed multiple entries, categories of statements missed were examined. If 2 or less entries were missed in any one category (attitude, intention, subjective norm, or perceived behavioral control), the subject data were included and the missing entries were replaced with the median value for each question. One survey was not used because 3 perceived behavioral control questions were missed. Three questions were reverse coded before analysis to account for negative phrasing. For example, the following statement measuring attitude, ‘‘Providing Medicare MTMS is not likely to be profitable for my pharmacy,’’ was reverse coded with strongly disagree ¼ 5, disagree ¼ 4, neutral ¼ 3, agree ¼ 2, and strongly agree ¼ 1. Table 2 shows the remaining 2 statements that were reverse coded. Summated scales were created for attitude, subjective norm, perceived behavioral control, and intention. Higher scores signified more positive attitude toward Medicare MTMS, more favorable attitudes of others toward MTMS, more control over providing MTMS, and stronger intention to provide MTMS. Two dummy variables were created for practice setting. In addition to the ‘‘independent pharmacy site’’ variable, 1 variable accounting for the ‘‘chain pharmacy’’ practice setting and 1 variable accounting for all ‘‘other practice sites’’ were created. One dummy variable was also created for the amount of time spent per day on care-based services that are reimbursed: zero hours ¼ 0, and 1 or more hours ¼ 1. A new variable titled ‘‘advanced degree’’ was created to encompass those holding a PharmD, PhD, or other higher degree beyond a Bachelor’s. Dichotomous variables were created for both past and current participation in care-based services to account for participation in any type of care-based service in either the past or the present. Descriptive statistics including frequencies, mean, median, standard deviation, range, and maximum and minimum values were calculated. Scale reliability was measured for each of the 4 scales (attitude, subjective norm, perceived behavioral control, and intention) using Cronbach’s alpha. Linear regression was used with the dependent variable intent to provide MTMS and the following independent variables: attitude, subjective norm, perceived behavioral control, gender, years of practice, degree, practice setting, past participation in care-based pharmacy programs, the amount of time spent providing care-based services that are reimbursed, and payment received from cash-paying customers for care-based services. Both past and current participation in care-based pharmacy programs were not included in the regression analysis because of their high correlation. Past participation was chosen because it captures a larger field of participation. Pharmacists who have participated in a care-based program at any time in the past have gained some experience in the provision of care-based services and therefore would be expected to have a stronger intent to participate in MTMS. Very few respondents had completed a residency or certification so these variables were not included in the analysis.
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3. Results Five survey packets were returned unopened because of changes of address. Out of 212 surveys received, 203 had usable data. The usable response rate ranged from 21% to 41%. A range was calculated because the number of pharmacies that had a second pharmacist was not known. The lower rate assumes that every pharmacy had at least 2 pharmacists, and the higher rate assumes that every pharmacy had only the manager pharmacist. Those who completed the survey generally held a Bachelor’s degree, had not completed a residency, had participated in the Iowa Priority program in the past or are currently participating, spent an average of zero hours per week providing care-based services for which they are reimbursed, and were not currently receiving payment from cash-paying customers for pharmaceutical care services (Table 1). Table 2 lists descriptive statistics for individual items including the percentage of respondents answering positively (either agree or strongly agree) versus negatively (disagree or strongly disagree) for each statement. In terms of attitudes toward MTMS, pharmacists tended to agree that pharmacist participation in providing Medicare MTMS is an important step in moving the profession of pharmacy forward and would allow them to provide better care to their patients. They were less likely to agree that providing MTMS would be profitable for their pharmacy and that it would attract more patients to their pharmacy. While slightly over half of the pharmacists surveyed agreed that involvement in Medicare MTMS will improve their job satisfaction, almost 70% agreed that participation in Medicare MTMS will increase their stress level at work. For subjective norm, pharmacists were somewhat more likely to agree that patients and store managers would approve of them providing MTMS than they were to agree that physicians would approve of them providing MTMS. However, 68.1% still agreed that physicians would approve of them providing MTMS services. Fewer respondents agreed that other pharmacists they knew intended to provide MTMS or that patients would be disappointed if they did not provide MTMS. For the construct perceived behavioral control, more pharmacists agreed that they had the necessary knowledge and skills to provide MTMS to Medicare beneficiaries than agreed that they had the necessary support staff, computer support, or time to provide MTMS. Respondents tended to agree that pharmacists would be the main professional providers of MTMS but did not agree that it would be entirely up to them whether MTMS was provided at their pharmacy. Pharmacists generally showed strong intent to provide MTMS, with 72% agreeing or positively agreeing that they intended to provide MTMS at their pharmacy and 75% agreeing or strongly agreeing that they planned to actively enroll eligible patients at their pharmacy in MTMS programs. Pharmacists showed more willingness to speak with store management about
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K.E. Herbert et al. / Research in Social and Administrative Pharmacy 2 (2006) 299–314 Table 1 Sample demographics and descriptive statistics, N ¼ 203 Characteristic
n (%)a
Gender Male Female
117 (57.6) 86 (42.4)
Pharmacy practice setting Independent Chain Mass merchandiser Grocery store Hospital Clinic Other
102 52 2 24 4 11 8
(50.2) (25.6) (1.0) (11.8) (2.0) (5.4) (3.9)
58 41 59 45
(28.6) (20.2) (29.1) (22.2)
Degree Bachelor’s PharmD Master’s PhD Other
154 46 0 1 2
(75.9) (22.7) (0.0) (0.5) (1.0)
Residency completion Yes No Unanswered
9 (4.4) 193 (95.1) 1 (0.5)
Current participation in care-based services Outcomesb Iowa priorityc Iowa Medicaid pharmaceutical case managementd Other
70 110 62 8
(34.5) (54.2) (30.5) (3.9)
Past participation in care-based services Outcomesb Iowa priorityc Iowa Medicaid pharmaceutical case managementd Other
87 120 74 7
(42.9) (59.1) (36.5) (3.4)
Currently receive payment from cash-paying patients for any care-based services Yes No Unanswered
30 (14.8) 169 (83.3) 4 (2.0)
Experience (y) 0-10 11-20 21-30 31 or more
Average time spent each day providing care-based services that are reimbursed (hrs) Zero 142 (70.0) 1-2 48 (23.6) 3-4 2 (1.0) (Continued)
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Table 1 (Continued) Characteristic More than 4 Unanswered
n (%)a 3 (1.5) 8 (3.9)
a
Percents do not all sum to 100 because of rounding. An Iowa-based company that provides reimbursement for selected pharmacist services. c A nonprofit discount card for Medicare beneficiaries that provides reimbursement for medication reviews and other selected pharmacist services. d The Iowa Medicaid program pays pharmacists to provide pharmaceutical case management services to targeted patients. b
offering MTMS than to contact insurance companies to arrange for MTMS to be provided at their pharmacy. There was considerable variability in pharmacists’ scores on each of the 4 TPB scales, showing that pharmacists have very different opinions related to MTMS and vary in the strength of their intent to provide these services to their patients (Table 3). Cronbach’s alpha was above 0.70 for all 4 scales, with the intent scale having the best reliability. This level of reliability meets the generally accepted criteria for internal consistency and supports the use of summated scales for each of the constructs.18 The linear regression analysis (Table 4) found only the constructs of attitude, subjective norm, and perceived behavioral control to be significant predictors of pharmacists’ intention to provide MTMS (P < .05). For each 1-point increase in the attitude score, there was a 0.19 increase in the intent score, and for each 1-point increase in the subjective norm score, there was a 0.41-point increase in intention. For each 1-point increase in the perceived behavioral control score, there was a 0.27-point increase in the intent to provide MTMS score. The adjusted R2 value was equal to 0.632, which means that 63.2% of the variation in intent was explained by the independent variables. None of the demographic or practice setting variables was significant at P < .05, but past participation in care-based services approached significance (P ¼ .06), with people who had participated in care-based service programs showing stronger intent to provide MTMS.
4. Discussion The TPB effectively predicted pharmacists’ intention to provide Medicare MTMS. As shown in Table 3, the attitude, subjective norm, and perceived behavioral control scores all averaged around 70% (24/35, 22/30, and 30/45, respectively). These findings demonstrate positive attitudes, favorable subjective norms, and substantial perceived behavioral control toward the provision of Medicare MTMS. The constructs of attitude, subjective norms, and perceived behavioral control were all significant, and the model
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explained 63.2% of the variation in intent to provide. Subjective norm was the most important predictor of intention to provide MTMS. This is different from many health-related TBP studies where attitude and perceived behavioral control were most important7 but is consistent with past TBP research in pharmacy.9 Interestingly, practice setting, defined as independent, chain, and ‘‘other’’ community pharmacy settings, and demographic variables such as ‘‘advanced degree,’’ which essentially compared those holding a PharmD versus those holding a Bachelor’s degree, were not significant predictors of intent to provide Medicare MTMS. Past experience with care-based service programs approached significance, and past experiences also may have influenced pharmacist opinions reflected in the attitude, subjective norm, and perceived behavioral control items. For example, pharmacists who had a good experience with the Iowa Medicaid pharmaceutical case management program may have had a more positive attitude toward Medicare MTMS, while pharmacists who had a negative experience with the Medicaid program may have had a more negative attitude toward Medicare MTMS. The survey results show that while pharmacists think that MTMS is beneficial for the profession and for patients, there still remain substantial barriers to implementation. Major perceived barriers seemed to be lack of support staff (21.4%), computer support (13.9%), and time (30.0%), while lack of skills and knowledge was less of a concern (10.4%). This implies that MTMS training should be focused on managing the pharmacy environment to provide MTMS rather than on the clinical skills necessary for MTMS. However, it is important to note that these results are from self-reported surveys and may not be an objective representation of the pharmacists’ knowledge and skills. Pharmacists were split on whether providing MTMS would be profitable, likely due to the lack of information available on MTMS reimbursement at the time the survey was conducted. In spite of the perceived barriers, pharmacists generally showed strong intention to provide MTMS. The high level of intention to speak to store management about providing MTMS (68.0%) and actively enroll eligible patients in MTMS programs (74.8%) is encouraging. However, the lower levels of agreement with statements about contacting insurance companies to arrange for MTMS to be provided (54.2%) and actively working to ensure a role for pharmacists (59.5%) show some unwillingness to be proactive in providing MTMS. This finding is of concern because Medicare PDPs’ tendency likely will be to keep MTMS in-house. MTMS are an administrative cost for the PDPs since they do not receive additional funding from the government for providing them. This gives them an incentive to minimize the cost of their MTMS programs. Therefore, obtaining the opportunity to provide MTMS may require some effort and persistence on the part of community pharmacists. Although this study provides useful information in the prediction of pharmacists’ intention to provide MTMS, there are some limitations. There
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Table 2 Survey statements and descriptive statistics by construct Survey statement
Mean (SD)a
Nb
Percent agreec,f
Attitude
Pharmacist participation in providing Medicare MTMS is an important step in moving the profession of pharmacy forward. My Medicare patients will trust me more if I provide MTMS. Providing Medicare MTMS is not likely to be profitable for my pharmacy.e Participation in Medicare MTMS will allow me to provide a higher level of care to Medicare beneficiaries. Participation in Medicare MTMS will increase my stress level at work.e Participation in Medicare MTMS will attract more patients to my pharmacy. Involvement in Medicare MTMS will improve my job satisfaction.
4.33 (0.73)
203
90.1
2.0
3.57 (0.93) 2.99 (0.91)
203 203
54.2 28.0
12.8 28.1
4.05 (0.76)
203
86.2
4.9
3.67 (0.86)
203
69.4
10.9
3.38 (0.87)
202
49.5
15.9
3.50 (1.00)
203
54.2
15.7
3.98 (0.71)
203
77.9
2.0
3.78 (0.81)
201
68.1
4.9
4.20 (0.77)
203
82.7
1.5
3.25 (0.67)
202
31.7
8.9
3.17 (0.81)
203
33.4
18.3
3.41 (0.81)
203
44.8
9.4
Subjective norm
Patients in my community would like to see me provide Medicare MTMS. Physicians in my community would approve of me providing MTMS to Medicare beneficiaries. My pharmacy/store manager(s) would support me providing MTMS to Medicare beneficiaries. Other pharmacists I know intend to provide MTMS to Medicare beneficiaries. Patients at my pharmacy will be disappointed if we do not provide Medicare MTMS. Physicians in my community would approve of pharmacists having their own provider numbers.
Percent disagreed,f
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Construct
Perceived behavioral control
I will actively work to ensure that adequate reimbursement is established for the provision of Medicare MTMS. I plan to speak with pharmacy/store management about offering Medicare MTMS. I plan to actively enroll eligible Medicare patients at my pharmacy in MTMS programs. If necessary, I will contact insurance companies to arrange for Medicare MTMS to be provided at my pharmacy. I intend to provide MTMS to Medicare beneficiaries. I will actively work to ensure a role for pharmacists in the provision of MTMS to Medicare beneficiaries.
3.23 (1.08)
202
47.0
29.3
3.45 (1.01) 2.76 (0.94)
201 203
55.2 22.7
21.4 42.9
3.21 (1.27)
203
46.3
37.4
3.64 (0.88)
203
61.1
9.9
3.08 (1.02) 3.38 (0.84)
203 203
39.9 48.7
30.0 14.8
3.43 (0.90)
202
49.0
13.9
3.72 (0.89)
203
66.5
10.4
3.78 (0.81)
203
71.9
7.4
3.83 (0.84)
200
68.0
6.5
3.94 (0.77)
202
74.8
3.0
3.39 (1.04)
201
54.2
21.9
3.86 (0.77) 3.66 (0.81)
203 200
71.9 59.5
3.9 7.0
311
MTMS, medication therapy management services. a Coded as 1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neutral, 4 ¼ agree, 5 ¼ strongly agree. b Total number of usable surveys returned ¼ 203. c Percent stating they agreed or strongly agreed. d Percent stating they disagreed or strongly disagreed. e The statement was reverse coded in the relevant summated scale to account for negative phrasing. Information in this table is based on raw data. f Percents were calculated using the number of surveys with valid responses (listed in the N column) as the denominator.
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Intent
Pharmacists will have some role in deciding the specific provisions of the Medicare MTMS program. I will have the necessary support staff to provide Medicare MTMS. For me, providing MTMS to Medicare beneficiaries would be difficult.e It is entirely up to me whether or not Medicare MTMS will be provided at my pharmacy. Pharmacists will be the main professional providers of Medicare MTMS. I will have the necessary time to provide Medicare MTMS. I will have to provide Medicare MTMS in order for my pharmacy to stay competitive. I have the necessary computer support to provide Medicare MTMS. I have the necessary knowledge and skills to provide MTMS to Medicare beneficiaries.
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was a low response rate, which may be due to lack of knowledge about the Medicare MTMS. Approximately 3.8% of surveys returned were not completed by the respondents because of lack of adequate education about MTMS. The surveys were anonymous, so it was not possible to compare respondents and nonrespondents. The results cannot be accurately generalized to non-Iowa pharmacists because of the sample studied. It also may not be possible to generalize to all Iowa community pharmacists. Although the pharmacy managers were selected randomly, participation of staff pharmacists was decided by the pharmacy manager. This may have created bias if pharmacy managers selectively chose to give the surveys to staff pharmacists who shared their opinions. It also is likely that more pharmacy managers than staff pharmacists completed a survey. This further limits the generalizability, although store managers may have more influence in deciding whether a pharmacy participates in MTMS programs and thus are more important to survey. Some information that would have been helpful in the analysis was not included in the survey. For example, the survey did not obtain information on whether respondents were managers or staff pharmacists. When measuring barriers to the provision of MTMS, information was not collected pertaining to the volume of prescriptions each pharmacy filled per day. This information would have been helpful to provide a more specific measurement of practice setting instead of using only pharmacy type (independent versus chain versus ‘‘other’’). There also was poor variability in the time spent per day providing care-based services that are reimbursed. It may have been better to measure time spent per week rather than per day. A final limitation is that validity was not assessed, other than a content or ‘‘face’’ validity check during the survey development process. Future research opportunities include readministering the same survey after the Medicare drug benefit takes effect on January 1, 2006. Pharmacists’ attitudes and intent to provide Medicare MTMS may change significantly once they learn more about what opportunities to provide MTMS will be available in their region. It also will be important to use the TPB to examine pharmacists’ actual provision of MTMS.
5. Conclusions Pharmacists generally showed positive attitude, favorable subjective norms, substantial perceived behavioral control, and positive intent to provide MTMS, but these feelings varied in strength as shown by the ranges for these constructs in Table 3. The TPB was shown to be a good model to measure and predict pharmacists’ behavioral intention to provide MTMS. The linear regression analysis showed perceived attitude, subjective norm, and behavioral control to be significant predictors of intent (P < .05), while demographic and practice setting characteristics were not significant. This
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Table 3 Theory of planned behavior scale constructs used to measure pharmacists’ characteristics and intent to provide Medicare MTMS Scale
Items
Mean (SD)a,b
Min
Max
Cronbach’s alpha
Attitude Subjective norm Perceived behavioral control Intent
7 6 9 6
24.16 21.79 30.38 22.47
9 14 18 7
35 29 45 30
0.812 0.770 0.721 0.881
(4.18) (3.13) (4.94) (4.00)
MTMS, medication therapy management services. a N ¼ 203. b Individual items were measured on a Likert scale (1 ¼ strongly disagree through 5 ¼ strongly agree). Higher scores signify more positive attitudes, more favorable subjective norms, more perceived behavioral control, and stronger intent to provide Medicare MTMS.
survey provides some insight into pharmacists’ potential participation in MTMS as well as challenges, including time and staffing constraints, pharmacist perception of increased stress with the provision of MTMS, and some lack of willingness to actively pursue MTMS opportunities. Strategies to help pharmacists provide MTMS should focus on organizational factors to find time and support to provide MTMS rather than individual educational or training needs.
Table 4 Multivariate linear regression analysis predicting intent to provide Medicare medication therapy management services Variable
b
Standard error
t statistic
P value
Constant Attitude Subjective norm Perceived behavioral control Gendera Years of practiceb Advanced degreec Chain settingd ‘‘Other’’ settingd Past participation in care-based services 1 h spent each day providing reimbursed care-based services Payment received from cash-paying customers for care-based services
0.186 0.191 0.408 0.268 0.683 0.086 0.098 0.202 0.503 0.734 0.284
1.493 0.062 0.081 0.058 0.432 0.217 0.514 0.436 0.438 0.390 0.485
0.125 3.098 5.022 4.606 1.582 0.394 0.191 0.463 1.149 1.883 0.586
.901 .002 .000 .000 .115 .694 .848 .644 .252 .061 .558
0.224
0.597
0.375
.708
N ¼ 203. Adjusted R2 ¼ 0.632. a Gender coded, 1 ¼ male, 0 ¼ female. b Years of practice coded, 1 ¼ 0-10 y, 2 ¼ 11-20 y, 3 ¼ 21-30 y, 4 ¼ 31 or more years. c Summated variable, where 1 ¼ respondents holding a PharmD, PhD, or other beyond Master’s degree, ¼ 0 otherwise. d Dummy variables created for practice setting. Reference variable is independent pharmacy.
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References 1. American Pharmacists Association Understanding Medicare Reform: What Pharmacists Need to KnowdMonograph 2: Medication Therapy Management Services and Chronic Care Improvement Programs. American Pharmacists Association.