Evaluating Satisfaction With Pharmacist-Provided MTM Services in a Medicaid Population

ABSTRACT

Objectives: Optimizing patient outcomes is a goal for medication therapy management (MTM) programs, with patient satisfaction representing a valuable measure to provide information about pharmacist-delivered services and the overall effectiveness of the program. The objective of this study was to assess patient satisfaction after engaging in a telephonic comprehensive medication review (CMR) with a pharmacist in a Medicaid population.

Study Design: This was a retrospective cohort study.

Methods: A quality assurance component of the MTM program was incorporated as a survey evaluating patient satisfaction. Three questions were administered at the conclusion of the CMR, with 2 questions conducted during a follow-up review. Of the 5 total questions, 2 were open response, 1 used a 5-point Likert scale, and 2 were yes/no questions.

Results: Response rates of 93.0% and 53.5% for the first and second halves of the survey, respectively, were achieved. Seventy-eight percent of patients indicated satisfaction with the MTM program, 63.5% reported that the medication review was helpful, and 80% reported experiencing a very good level of care. In addition, 59% found the patient takeaway documents received after the CMR to be helpful and 81% felt they had a better understanding of their medications. A subgroup analysis found that of the patients who reported feeling that the CMR was helpful, 66% were taking 7 or more medications.

Conclusions: Overall, Medicaid patients in this study were very satisfied with the telephonic MTM services provided and found the information relayed during the conversation with the pharmacist to be helpful. Further studies are recommended to confirm these findings.

Am J Manag Care. 2022;28(6):282-286. https://doi.org/10.37765/ajmc.2022.89155

Takeaway Points

Medication therapy management (MTM) services have been performed with Medicare patients for more than 10 years. This article summarizes a pilot project that offered the same services to a cohort of Medicaid patients, then assessed the patients’ satisfaction with the program and with the documents provided at the conclusion of each comprehensive medication review. This project was included as part of a quality improvement initiative for the program.

• Overall, Medicaid patients were satisfied with pharmacist-provided MTM services, felt that participating in the comprehensive medication review was helpful, and deemed the level of care received by the pharmacist to be very good.
• Medicaid patients valued the patient takeaway documents provided after the review.
• The response rate when completing the survey while having the patient already engaged on the phone was much higher than when attempting to finish the remainder of the survey by phone after a period of time had passed.

Medication therapy management (MTM) programs have become an important aspect of patient care delivery systems. Through regulations, CMS has mandated that Medicare Part D sponsors establish programs that offer MTM services to qualifying Medicare patients.¹ To be eligible, the patient must have several diagnosed chronic conditions, be taking a minimum number of chronic medications, and meet an annual medication cost threshold.² The MTM programs must include a live conversation with the patient or caregiver (called the comprehensive medication review [CMR]) and target patients at high risk of experiencing medication-related events; the goals are to optimize patient outcomes, reduce adverse effects, and improve medication use and adherence.^2,3 In addition, MTM services are intended to promote patient self-management of their health conditions and to represent a collaborative effort among the patient, the physician, and the pharmacist.^2,3 CMS also created standardized document templates that are completed during the CMR and provided to the patient later.³ These documents include the personalized medication list (PML) and the medication action plan (MAP), which are intended to assist the patient in the self-management of their disease states and medications.³

A recent shift in health care has been to focus more on quality measures and value-based care, including assessing the benefits of pharmacist-provided services.⁴ With optimizing patient outcomes as a goal of MTM programs, and pharmacists being listed as the provider of these services, evaluating humanistic outcomes measures, such as patient satisfaction, can provide insight into current practices and help guide program delivery.^4,5 One consensus document listed patient satisfaction as a measure that can support the overall effectiveness of a MTM program.⁶ MTM services have been shown to increase patient participation, improve health outcomes, and lower medication costs,⁷ but few studies to date have evaluated patient satisfaction with pharmacist-led MTM services.^5,8,9

Of these studies, one indicated that patients value MTM services, with 80% to 89% of patients being highly satisfied with the quality of the services provided by their pharmacist.⁸ Another study found that those who received MTM services spoke very highly of the services received.⁸ The participants also recognized the importance of having a pharmacist as part of the health care team because of the accessibility of MTM pharmacists.⁹ An additional study assessed the impact of telephonic MTM services offered by a health plan.⁵ The results revealed that patients were pleased with the services, with a mean satisfaction score of 4.3 (1, strongly disagree; 5, strongly agree), and indicated that their pharmacists were accessible and addressed their concerns adequately.⁵

To date, limited data have assessed patient satisfaction with the provision of pharmacist-provided MTM services within a Medicaid population. Also limited are data regarding the provision of MTM services in special patient populations, such as those with health literacy challenges or language barriers. Medicaid, in contrast to Medicare, has no specific criteria or regulations for providing MTM services. In addition, although there is guidance on the best framework for providing MTM services—such as utilizing the 5 core elements or the pharmacist patient care process—no standardized method currently exists for performing MTM services or assessing outcomes within MTM programs.^10,11

The Center for Quality Medication Management (CQM) at the University of Florida offered MTM services to a subset of Medicaid patients telephonically. The goals of the MTM program in this population were to improve the quality of care and prescribing practices, to promote medication adherence, and to lower medication costs and inappropriate spending.¹² Quality improvement was also included as part of the program, and survey questions were administered at the end of the CMR.

This study sought to analyze the level of patient satisfaction with pharmacist-provided telephonic MTM services in a Medicaid population utilizing the survey question data collected as part of the quality improvement initiatives of the program. This study received approval from the institutional review board of the University of Florida.

METHODS

In 2016, CQM offered telephonic MTM services (a CMR and quarterly follow-ups) to patients enrolled in a Medicaid waiver program. The patients qualified for this program if they were receiving Medicaid benefits and determined to be very low income or disabled per Medicaid-specific criteria. The CMRs were provided by a team of pharmacists and student pharmacists. All CMRs were conducted telephonically with the patient or their caregiver, and only English-speaking patients were included for CQM to contact. If not successful on the first call, multiple contact attempts (3-6) were made to each patient for completing the CMR. The quality assurance survey was voluntary and offered to each patient at the conclusion of the CMR. The patient was transferred to a different pharmacist to administer the survey questions to help prevent any potential bias. After completing the CMR, patient care documents (PML and MAP) utilizing the Medicare standardized templates were mailed to each patient.

The survey was created in collaboration between CQM and administrators of the Medicaid waiver program. The survey was conducted in 2 parts, with the first part being administered at the end of the CMR while the patient was still on the phone. The second part was conducted with the patient telephonically 30 days later during a follow-up review as part of the normal program workflow process. Only 1 contact attempt was made to each patient for completing the follow-up review and second half of the survey. The first half of the survey consisted of 2 open-ended questions and 1 Likert scale question, all related to patient satisfaction. The second half of the survey contained 2 additional questions related to the usefulness of the documents mailed to the patient and the information provided by the pharmacist during the CMR. All patients who successfully completed a CMR were included in the study regardless of their participation in both parts of the survey. There were no incentives or compensation offered for participation in the CMR or survey. Survey questions are included in the Table.

Data Analysis

All patients receiving a CMR were included in the results. Qualitative data analysis (summative content analysis) was used to evaluate the survey answers to the open-ended questions. Survey answers were classified into discrete categories based on identified patterns and keywords. Likert-scale analysis was used to summarize the survey results for closed-ended questions. A subgroup analysis was also conducted based on the number of medications that the patient was taking at the time of the review. This subanalysis was done to determine if patients taking at least 7 chronic medications, who are considered likely to be more complicated, found the review to be more helpful than patients taking fewer than 7 medications. This number of medications was chosen based on internal data and demographics for the participants in the program.

RESULTS

A total of 129 patients participated in a CMR between June and August 2016, all of whom were included in this study. An overall response rate of 93.0% was observed, with 120 patients consenting to participate in the first half of the survey. In addition, 53.5% successfully answered the remainder of the survey questions at the 30-day follow-up review. Fifty-nine percent of the patients were male, and 57% were aged 41 to 60 years. In addition, 56% reported taking 7 or more chronic medications.

In response to the question about the best part of the program, 78% indicated that they recognized value in the MTM services provided by the pharmacist. Twenty-six percent reported that the medication review was informational, 17% described the pharmacist as being personable and caring, and 8% commented that they “appreciated the interactive component of the review.” Sixteen percent of the patients felt that the medication review was helpful and 11% were appreciative of the time spent with the pharmacist. Eleven percent indicated that they were unsure if the review was beneficial as they had nothing to compare the services to because this was their first instance of participating in a CMR with a pharmacist. In addition, 4% of the responses were classified as “other,” in which the respondents’ concerns were about their Medicaid coverage and not related to the CMR or the pharmacist (Figure).

When asked “Did this review of your medications help you?” 63.5% of the patients reported finding the review helpful. Some described the review as a good refresher of information previously received, whereas others concluded that they had a better understanding of their medications and health after talking with the pharmacist. Almost 8% of the patients reported that the review was neither helpful nor unhelpful and that participating in the review only confirmed their current knowledge vs providing any new information. Approximately 16% described the review as not being helpful at all, whereas 6.2% did not provide a response to the question. The subgroup analysis revealed that 66% of the patients who reported feeling the medication review was helpful were taking at least 7 medications. In addition, 90% of all responding patients were happy with the services provided, reporting that the care they received from the pharmacist was either very good or good. There were very few and no responses for poor and very poor, respectively, indicating an overwhelmingly positive response (Table).

For the second half of the survey, patients received 1 follow-up phone call 30 days after the initial survey. They were asked 2 additional questions, one about their perceived usefulness of the documents produced as a result of the CMR, and the other to further assess their satisfaction with the medication knowledge provided by the pharmacist during the review. Of the 129 patients contacted at follow-up, 53% responded to the additional survey questions. Overall, 59% of the responding patients agreed that the mailed patient care documents were helpful, 19% reported not yet having received or reviewed the documents, and 16% indicated that the documents were not useful. In addition, 6% of the patients stated that the documents were just filed away and they were using an electronic means of keeping track of their medications. The patients were also asked to recall information received during the CMR and assess whether the pharmacist provided them with a better understanding of their medications. Of the 69 respondents, 91% answered this question. Eighty-one percent reported that even after 30 days had passed, the CMR was helpful. In contrast, 13% of the patients reported not finding the information helpful, another 5% stated that the service was “alright,” and 2% indicated being unable to recall speaking with a pharmacist previously (Table).

DISCUSSION

The CQM is focused on providing patient care of the highest possible quality. Assessing the level of patient satisfaction with the pharmacist-provided MTM services is a way in which CQM can continue to improve. The study results show that most patients participated in the survey and indicated being satisfied with the MTM services. The 93% participation rate for this study is higher than that of several comparable studies, which had response rates of 30.4%, 60%, and 80%; a fourth study had a slightly higher response rate at 95.4%.^5,13-15 The response rate to the second half of the survey is lower, likely because only 1 contact attempt was made for the follow-up reviews as part of the normal CQM processes.

When patients were asked about what they felt was the best part of the program, most indicated that the review was educational, the pharmacist was caring and personable, and they enjoyed the interactive portion of the review so they could ask questions. This is consistent with the results from a survey by Kim et al in which respondents indicated that they appreciated the education that was provided during a medication review and a positive interaction with the pharmacist.¹³

In response to the question about how the review of medications helped them, the respondents overwhelmingly indicated that the review was helpful (with patients taking 7 or more medications almost twice as likely to say so compared with those taking fewer than 7 medications). Moczygemba et al found similar results, stating that “patients appreciated receiving updated medication-related information and developed an understanding of their medication regimens,” and Kim et al found that 40% of patients taking 6 to 10 medications and 42% taking more than 11 medications found greater benefit from MTM services than did patients taking 5 or fewer medications.^5,13 Overall satisfaction with the care experienced with the MTM program during this study was high at 90%. These data echo those of a similar study in which patients indicated generally being very satisfied with their telephonic MTM care.⁵

One question asked of the patients at the follow-up review sought to determine whether they found the mailed documents helpful. The documents were helpful, 59% of the patients stated; a subset, however, indicated that they had not reviewed the documents at the time of the call. This aligns with the results found by Brandt et al in which 52.5% of their respondents found the PML and MAP documents to be helpful, with the PML being most useful because it contains the medications with directions for use and indications.³

Finally, the remaining question assessed whether the patient felt the information provided by the pharmacist during the CMR helped the patient better understand their medications, even 30 days later. The intent was to determine if the patient felt differently after a period of time had passed. The majority of patients reported that participating in the CMR did help with their understanding of their medications.

Limitations

This study is not without limitations, including the lack of a validated survey tool to assess patient satisfaction. The questions asked of the patients during this study were part of the normal workflow and quality assurance program. The intent of the questions was to improve the program itself, and the study was developed afterward. The use of a validated survey tool could have provided better or more consistent results. In addition, although the pharmacist completing the survey was not the same one who engaged in the CMR with the patient, potential bias may have been introduced with the patient completing the survey while still on the call. The patient may have felt pressure to answer questions positively vs completing the survey by mail or at a different time. In addition, patients included in this survey were from a subset of a Medicaid population and were English speaking only. This may limit the generalizability of the study results. Another limitation is the response rate for the second half of the study. There was only 1 contact attempt made to administer the survey. The response rate would likely be higher if the same number of call attempts were made for the follow-up review as for the initial CMR.

CONCLUSIONS

Patient satisfaction is an integral part of measuring the quality of a patient care program. Overall, the patients in this study indicated being very satisfied with the telephonic MTM services provided and found information relayed during the conversation with the pharmacist to be helpful. Patients taking at least 7 medications appeared to find the MTM services the most helpful. In addition, patients indicated that the PML and MAP documents were useful and reported having a better understanding of their medications due to speaking with the pharmacist. It is recommended that further studies be conducted to confirm these study findings.

Author Affiliations: Center for Quality Medication Management, University of Florida College of Pharmacy (TER, TI, AP), Gainesville, FL.

Source of Funding: The medication therapy management services project was supported by a grant funded by the Agency for Healthcare Administration (AHCA); contract number MED130. This manuscript was not funded, is solely the responsibility of the authors, and does not represent the official views of the AHCA.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (TER, TI, AP); acquisition of data (TI, AP); analysis and interpretation of data (TI); drafting of the manuscript (TER, TI, AP); critical revision of the manuscript for important intellectual content (TER, TI, AP); statistical analysis (TI); provision of patients or study materials (TER); administrative, technical, or logistic support (TER); and supervision (TER).

Address Correspondence to: Teresa E. Roane, PharmD, MBA, BCACP, CPh, University of Florida College of Pharmacy, 1225 Center Dr, PO Box 100486, Gainesville, FL 32610. Email: troane@cop.ufl.edu.

REFERENCES

1. Medicare Prescription Drug, Improvement, and Modernization Act of 2003, HR 1, 108th Cong (2003). Pub L No. 108-173. Accessed April 23, 2021. http://www.gpo.gov/fdsys/pkg/PLAW-108publ173/pdf/PLAW-108publ173.pdf

2. McGivney MS, Meyer SM, Duncan-Hewitt W, Hall DL, Goode JVR, Smith RB. Medication therapy management: its relationship to patient counseling, disease management, and pharmaceutical care. J Am Pharm Assoc (2003). 2007;47(5):620-628. doi:10.1331/JAPhA.2007.06129

3. Brandt NJ, Cooke CE, Sharma K, et al. Findings from a national survey of Medicare beneficiary perspectives on the Medicare Part D medication therapy management standardized format. J Manag Care Spec Pharm. 2019;25(3):366-391. doi:10.18553/jmcp.2019.25.3.366

4. Medication therapy management digest: perspectives on MTM service implementation. American Pharmacists Association. 2008.Accessed May 4, 2022. https://www.researchgate.net/publication/315614322_Perspectives_on_MTM_service_implementation_APhA_Medication_Therapy_Management_Digest

5. Moczygemba LR, Barner JC, Brown CM, et al. Patient satisfaction with a pharmacist-provided telephone medication therapy management program. Res Social Adm Pharm. 2010;6(2):143-154. doi:10.1016/j.sapharm.2010.03.005

6. Academy of Managed Care Pharmacy. Sound medication therapy management programs: 2006 consensus document. Case Manager. 2006;17(4):47-50. doi:10.1016/j.casemgr.2006.05.006

7. Holsclaw SL, Olson KL, Hornak R, Denham AM. Assessment of patient satisfaction with telephone and mail interventions provided by a clinical pharmacy cardiac risk reduction service. J Manage Care Pharm. 2005;11(5):403-409. doi:10.18553/jmcp.2005.11.5.403

8. Christensen DB, Roth M, Trygstad T, Byrd J. Evaluation of a pilot medication therapy management project within the North Carolina State Health Plan. J Am Pharm Assoc (2003). 2007;47(4):471-483. doi:10.1331/JAPhA.2007.06111

9. Tomaszewski D, Cernohous T, Vaidyanathan R. Evaluating patient preferences for different incentive programs to optimize pharmacist-provided patient care program enrollment. J Manag Care Spec Pharm. 2017;23(11):1140-1147. doi:10.18553/jmcp.2017.23.11.1140

10. de Oliveira DR, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm. 2010;16(3):185-195. doi:10.18553/jmcp.2010.16.3.185

11. Medication therapy management in pharmacy practice: core elements of an MTM service model: version 2.0. American Pharmacists Association. March 2008. Accessed May 4, 2022. https://aphanet.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf

12. The pharmacists’ patient care process. Joint Commission of Pharmacy Practitioners. May 29, 2014. Accessed April 18, 2021. https://jcpp.net/patient-care-process/

13. Kim S, Martin MT, Pierce AL, Zueger P. Satisfaction with medication therapy management services at a university ambulatory care clinic. J Pharm Pract. 2016;29(3):199-205. doi:10.1177/0897190014550718

14. Moon J, Kolar C, Brummel A, Ekstrand M, Holtan H, Rehrauer D. Development and validation of a patient satisfaction survey for comprehensive medication management. J Manag Care Spec Pharm. 2016;22(1):81-86. doi:10.18553/jmcp.2016.22.1.81

15. Moultry AM, Poon IO. Perceived value of a home-based medication therapy management program for the elderly. Consult Pharm. 2008;23(11):877-885. doi:10.4140/tcp.n.2008.877