ABSTRACT
This dissertation consists of three studies, each applying a different method, to evaluate the use of pharmacists on the primary care team for people with chronic health conditions, such as high blood pressure and diabetes. Pharmacist interventions, also called Medication Therapy Management (MTM) services, are the subject of considerable current debate in health reform policy. Major associations representing pharmacists are advocating for legislation that will establish reimbursement for MTM services for a wide range of chronic conditions. The studies included in this report address unanswered research questions regarding 1) whether enough evidence exists to conclude that MTM services interventions will result in cost savings and significant return on investment, 2) which patient populations might benefit most from MTM services interventions, and 3) what are the challenges associated with the implementation of these types of MTM services in collaborative partnerships with public and private community health entities.
The first paper in the trilogy examined the existent literature on the cost-benefits of MTM programs. The findings suggest that existing economic studies of MTM services are lacking in quality and additional high-quality cost-effectiveness research work needs to be completed before there is enough evidence to support reimbursement and policy changes.
The second study considered whether different populations of people who have commercial health insurance, Medicare insurance, or Medicaid insurance who take long-term medications were more or less likely to receive medication monitoring. Presumably, those who take long-term medications but may not be receiving proper monitoring could benefit from interventions such as MTM services. Through quantitative regression analysis, it was determined that for populations on widely prescribed medications, such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and diuretics - those with commercial insurance were almost three times less likely to be monitored than those with Medicare insurance. Also, significant effects on medication monitoring were found for important patient characteristic covariates including gender - females less likely to be monitored, age - older age associated with lower likelihood of monitoring, and income - higher income associated with higher likelihood of monitoring.
The final study examined the efforts of a multi-sector collaborative partnership implementing an MTM services intervention using community pharmacists to assist with treatment of a population of school district employees and their dependents who have diabetes in San Diego, California. Contextual, resource, leadership, and internal conflict factors were evaluated with qualitative analysis to determine their effect on the abilities of the partnership to complete its initiatives. New contributions as a result of this research include developing a cost model to provide MTM services, quantifying relationships between health insurance status and medication monitoring, and revealing practical lessons on implementation of MTM models. This work provides an objective view on these subjects while adding to the growing number of studies on incorporating pharmacists on the primary care team.
