17 Telepharmacy: building a connection to close the healthcare gap

Introduction

The United States is a country in transition. According to the US Census Bureau for 2010, about 60 million Americans, 19% of the population, lived in rural areas.¹ Although rural counties demonstrated a 3% growth in population since the 2000s, according to Pew Research Analysis, today, within each county, there has been about a 52% decline in population due to economic shifts.² Rural communities face multiple challenges that result in disparities compared to urban settings. Primarily, access to quality care is limited due to the lack of human and capital resources. Difficulties recruiting and retaining quality health care professionals (particularly for areas competing with urban settings)³ and reduced funding and payer reimbursement for providers create barriers to consistent care. Patients in rural communities are also more likely to be older, less affluent and underinsured,^4,5 with higher rates of chronic conditions and adverse health outcomes compared to those in urban settings.⁶

Although the current supply of pharmacists in the United States is mostly meeting demand,⁷ many of these pharmacists are not practicing in rural areas. The RUPRI Center for Rural Health Policy Analysis found that between 2003 and 2018, more than 1,200 independently owned pharmacies closed in rural communities.⁸ Of this, 589 rural communities that had one pharmacy in 2003 had zero by March 2018.⁸ With rural areas experiencing a shortage of other health care practitioners as well, the closing of pharmacies in these areas could also mean the loss of the only healthcare practitioner who may have been providing services to the community and filling a critical void. Telepharmacy, or the provision of services by pharmacists to patients or their caregivers using technology,⁹ has become an increasingly popular strategy to fill such these voids while expanding both the role of and career opportunities for pharmacists. Telepharmacy provides a cost-effective means for pharmacists to provide routine and highly specialized clinical services in remote areas where the need may be greatest. In addition to remote order entry, order verification, and medication dispensing, telepharmacy services performed by pharmacists can include drug reviews and monitoring, assessment of patients and clinical outcomes, patient counseling, medication therapy management, sterile and non-sterile compounding verification, drug information, and clinical consultations with other health care practitioners.¹⁰

The Centers for Medicare & Medicaid Services (CMS) encourages innovative healthcare models and recognizes the value of integrating pharmacists to coordinate the Triple AIM Initiatives to improve patients’ care experience, improve population health, and reduce per capita healthcare costs. One of the ways Managed Care Organizations (MCOs) employ cost-saving and innovative practices is by providing telepharmacy services to their members.¹¹

CMS adopted the Pharmacy Quality Alliance (PQA) MTM Completion Rate as a performance metric by which program sponsors will be evaluated. This requires sponsors offering Part D plans to establish MTM programs provided by pharmacists or other qualified providers to their members with the goal of optimizing therapeutic outcomes and reducing the risk of adverse events. Pharmacists at MCOs, PBMs, retail pharmacies, or MTM centers can utilize pharmacy and medical claims to identify eligible members to provide telephonic MTM services. The MTM programs target Part D enrollees with multiple chronic diseases, who are taking multiple Part D drugs, and who are likely to incur annual costs for these Part D drugs that exceed predetermined level; however, these services may be expanded to members who do not meet the eligibility criteria. Each sponsor has the ability to set the minimum number of chronic conditions as well as the minimum number of covered Part D drugs the member must have filled to be eligible for the MTM program. At the minimum, sponsors must offer interventions for members and prescribers utilizing an annual comprehensive medication review (CMR) and quarterly targeted medication reviews (TMRs).¹²

Case

CC: “I need my medication reviewed because I received this letter from my insurance.”

Patient: GM is a 75-year-old Caucasian female of Scandinavian descent who lives independently in a rural town in upstate New York. She is wheelchair-bound and uses mail order for all of her prescriptions. She prides herself on her home cooking and enjoys baking “Amish” style pies with lard. GM would like to be more active but since GM became wheelchair bound, she does not believe that she can exercise and spends most of her free time knitting in front of the television or reading magazines that she receives in the mail. She is interested in sitting down with someone to learn more about why she is taking so many medications as well as healthy lifestyle changes but is unable to get transportation to the local pharmacy and does not have internet access.

HPI: GM has LASARA insurance and is eligible for a CMR by a pharmacist because she is currently taking more than eight medications to manage her chronic diseases. GM appears on the LASARA MTM pharmacist’s quarterly report indicating to complete a CMR.

PMH: Osteoporosis; diabetes; HTN; vitamin D deficiency

FH:

• Father: T2DM and hyperlipidemia, died of heart attack at 83 years
• Mother: osteoporosis and hypertension, died of old age at 93 years

SH:

• Smokes cigarettes (one PPD)
• Drinks socially (1 glass of wine)
• Loves Mountain Mist (2 liters/day)
• Little to no physical activity

Medications:

• Miacalcin Instill 1 spray in one nostril once daily
• Calcium Citrate 250 mg and vitamin D 200 units twice daily
• Metformin 500 mg twice daily
• Lisinopril 10 mg daily
• HCTZ 25 mg once daily
• Lantus 25 units at bedtime
• Novolin R sliding scale three times a day before meals
• Senna S one tablet daily
• Miralax daily
• Diazepam 5 mg 1 tablet daily as needed for anxiety
• Ambien 5 mg daily as needed for insomnia
• Norco 5/325 mg every 6 hours as needed for pain

Vaccinations: Up to date

Labs: None available at this time

SDH: Patient resides in government-subsidized senior housing in rural upstate New York. She retired from her job as a Processing Technician at a multinational information technology company. She completed her Associates Degree in Computer Science from SUNY Broome. Her income consists of her pension and social security checks. Her family has relocated and may visit 1-2 times a year.

Case Questions

1. What healthcare challenges do patients encounter in the rural setting?

2. How might a patient be identified for telepharmacy services in managed care?

3. In addition to a CMR, what additional services could be provided by a telepharmacist to GM?

4. What may be perceived advantages and disadvantages of telepharmacy?

Author Commentary

With an increasing number of rural communities becoming pharmacy deserts, telepharmacy is an innovative pharmacy practice option that has the potential to both introduce and expand routine and clinical pharmacy services, while ensuring care in our rural populations is not lost. Telepharmacy not only benefits the rural patients who will be able to receive the high-quality services, but it also benefits rural hospitals, both small and large, by giving them access to 24-hour pharmacy coverage and helping them to expand its services. With renewed or continued access to pharmacy services, telepharmacy could also minimize or eliminate variables at the health care system level that contribute to health disparities, such as the availability of healthcare practitioners and the geographic location of services.

Patient Approaches and Opportunities

It is important to recognize that telepharmacy is becoming one of the preferred strategies to expand pharmacy services to rural communities. As telepharmacy continues to evolve, we will see additional models developed and improved, while the role of the pharmacist is also further defined. Today, the pharmacist is responsible for supporting the patient and encouraging the use of the technology-based telepharmacy services. Rural patients may have limited access and experience with computers, cell-phones, webcams, and other software used to host clinical services.  Thus, patients may be apprehensive to the service and engaging an unknown pharmacist through the use of technology. It is critical to the pharmacist-patient relationship that time is dedicated to discussing any potential discomfort and/or concerns about the telepharmacy service before addressing the goals of the interaction. As pharmacists, insurance companies, PBMs, and other providers decide to expand their services to include a telepharmacy component, an environmental scan and/or needs assessment is critical to the success of the initiative.