Angela C. Riley, PharmD
Sara A. Spencer, PharmD, MS, BCGP
Latasha Wade, PharmD
At the end of this case, students will be able to:
- Discuss the barriers to quality health care in rural settings
- Describe the types of available telepharmacy services
- Define Medication Therapy Management (MTM) and the requirements as developed by managed care organizations
- Explain the advantages and disadvantages of telepharmacy services
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
You are a pharmacist scheduled for a CMR using the telepharmacy service with a patient on your quarterly report.
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
- Father: T2DM and hyperlipidemia, died of heart attack at 83 years
- Mother: osteoporosis and hypertension, died of old age at 93 years
- Smokes cigarettes (one PPD)
- Drinks socially (1 glass of wine)
- Loves Mountain Mist (2 liters/day)
- Little to no physical activity
- 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.
1. What healthcare challenges do patients encounter in the rural setting?
The challenges that rural patients encounter in accessing healthcare leads to health disparities. Patients in the rural areas of the United States face barriers that result in unmet healthcare needs. Because the community lacks access to health care services and/or the patients have minimal to no insurance coverage, there is often decreased preventative/screening services and early diagnosis and treatment of illness. The rural population has demonstrated an increased reliance on self-care and/or informal care provided by family members and friends, which may result in disease progression and lengthy hospitalization.11 Compounded with the other challenges impacting rural life overall, including provider shortages, lack of insurance or underinsured, aging workforce, long work hours, poor infrastructure and transportation concerns, social stigma and privacy concerns, isolation, lack of broadband internet, fewer social opportunities and other issues around spouses’ and children’s needs, the rural population have several challenges to remain healthy.
2. How might a patient be identified for telepharmacy services in managed care?
Patients can be identified for telepharmacy services in managed care based on their chronic disease states, the number of medications they are taking or their annual cost of Part D medications that exceed the predetermined threshold. Many plans offer these services as a courtesy to their members or to those who may not meet the eligibility requirements. Managed care pharmacists have the ability to view individual member’s pharmacy claims to address nonadherence, clarify medication-related concerns, identify adverse events, and provide education. Since these are telephonic encounters rather than face-to-face, members have the ability to schedule sessions at their convenience and from the comfort of their home.
3. In addition to a CMR, what additional services could be provided by a telepharmacist to GM?
A telepharmacist could counsel GM on her medications to ensure she understands why she is taking each medication, how each medication should be taken, and what to expect when taking each of her medications. In addition, a telepharmacist could also assess the safety and efficacy of GM’s medications, determine the stability and control of GM’s medical conditions, and provide additional information to GM about her medications and medical conditions.
4. What may be perceived advantages and disadvantages of telepharmacy?
Advantages of telepharmacy could include:
- >The introduction, continuation, or enhancement of high-quality pharmaceutical care to patients in rural areas
- The introduction, continuation, or enhancement of routine and specialized pharmacy services to rural hospitals
- An opportunity for on-site pharmacists in the community and hospital pharmacists to engage, to a greater degree, in the provision of clinical services while telepharmacists cover remote order entry, processing, order verification, and dispensing.
- The potential for 24/7 access to a telepharmacists
- An arguably more cost-effective option compared to establishing a new pharmacy in a rural area or hiring additional pharmacists to provide coverage in community, hospital, and clinic settings
Disadvantages of telepharmacy could include:
- >Differences in state laws and regulations related to telepharmacy
- The potential for additional licensing requirements to engage in telepharmacy practice
- Potential on-site visits to the telepharmacy, remote site required by state laws and regulations
- Resources needed to start a telepharmacy service (e.g., financial, technology assets, knowledge, effort)
- Implementation of telepharmacy services
- Potential increase in workload
- Lack of familiarity with telepharmacy services by the community, hospital and pharmacy administrators, and healthcare practitioners and the need to gain their buy-in to offer services
- Not all insurance companies may reimburse for telepharmacy services
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.
Related chapters of interest:
- Plant now, harvest later: services for rural underserved patients
- More than just diet and exercise: social determinants of health and well-being
- Communicating health information: hidden barriers and practical approaches
- Telepharmacy: A Pharmacist’s Perspective on the Clinical Benefits and Challenges: https://www.dovepress.com/telepharmacy-a-pharmacistrsquos-perspective-on-the-clinical-benefits-a-peer-reviewed-fulltext-article-IPRP
- The North Dakota Telepharmacy Project: Restoring and Retaining Pharmacy Services in Rural Communities: https://journals.sagepub.com/doi/pdf/10.1177/875512250402000107
- The North Dakota Telepharmacy Project: https://www.ndsu.edu/telepharmacy/
- One the Line: Telepharmacy Technology Expands Hospital Pharmacists’ Reach: https://www.pharmacytoday.org/article/S1042-0991(16)00530-2/fulltext
- Federal Office of Rural Health Policy: https://www.hrsa.gov/rural-health/index.html
- Rural Healthy People 2020: https://srhrc.tamhsc.edu/rhp2020/index.html
- National Rural Health Association Policy Documents: https://www.ruralhealthweb.org/advocate/policy-documents
- 2018 Medicare Part D Medication Therapy Management (MTM) Programs Fact Sheet: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/CY2018-MTM-Fact-Sheet.pdf
- Rural America-Story Map Series. https://gis-portal.data.census.gov/arcgis/apps/MapSeries/index.html?appid=7a41374f6b03456e9d138cb014711e01. Accessed November 1, 2018.
- Parker K, Hororwitz JM, et al. “Demographic and Economic Trends in Urban, Suburban and Rural Communities.” What Unites and Divides Urban, Suburban, and Rural Communities, Pew Research Center’s Social & Demographic Trends Project, 22 May 2018, http://www.pewsocialtrends.org/2018/05/22/demographic-and-economic-trends-in-urban-suburban-and-rural-communities/. Accessed November 1, 2018.
- Health Care Workforce Distribution and Shortage Issues in Rural America. National Rural Health Association. https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/HealthCareWorkforceDistributionandShortageJanuary2012.pdf.aspx?lang=en-US. Accessed November 1, 2018.
- Cohen SA, Cook SK, Sando TA, et al. What aspects of rural life contribute to rural-urban health disparities in older adults? Evidence from a national survey. J Rural Health. 2018;34(3):293-303.
- The Future of Rural Health. National Rural Health Association. February 2013. https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/FutureofRuralHealthFeb-2013.pdf.aspx?lang=en-US. Accessed November 1, 2018.
- Sriram U, Morgan EH, Graham ML, et al. Support and sabotage: a qualitative study of social influences on health behaviors among rural adults. J Rural Health. 2018;34(3), 88-97.
- Pharmacy Manpower. Pharmacist Demand Indicator. National Pharmacist Demand Quarter 3, 2018. https://pharmacymanpower.com/index.php. Accessed November 3, 2018.
- Rupri Center for Rural Health Policy Analysis. Update: Independently Owned Pharmacy Closures in Rural American, 2003-2018. https://cph.uiowa.edu/rupri/publications/policybriefs/2018/2018%20Pharmacy%20Closures.pdf. Accessed November 3, 2018.
- National Association of Boards of Pharmacy. Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy. https://nabp.pharmacy/publications-reports/resource-documents/model-pharmacy-act-rules/. Accessed November 3, 2018.
- Alexander E, Butler CD, Darr A, Jenkins MT, Long RD, Shipman CJ, et al. ASHP Statement on Telepharmacy. Am J Health Syst Pharm. 2017;74(9):e236-e241.
- Institute for Healthcare Improvement Website. http://www.ihi.org/Topics/TripleAim/Pages/default.aspx. Accessed November 5, 2018.
- 2018 Medicare Part D Medication Therapy Management (MTM) Programs. Center for Medicare & Medicaid Services (CMS). https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/CY2018-MTM-Fact-Sheet.pdf. Accessed November 5, 2018.
- Healthcare Access in Rural Communities Introduction. Rural Health Information Hub. www.ruralhealthinfo.org/topics/healthcare-access#population-health. Accessed November 5, 2018.
- Telehealth. Rural Health Information Hub. https://www.ruralhealthinfo.org/topics/telehealth. Accessed November 5, 2018.
- Littauer SL, Dixon DL, Mishra VK, Sisson EM, Salgado TM. Pharmacists providing care in the outpatient setting through telemedicine models: a narrative review. Pharm Pract (Granada). 2017;15(4):1134.