Medication therapy management: Timothy Ulbrich at TEDxUniversityatBuffalo



there are no surprises when I say that our our health care system is messy we're spending money at an unsustainable rate of growth and we're not keeping up with quality what may surprise you is that in almost every town in America and in some places at more than one corner we have a health care provider that can return almost ten dollars for every one dollar that we spend you know I'll never forget that that first time that I walked into a pharmacy I shadowed at a mom-and-pop shop in Williamsville New York and I was gracious to the owners that they let me spend the day there I left that day thinking this is pretty cool this is pretty cool to see a pharmacist interacting with patients all day long making a difference in their lives I naively left that day though thinking that the the only role of the pharmacist was to make sure that the medication was safely given to the patient what I didn't realize at the time is what a pharmacist would and could be doing in today's health care system fast forward over ten years from then and pharmacists all across the country are breaking the traditional chain of just receiving a prescription deciphering the messy handwriting filling that medication and providing it to a patient and so today I want to make three main points one your local pharmacist is not who you think they are – we have a medication use crises and three we need to invest small to save big and so why am i proposing that a pharmacist play such an active role in our healthcare system today if you look at that numbers just based on the volume of pharmacists that we have in this country as well as the hours that they're available pharmacists are one of the most accessible health care providers that we have in any given week the equivalent of the entire US population 315 million people will walk through the doors of a pharmacy that's especially important considering that one physician group is projecting that we're going to have a shortage of 62,000 primary care physicians by two fifteen with that number potentially to double by 2025 and so I think for all of us when you hear the word pharmacist or local pharmacist or community pharmacists something different probably comes to mind for some of you maybe you're thinking about the old apothecaries with the soda fountain machines for others of you maybe you're thinking about a more modern example of a traditional chain pharmacy or independent pharmacy where you visited to pick up a prescription recently for yourself or for a family member regardless of your perception and your thought of a pharmacist that role has been rapidly evolving over the last five to ten years we now have pharmacists in every single state providing immunizations to patients we have pharmacists all across the country that are are working to address the chronic illnesses that are attacking our healthcare system diabetes high blood pressure high cholesterol and asthma to name a few we have pharmacists all across the country that are working side by side with a physician in their office to provide better patient care we have pharmacists all across the country that are addressing the problems that we know we have with transitions of care the problem we know we have when when patients are coming into the health system when they're transferring within that system and when they're leaving the health system and we have pharmacists all across the country that that are really working hard in the hospital team to be an integral member of that interprofessional team to provide optimal patient care and so the pharmacists no matter what that setting is has the primary responsibility of not only making sure that the patient safely receives the medication that's not enough in today's health care system we need to make sure that every medication we recommend is safe is effective and is affordable and so for every patient that is an individual decision an individual treatment we cannot afford to be making cookie cutter decisions on a population that we know is so different we know that you have very different needs than I do we know that you have a different genetic makeup that ultimately will determine how medications acting body we know that because of the medications that you're taking versus the medications that I'm taking there's a higher likelihood or different likelihood of interactions that may occur between that we know that you have very different issues than I do based on cost based on perceptions as it relates to medications in the role based on perceptions of the severity of disease all of those require that we have an individual approach personalized medicine that we're applying and pharmacists are uniquely positioned to provide that service and so the good news is that we have somebody available that can provide this service the bad news is that we have a perfect storm right now that is attacking our health care system that perfect storm includes three different things one excessive and at times inappropriate medication use two poor adherents are simply put how are patients taking medications relative to what's been prescribed and three we have vast communication problems not only between providers but from a provider to a patient and so let's look at that first component of excessive and at times inappropriate medication use we know the numbers don't lie we have seen a 36 percent growth in the number of prescriptions that have been dispensed in the United States from 1999 to 2009 while the population has only grown nine percent we have been called generation rx because of our dependence on prescription medications as a quick fix to address the problems that we have we know that on average in the United States we have over ten percent of the population that takes more than five medications on a regular basis we know that we have available over 10,000 prescription medications over 300,000 over-the-counter medications that when used appropriately can be one of the best tools that we have to fight chronic illnesses but when used inappropriately our taxing our healthcare system and the patient a significant amount of money we know that we have a rise in the number of herbal and dietary supplements that are being used and we know that we have at least one third of the population over the age of 50 that is taking an herbal or dietary supplement on a regular basis but only 1/3 of those reporting that their physician was aware that they were using that medication and so as you start to mix all those together in terms of prescriptions over-the-counter herbal and dietary supplements the chance for drug interactions and other problems begin and so the first issue we have contributing to this perfect storm is excessive and at times inappropriate medication use the second problem we have is poor adherence or simply put how is a patient taking a medication relative to what's been prescribed the numbers are staggering one out of every two or 50% of patients that have a chronic illness are not taking their medications as prescribed fifty percent of patients with a chronic illness are not taking the medication as prescribed and so hopefully you're asking yourself why why are people not taking their medications as prescribed and the reality is that's a very complex problem that takes a significant amount of time to address is it a cost issue is it an access issue is it a transportation issue is it their perception of how medications are used is their perception of the severity of the disease or is it may be a side effect that they're having from the medication the point is that it takes a significant amount of time to find out why they're not taking their medications but we need to spend that time if 50% of people aren't taking them as prescribed and so we can give the perfect medication but it doesn't matter if it's not being taken and the third issue we have is inappropriate and poor communication not only between providers but from a provider to a patient and as I'm sure you all can relate to we have vast communication problems where patients are seeing multiple different providers that are contributing to their care we have patients that are seeing a a primary care physician plus maybe they're seeing an endocrinologist for the diabetes may be a cardiologist for their heart condition and maybe some other type of specialists as well and so in an ideal setting where communication is perfect and those providers are individually providing their expertise that's a great system the problem we have in our system is that the communication is a tangled mess we have inappropriate communication across providers that ultimately is resulting in worse patient care and so the question is how do we improve that communication a great example of this in pharmacy is that if you're somebody who's getting medications at more than one store let's say you get a couple medications at your grocery store pharmacy and you get a couple more at your local chain pharmacy more often than not those systems are not talking to one another and so if you're picking up a medication at one store more often than not the pharmacist is not aware of the other medications that you're taking and therefore cannot properly screen to make sure there's no drug interactions and so not only do we have issues of communication between providers but also from a provider to a patient and that problem we know is called health literacy health literacy or simply put how does a patient understand and utilize the health information that they're given we know from a 2004 Institute of Medicine report that one out of every two adult Americans 90 million adults do not have the appropriate level of health literacy to understand and act on the information that they're given and so if we don't have appropriate health literacy we know that those with lower health literacy have worse adherence we know that those with lower health literacy are likely to have more inappropriate medication use seek less preventive care and ultimately utilize hospital services more costing the healthcare system more money and so we have this perfect storm of excessive and at times inappropriate medication use of poor adherence and a communication problems between providers and from a provider to a patient and so that's the gloom and doom the good news is that we have a provider in a pharmacist that is accessible and that is ready to provide a service called the medication checkup service that can help resolve the issues we're having with this perfect storm and so this is how a medication checkup service works simply put a pharmacist will start to sit down with the patient one-on-one to identify all of the met occasions that they're taking prescription over-the-counter dietary and herbal supplements from all of the providers that they're seeing and they start to see the big picture of what's going on and so as we're going through that that individual care with that patient we start to ask ourselves several different questions one are the medications appropriate for the conditions that the patient has are they the best medications for the conditions that the patient has are there any barriers to the patient taking these medications such as cost such as access such as side effects and are there any other cheaper generic alternatives that may be available that could save the patient money that they'd be more likely to take that medication and that would save the system money as well and so I'm sure you all can relate to somebody whether it's a family member a friend or co-worker that's taking five 10 15 20 25 or more medications and as you start to pile up these medications especially from different providers the likelihood of drug interactions and other problems that's costing patient care as well as costing our healthcare system money will increase and so I want to walk through a few different examples of three patients so you can get an idea of what types of services and what types of problems we'll identified during this medication checkup service first I want you to meet Jane Jane's a 7 year old female that for years has been self treating headaches over the counter with aspirin and so during the medication checkup service we sit down with Jane and we start to ask some more questions and we identify that she's also been self treating her heartburn over the counter and as we start to ask more questions and more questions we we find out that the timing of the heartburn syncs up with the timing of when she was using more aspirin because not only was she having headaches but she also was having more knee pain from her arthritis and so this is a classic example of a medication that's being used to treat a condition that's caused by another medication a medication that that is being used to treat a condition that's caused by another medication and so in Jane's case it's likely that she's having the heartburn from the aspirin a common side effect of excessive use of that medication and so we need to ask more questions as we sit down with Jane why is she having chronic headaches is aspirin appropriate for her as an individual patient and does this need further evaluation by the physician to make sure it's not something more serious like ulcers I want you to meet Steve Steve's a 59 year old male that that was recently given an expensive brand-name cholesterol medication and during our medication checkup we identify that that Steve has recently lost his job lost his health care benefits and ultimately didn't want to tell his physician that he's been cutting and splitting the medication in half because he hasn't been able to afford it and so we sit down with Steve and we start to talk to him in and as we look at his lab work we identify for that where his numbers are today and where they need to be based on who he is as an individual patient he doesn't need that expensive brand-name cholesterol medication and so we recommend a cheaper generic alternative that he can take every day that will help him reach his goals that will save him money and ultimately save the system money as well I want you to meet Josie Josie is a five year old girl that that has severe pediatric asthma and her asthma really limits her from any types of productive activities her mom's had a miss a lot of work recently because Josie's had him in school and as we sit down in the medication checkup service we identify that Josie was recently given a new inhaler for her asthma but the symptoms really haven't been getting any better and so we asked her to show us how she's using that inhaler and we find a very common problem that you'll see in pediatric patients using inhalers the proper steps aren't being followed and so we work with the physician to recommend a holding device that will help her properly administer the medication so she gets the full dose and ultimately here her symptoms will resolve and so this is a great example of an appropriate medication that's not being used an appropriate way and so the question hopefully you're asking yourself is what evidence do we have for this type of service what evidence do we have for utilizing a pharmacist in this type of medication check-ups and in 2011 the Surgeon General's Office released the report that really outlined how our pharmacists being utilized in our health care system and what evidence do we have for utilizing them on a regular basis and what they saw is not only in addition to improving patient health such as improving blood pressure improving cholesterol or improving diabetes numbers they also show that when they looked at over two decades worth of data that for every one dollar we spend on clinical pharmacy services we're going to return approximately ten for every one dollar we spend on clinical pharmacy services or return approximately ten and so the stories can go on and the facts and figures can go on but I think you get the point I think you get the point that we have a perfect storm that's attacking our healthcare system in an excessive and at times inappropriate medication use and poor adherence and a communication problems not only between providers but from a provider to a patient and so the question is when are we going to stop being reactive and when are we going to be preventative in the approach we take and the good news is that we have a medication checkup and we have a pharmacist a provider that is positioned ready and trained to provide that service and so if you're our patient that that you think could benefit from this type of service I would encourage it you talk to your local pharmacist if you have a family member a friend or relative that you think could benefit from this type of service I would encourage that you have them talk to their local pharmacist if you are an employee or a benefits manager and you're struggling to control the healthcare costs of your employees I would encourage you to talk to your local pharmacist about setting up a plan that would be specific for you if you're a pharmacy administrator or manager I would encourage you to support your pharmacists in these efforts and if you're a legislator I would ask that you help pharmacists be recognized as healthcare providers and federal legislation that would allow them to be appropriately reimbursed for the service and so the good news is that in almost every town in America and in some places at more than one corner we have a health care practitioner that is accessible that is trained that is knowledgeable and that is looking out for your health we have a health care practitioner that is able to provide better quality care at a lower cost and so if you don't already I would encourage you that you know your medicine and know your pharmacist there are a critical tool to your valuable health thank you very much

10 comments

  1. Hmm unfortunately it seems like you may be casting pearls before swine Tim. Not many comments, I guess people only listen what they want to what they want to hear. Bless you and your work. I’ll be keeping up with it.
    //shared//

  2. You are a very wise Man Tim, you have done your research and truly understand the human condition and not just a bunch of demographics. This mans approach to medicine will save mankind from consuming itself.

  3. This is a serious bottleneck effecting indirectly unrelated areas of society for every single of one us… THIS IS WHY WE ARE LOOSING THE WAR ON DRUGS. The only conspiracy is us all wanting to control our therapy because of fear, pain, fear of pain or fear of fear itself.

  4. As a caregiver and one who took medication orders for the top Online Pharmacy in the U.S.A, I learned that by using a system of recording and managing medication records an individual can:
     
    1. Reduce waste of medications (e.g. too many meds on hand)
    2. Reduce abuse of medications (e.g. taking meds that are old, the wrong dose or the wrong type.)
    3. Become more educated in dispensing medications.
    (e.g. correct out-dated or incorrect information on medication labels.)
    4. Take ownership by having more intelligent interaction with health care providers.
    I wrote a book on this issue to help the millions who are looking to be more independent and organized in their health care decisions: Organize and Maintain Medications (A Caregiver's Guide to Keeping Good Records and your Sanity)
    http://www.amazon.com/Organize-Maintain-Medications-Caregivers-Keeping-ebook/dp/B0092RNV1M/ref=pd_sxp_f_r/181-4593149-0791215

  5. Well done Tim.  Similar problems here in Ireland, and we're awaiting resource allocation in order to be able to provide the service!

  6. Great video!
    Ramsell believes the power of MTM can save the Healthcare System.
    Our MTM solution helps Sponsors standardize quality interventions, improve clinical outcomes and control costs.

  7. Thank you Dr. Ulbrich for an excellent presentation that clearly explains what MTM is and why it's important and cost effective. Our healthcare system cannot afford to keep wasting $300B every year on this complex patient-focused problem. Pharmacists are more than ready and able to help fix what is obviously broken. It's time our efforts are officially recognized, utilized and capitalized!

  8. Great points, Dr. Ulbrich. Lucky to have you as a professor at The Northeast Ohio Medical University College of Pharmacy.

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