By Paul Grundy, MD, President, GTMRx Institute
December 18, 2020
Let doctors be doctors: Comprehensive medication management supports primary care
Primary care physicians face overwhelming pressure right now—and not just because of the pandemic. Even in the best of times, we ask too much from them. Instead of letting them be healers and diagnosticians, we make them responsible for every aspect of patient care. A large part of that responsibility is finding the right medication for the right patient.
Not only is this a huge burden on the doctor—it’s also the wrong approach to medication management. We must address the burden and we must improve medication outcomes. After all, 73.9% of primary care visits involve medication prescribing.
At the GTMRx Institute, we believe the best way forward is through a more rational and systematic approach to medication use, comprehensive medication management (CMM).
So, what exactly is CMM? Let’s start with the official definition.
The standard of care that ensures each patient’s medications (whether they are prescription, nonprescription, alternative, traditional, vitamins or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken and able to be taken by the patient as intended.
Put more simply, it’s a process that connects the right medications to the right patient with the right dosage at the right time and a process that evaluates whether our patient is achieving clinical goals of therapy.
Think about it this way: Patients will always be on medications. We aren’t going to change that. The value CMM brings derives from having a better patient outcome as a result of appropriate use of medications. We know CMM works. CMM improves medical outcomes by ensuring medications are appropriately and effectively used while also reducing the total cost of care. It also lightens the primary care provider’s load. As a result, physicians feel greater satisfaction in their work.
Making it happen
CMM increases patient access to pharmacist-led medication management conducted as part of an interprofessional team activity and in collaboration with the primary care physician. These clinical pharmacists can prevent—or identify and resolve—medication therapy problems: In other words, they optimize medication use.
Optimizing medication requires transformation and, in this case, transformation is a three-legged stool.
- Technology must evolve: We’re already seeing this with advances in health IT, AI and pharmacogenomics. Such tools will allow us to create care plans and supporting medication plans that are informed by data and personalized to the patient.
- Payment models must support value and the interprofessional team: There’s only one way to herd cats, and that’s to move the food. We must reward value, and we’re already moving in that direction. Soon, no outcome will mean no income. But that shift requires not only a change in reimbursement; it requires a change of heart and mindset.
- The culture of health care must change: Practices need to transform from the mindset of managing an episode of care to proactively managing a population and developing a healing relationship of trust. A large part of that entails a move toward person-centered, team-based care.
It’s a team sport
For too long, we’ve thought about the physician as a human storage device who holds everything about all their patients in their heads. We’ve expected them to be an expert in everything. Clearly, that approach has failed physicians and patients alike.
We must move to a more collaborative model. CMM enables the interprofessional team—which includes a clinical pharmacist—to work collaboratively with the physician to ensure appropriate use of medications and gene therapies.
This team-based approach lightens the physician’s burden: The physician can rely on team members to bring their unique expertise to patient care. I’m talking about a team of professionals, each with their own strengths, skill sets, training and education. This allows the primary care physician to focus on two critical tasks: handling difficult diagnostic dilemmas and creating patient relationships.
Other members of the team are responsible for what they do best. For example, the clinical pharmacist is the expert in medication optimization. The physician can rely on their expertise, and together, they can develop the medication plan.
A team may also include the following:
- A nurse or a nurse practitioner, who may be much better at patient engagement.
- The behavioral health professional, who is the ideal professional for integrating above the neck with below the neck.
- The nurse educator, who has the greatest expertise in teaching patients what they need to know about their care.
- Other experts as needed, working at the top of their license.
It should go without saying—but I’m going to say it anyway: For this approach to work, team members must trust one another, and they must share a passion to get the medications right for every patient.
Above all, the team needs a trusted healer. That may be the physician, but it can also be a nurse practitioner, a PA or some other professional. Patients need to have someone to turn to when the chips are down. We all need someone who cares. That’s who we are as humans. So much of the work I’ve done over the years comes down to supporting a healing relationship between a patient and a primary care healer.
Why we need this now
Turning to the process of care that is comprehensive medication management, we can prevent thousands of avoidable deaths each year. Non-optimized medication therapy led to an estimated 275,000 avoidable deaths and cost $528.4 billion, in 2016. People are dying because their medications are not being managed to ensure appropriate use.
This is unacceptable. I believe implementing CMM is the best way to bring about the changes we need. Optimal patient care cannot happen without a systematic approach to medication use. It’s that simple. We have to get the medications right or we are failing our patients.
If you agree—or even if you are simply intrigued—I encourage you to explore the GTMRx Institute website. There we offer tools, guidance and evidence for practicing clinicians, for policymakers and for employers as health plan sponsors to bring about much-needed change to optimize medication use. Be part of getting the medications right.
References: Slone Epidemiology Center at Boston University. Patterns of medication use in the United States 2006: a report from the Slone Survey.  McInnis T, Webb E, and Strand L. The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes, Patient Centered Primary Care Collaborative, June 2012  The Outcomes of Implementing and Integrating Comprehensive Medication Management in Team-Based Care: A Review of the Evidence on Quality, Access and Costs, GTMRx, October 2020  Watanabe, JH, McInnis, T, & Hirsch, JD. “Cost of Prescription Drug–Related Morbidity and Mortality.” Annals of Pharmacotherapy, 2018; 52(9), 829–837