Announcer (00:04):
Welcome to 340B Insight from 340B Health.
David Glendinning (00:12):
Hello from Washing D.C., and welcome back to 340B Insight. The podcast about the 340B Drug Pricing Program. I'm David Glendinning with 340B Health. This episode is sponsored by Verity Solutions, an innovator in 340B program optimization. Verity Solutions drives continually improved 340B solutions and vigilantly addresses regulatory changes so that their customers can dedicate fewer resources to program administration and more resources to community wellness. Our guest today is Jessica Tilton, a clinical pharmacist at University of Illinois Health. Our previous episode with our own Caroline Steinberg, focused on the need for covered entities to conduct research on the patient benefits of the 340B program. We are continuing that conversation with Jessica to hear some great examples of how our health system has done just that. But before we go to that interview, let's take a minute for a roundup of 340B news.
David Glendinning (01:21):
Controversial moves by pharmaceutical manufacturers to cut off 340B pricing on their drugs expanded at the beginning of this month. Following the lead of the company, Eli Lilly, both AstraZeneca and Sanofi on October 1st stopped offering 340B prices on drugs that covered entities to spend through contract pharmacies. AstraZeneca implemented this new policy for all covered entities while Sanofi did so for hospitals that do not comply with company's demands for contract pharmacy patient claims data. The companies carry through on their threats in the face of strong opposition from safety net health providers, a majority of members of congress and numerous national hospital and pharmacy organizations. But one company appears to have backed off in earlier threat, at least for now, to cut off 340B pricing for covered entities that do not hand over claims data.
David Glendinning (02:14):
An executive with the manufacturer Novartis, faced critical questioning about its proposed policy change during a recent congressional oversight committee hearing. He said Novartis was still evaluating its next steps. And as of this recording, the company is still offering drugs at 340B prices through contract pharmacy arrangements. And the centers for Medicare and Medicaid services is evaluating numerous public comments on a proposal to deepen Medicare pay cuts to many 340B hospitals starting next year. One of those comment letters is from 340B Health in which we strongly oppose both the CMS plan for deeper part B rate reductions to these hospitals in 2021 and an alternative plan to keep the pay cuts that currently are in place. You can read our full comment letter in the show notes for this episode.
David Glendinning (03:12):
Now for today's feature interview with Jessica Tilton, the clinical coordinator for the University of Illinois Health, Medication Therapy Management clinic. Dr. Tilton is a clinical pharmacist in ambulatory care at UI Health, where she also works in the electrophysiology clinic. She also is a clinical assistant professor in the department of pharmacy practice at the University of Illinois at Chicago College of Pharmacy. Our own Myles Goldman sat down with Jessica to discuss the great work UI Health's Medication Therapy Management clinic is doing to demonstrate through data, how 340B helps improve patient health outcomes. Let's hear that conversation.
Myles Goldman (03:54):
Hello, I'm Myles Goldman, communications manager at 340B Health. Today, our guest is Jessica Tilton, the clinical coordinator for the University of Illinois Health Medication Therapy Management clinic. I'm looking forward to discussing the Medication Therapy Management program with you today, but first, welcome to the podcast, Jessica.
Jessica Tilton (04:12):
Thank you.
Myles Goldman (04:14):
Tell us about your day-to-day at the MTM clinic?
Jessica Tilton (04:18):
I wear several hats. At the Medication Therapy Management clinic, I am a first and foremost, a clinical pharmacist. I work intricately with the patients. I create that patient-pharmacist relationship. We all have our cohort of patients that we are considered the primary pharmacist for. And so those patients, I primarily see along with the rest of them. So in addition to be a clinical pharmacist, I am of course, the Medication Therapy Management clinic coordinator. And so what that means is that I'm responsible for making sure that we have students that are coming into clinic, residents that are coming into clinic, so that we have different levels of learners.
Jessica Tilton (05:03):
In addition to that, I ensure that we're producing research. I don't have to be responsible for, or create the ideas for all the research, but I do get to be the one that brags about it. The one that is the champion and tells everybody about all the good things that our clinic has done. In addition to that hat, I also am a clinical assistant professor. So, that means that I do teaching. I do that as I mentioned in the clinic, but then I also do that in the classroom as well.
Myles Goldman (05:33):
Well, part of the reason we're having you here today is to... So you can brag a little bit about research, but we'll get to that in a little bit. Tell me about UI Health and the community it serves?
Jessica Tilton (05:45):
The University of Illinois Hospital & Health Sciences System is made up of a 465-bed tertiary hospital, 21 clinics and 11 FQHCs. UI Health is an entity of UIC, which also encompasses seven health science colleges, which the college of pharmacy is one of those. UI Health is a safety net hospital, our [inaudible 00:06:12] percentage is roughly 42%. Our patient population is the underserved, primarily Latino and African-American.
Myles Goldman (06:23):
And it's right in Downtown Chicago, right?
Jessica Tilton (06:26):
Yes. UI health is located in Downtown Chicago. It's located in our Medical District.
Myles Goldman (06:32):
Let's start with the basics. What is Medication Therapy Management?
Jessica Tilton (06:36):
Medication Therapy Management or MTM is a pharmacist-run clinic. It is a referral-based clinic. So any healthcare provider at UIC can refer a patient to us through their electronic medical record. They're typically referred to us for non-adherence, for low health literacy, lack of coordination of their medications and for disease state management. The primary disease States to which we manage are diabetes, hypertension, asthma. Those are amongst the few that we do.
Myles Goldman (07:09):
And when was MTM clinic at UI Health started?
Jessica Tilton (07:13):
In the nineties, it was identified that the pharmacy's workflow, there was a wrench that was thrown in and every time there was a patient that had 10-plus medications. It just caused a lot more work for the pharmacy and so they decided that they would create a program for patients with 10-plus medications so that they would do them before the patient came. That they would do them all at one time, they would synchronize these medications and there would be a little bit of clinical oversight by a clinical pharmacist as well. Well, in the early 2000s, they hired their first pharmacist to make this into a clinic. And then subsequently I came on board with one or two other pharmacists, and we really transformed this from just being a refill 10-program that patients come and pick up their medications and it helps with workflow in making sure that the patients get the right medications to an actual clinic where they're coming in to see a clinical pharmacist, the same time that they are picking up their medications.
Myles Goldman (08:15):
And you're having conversations with patients as they come and that go, as you were saying well beyond just handing them their medications. You're speaking with them about a variety of issues, right?
Jessica Tilton (08:27):
When they come in, the primary thing that we're addressing is adherence. That we really have to get to the core reason as to why they're not adhering to their medications, and once we uncover that and address it and resolve those issues, then we can move on to things such as disease state management.
Myles Goldman (08:45):
And do you also discuss with patients issues they might be having with side effects?
Jessica Tilton (08:51):
Oh, absolutely. If they're having a side effect to the drug, we assess that. Every single time they come in, we're asking them, "How are you feeling? What is going on? Do you have any complaints today?" And then kind of tweaking it to see what is the core reason for this complaint? Could it be a side effect to the truck? We're definitely counseling them on any new medication or any adjustments in medications so they can be self-aware of whether a side effect could be occurring or not.
Myles Goldman (09:20):
And how often is a patient seen by a pharmacist in the clinic?
Jessica Tilton (09:26):
Sure. The first time a patient comes to us, it's a 60-minute visit. And that 60-minute visit is really evaluating what medications they have at home, and usually it's about load. And so we're sifting through those medications to see what they're actually taking, even though they have them doesn't mean that they're taking them. So we're identifying what they're taking and then looking in the electronic medical record to see what the physicians intended for them to be on. And usually we're having a compromise of like what we're actually going to start that particular day. Subsequent visits are monthly, generally speaking and they're 30-minute visits. The day of their appointment is tied to the day that their medications are due. We synchronize all of their medications so they're due on one day. And this is the day of their clinical visit as well. It's nice that it's tied to their medications and the reason why it's nice it's tied to their medications because it creates buy-in for the come to see us. But then also our clinic is embedded within the pharmacy.
Jessica Tilton (10:29):
So while we're not doing the filling and checking and processing and all of that sort of stuff, we can ensure that the patients have access to their medications. The pharmacy is letting us know if there's a prior approval is necessary, if the drug just is not covered no matter what, whether there's an alternative option that would be covered, we get to assess all of those things. And then we also have a technician that's solely works in the Medication Therapy Management clinic, and she is responsible for addressing all of those access issues and resolving them. And then bringing them to our attention if they need to be escalated up to us or if they need to be escalated to the physician.
Myles Goldman (11:09):
And you're speaking about coordination within the pharmacy team in a lot of ways, but how does coordination work between the pharmacists at the MTM clinic and a patient's primary care physician or other specialists they may be seeing?
Jessica Tilton (11:24):
The patients are referred to us by their providers. So they already know about us. There's already buy-in from the physicians. Now, what we're also doing when we see these patients is disease state management many times, and that can be diabetes or hypertension or dressing their asthma. And this is done through protocols. So there's a collaboration and coordination from the standpoint that we have approved protocols from the physicians for us to utilize to manage these patients. Now, if there's anything that we're doing that's outside of the realm of what we're allowed to do within these protocols, we reach out to the physicians. And there's numerous ways that we can do this. That's based on the acuity of the issue that's at hand, whether we go across the hall and go talk to them, or whether we page them, whether we have their cell phones or whether we communicate with them through the electronic medical records to resolve the issue.
Myles Goldman (12:15):
And looking specifically, is there a patient or two that come to mind that have been helped by the MTM clinic?
Jessica Tilton (12:23):
One patient that comes to mind directly right now was a patient that I had in electrophysiology clinic and in electrophysiology clinic, this patient's blood pressure was like 200 over 150. And so we had to send them to the emergency room and the physician said, "This needs more resources that I'm able to necessarily provide." And I said, "Well, we'll send them to the Medication Therapy Management clinic for them to assist with the blood pressure management and we can see this patient on a weekly basis to address what is the reason as to why their blood pressure is elevated? Is it an adherence issue? Is it just we need to titrate up these medications." So we saw the patient on a weekly basis and we were able to lower his blood pressure. And moreover, we were able to keep him out of the emergency room and out of the hospital.
Myles Goldman (13:15):
And with those powerful examples you shared, it's really important then to understand the role that 340B plays in the Medication Therapy Management clinic.
Jessica Tilton (13:23):
Without 340B savings that's pushed back into our clinic, we would not be as robust of a clinic as we are. We would not be able to touch the volume of patients that we reach currently.
Myles Goldman (13:37):
You and your colleagues at UI Health, and this is another reason I'm excited to have you on as a guest, have done some research on the health outcomes of patients who have been seen at the MTM clinic. And I'm hoping you can share with us about the research project.
Jessica Tilton (13:53):
Sure. There's several different initiatives that we've done. Some just are QI quality indicators that we have or just with adherence and hypertension. Our adherence levels are well above what is perceived to be an appropriate adherence level. And they're typically in the nineties. Other research that we've done is assessing our impact on diabetes and hypertension. And we've been able to show that we have statistically significant impact on A1C and systolic blood pressure. We were able to reduce A1C by 0.63% and reduce systolic blood pressure by 8.2 millimeters of mercury. So we utilized these findings and we created a subsequent study that utilized a hypothetical modeling to assess what our impact is if decrease somebody's blood pressure, what does that translate into?
Jessica Tilton (14:56):
We know that hypertension is a risk factor for developing cardiovascular diseases, and are we able to, with our reduction have any sort of impact on cardiovascular events? So we put the data points from our previous study into this model along with some cost analysis from the literature. And what we were able to find is that we reduced for a cohort of 200 patients over 10 years, we reduced cardiovascular events by 10, and we increased life years for this cohort by 4.5 years. Moreover, we reduced the cost to insurers by $500,000.
Myles Goldman (15:37):
And those are really important results. I did want to take a step back just to hear more about, at the beginning, what inspired the research?
Jessica Tilton (15:47):
What inspired the research was basically research is knowledge, without the research, we don't know that what we're doing is really having any impact on these patients. We want to think that it is, but we don't necessarily know unless we do research.
Myles Goldman (16:03):
And based on your experience, what advice would you give to other pharmacists who want to conduct research on 340B and the services that use 340B savings?
Jessica Tilton (16:12):
I think that if you have an idea, I think that you should go for it. I think that the idea can be small, it can start with a quality indicator and then blossom into research. I think you need to look for the resources out there that can support the research. If you don't know how to do statistics, you can find resources to help support processing those statistics or helping you create a sound research project. Also, looking at other clinicians at other institutions to drive your numbers, to drive your resources and to help come up with a research project that is followed through to fruition.
Myles Goldman (16:51):
And I imagine you worked with your institution's statisticians and other researchers to make the research possible?
Jessica Tilton (16:59):
Yeah, we have a really nice collaboration at UIC with the MTM clinic and with our department of health systems and outcomes and policies. So, I'm under the department of pharmacy practice and we've come up with numerous ideas. We're kind of the clinical minds behind what's going on. And then we have the researcher minds that is part of that [inaudible 00:17:24] group that really ensures that we have a sound research project and assists us with the appropriate statistics.
Myles Goldman (17:31):
And that's great to hear. The collaboration that went into this. Jessica, thank you so much for taking the time to speak with us and share with us more about the work that MTM clinic is doing at UI Health.
Jessica Tilton (17:45):
[inaudible 00:17:45] privileged to be here. Thank you so much, Myles.
David Glendinning (17:48):
Our thanks again to Jessica Tilton for sharing just a part of the growing body of evidence of how patients benefit from 340B discounts. If you want to learn more about 340B research, please check out the show notes or visit the 340B Health website. And because it's October, we are celebrating American Pharmacists Month. This year, we have even more reasons to highlight the contributions that pharmacists make to the patient care team at the hospital. For those of you listening who are pharmacists, please know that we value you and appreciate everything you do for your patients. Thank you.
David Glendinning (18:22):
Please plan to join 340B Health on Thursday, October 29th for a webinar recapping all the 340B action we have seen at the state level so far this year. While 340B and other drug pricing issues were very much in the Washington spotlight this year, there were numerous state policy changes and proposals that could affect the way you run your 340B programs. You can find the link to the webinar registration page in the show notes. What questions about research do you still have following today's episode? As always, if you have any questions or comments about any of the items we cover here at 340B Insight, please email us at podcast@340bhealth.org. We will be back in a couple of weeks with our next episode. Until then, thanks for listening and be well.
Announcer (19:14):
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