Mr. DePue is corporate clinical pharmacy director for Medicare at Coventry Health Care Inc in Glen Allen, Virginia. Dr. Hailey is chief pharmacy officer and senior vice president of Pharmacy Services at Coventry Health Care Inc.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provided the legislative framework for the program we all know as Medicare Part D. One of the requirements for all Medicare Part D program sponsors is that they offer medication therapy management (MTM) services to qualified plan members. The qualifying criteria for MTM services are set forth by the Centers for Medicare & Medicaid Services. To qualify, members must have a projected annual drug expenditure of $4000 or more, have multiple chronic disease states, and take multiple Part D medications.1 Prescription drug plan sponsors have the flexibility to design their MTM services within these guidelines.
In 2007, it is estimated that more than 26% of plan sponsors used outside sources to provide MTM services, and another 24% used a combination of internal staff and outside sources.2 This additional opportunity for face-to-face consultation with patients helps to strengthen the patient?pharmacist relationship and promotes loyalty to a particular store or chain. It also has the potential to improve health outcomes and quality of care.
Although MTM is recognized by most as an excellent opportunity for the pharmacy profession, it is not without challenges. With multiple Part D plan sponsors in the marketplace, a host of unique MTM programs exist, each with its own program requirements, methods for identifying qualifying patients, and documentation procedures.
Once providers of MTM services become familiar with the specific plan requirements and are supplied with qualifying patients, they will need to contact patients to set up an MTM counseling session. When the session is scheduled, pharmacist overlap will be necessary to ensure that normal pharmacy operations continue while the counseling session takes place. In addition, a private area will need to be set up in the pharmacy to protect privacy and allow the focus to be on the patient.
Each pharmacist performing MTM services will have his or her own counseling style. This may be based on personal preference, chain software for documentation of counseling services, or MTM software provided by the plan sponsor. Regardless of the flow of questions and documentation, it is important that providers ask patients to bring to the session all medications they currently take or plan to take, prescription or other. This brown-bag counseling session will allow the pharmacist to see the patient's entire medication regimen.
Although the ideal situation would be that patients have all of their prescriptions filled at 1 pharmacy and pharmacists have a full online history of medication use, this is not always the case. In addition, OTC products are typically not included in a patient's computer-based drug history. Often, many patients do not consider OTC medications or herbal supplements as medications when asked what they are taking. For these reasons, a brown-bag counseling session will give the pharmacist the most complete picture.
During the session, the pharmacist should make sure that the patient understands the purpose of all the medications, the frequency with which they should be taken, whether or not they should be taken with food or on an empty stomach, and the optimal time of day to take them. Because the pharmacist will have the complete medication picture, drug-to-drug interactions, therapy duplications, high-dose/low-dose considerations, patient adherence issues, and polypharmacy are some of the many areas that can be addressed. To promote consistency, pharmacies anticipating that they will be performing these services on a regular basis should use a software program or develop a form to document topics discussed, recommendations, and an action plan. If a form is developed, it should be created in a format that allows patients to take it with them after the session. This information also would serve as a record for the pharmacy and as documentation to transmit to prescriber(s) with any recommendations for the patient and physician.
Pharmacists providing this service will not always have time to prepare in advance for the session, nor will they know ahead of time all of the medications the patients will bring with them. For these reasons, the pharmacist should have easily accessible reference materials. Patients understand that pharmacists have not memorized every possible drug interaction and drug dose for every condition. A patient will not think less of a pharmacist for taking a moment to verify that an obscure herbal supplement does not interfere with warfarin levels. If anything, the patient will appreciate the extra effort by the pharmacist to ensure the most accurate information is used for the medication review.
Patient education materials are an integral component of MTM programs as well. Although the session will be geared toward medication adherence, disease state information provided as take-home reading is well received by patients. This material helps provide background information that the pharmacist will most likely not have time to explain in person. It would be impossible to have information prepared on every disease state, but there are common conditions seen in the senior population that cover the majority of patients. Pharmacists also can direct patients to reputable Web sites, such as those of the American Heart Association or American Diabetes Association, so that they may learn more about their condition(s).
With their extensive medication knowledge, pharmacists are long overdue to be reimbursed for cognitive services. Patients are likely to come in contact with their pharmacist more often than any other health care professional; thus, pharmacists are in the perfect position to influence patients and improve outcomes.
Although Medicare created a formal MTM program, these services do not have to be limited to the Medicare population. MTM can be made available for and promoted to all patients. For those who do not have MTM insurance coverage, the pharmacy can determine a reasonable rate to charge and what specific services will be provided. These one-on-one counseling sessions will help to strengthen the patient?pharmacist relationship and reinforce the role of the pharmacist as an integral part of the patient's health care team.