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When the Medicare Part D Prescription Drug Benefit launched on January 1, 2006, it ushered in a change for which the pharmacy industry has long advocated. That change was the opportunity for pharmacists to be reimbursed for patient counseling programs.
Since the initial focus will be on enrolling beneficiaries and collecting the data necessary to determine eligibility, most Medication Therapy Management (MTM) programs will not start in any robust manner until at least midyear. Because of the time frame involved, many Part D prescription drug plans (PDPs) have opted to initially handle programs in-house. Nonetheless, pharmacists may wish to strongly consider setting up programswhether or not they have contracted for services.
"We need to look at 2006 as the year for pharmacists to get MTM services up and running and for encouraging pharmacists to make contact with plans to learn about opportunities to contract for MTM service delivery," said Anne Burns, RPh, group director, practice development and research, American Pharmacists Association (APhA).
Edward J. Staffa, vice president, pharmacy practice and communications, National Association of Chain Drug Stores (NACDS), added: "During the first year of the Part D benefit, community pharmacy has the important opportunity to devise and implement MTM programs that demonstrate effective outcomes, so that, when CMS [Centers for Medicare and Medicaid Services] becomes more prescriptive as to how plans must deliver MTM services, the agency will have had the opportunity to see effective examples of community pharmacy-delivered MTM programs."
What Constitutes MTM?
CMS requires MTM for beneficiaries with multiple chronic diseases who are taking multiple Part D-covered drugs and who are likely to incur annual costs in excess of $4000. In addition, CMS has adopted a very broad definition of what constitutes MTM services. It includes elements designed to promote the following:
The general consensus is that most plans are providing services in-house during 2006. Some plans, however, such as Community Care Rx (CCRx), are rolling out pharmacy-based programs.
"Knowing [patients] and being able to see their reactions and facial expressions" is a benefit of pharmacist-driven MTM, said Kurt Proctor, PhD, RPh, chief operating officer (COO) of CCRx and Community MTM Services LLC. "You get a sense of whether they understand what you're talking about; they're more comfortable asking questions. There isn't anything in any form of human communication that can replace that relationship." Other companies, such as Humana
Inc, are taking a multifaceted approach. This approach combines ongoing written communications, outbound calls, and pharmacy-based consultations.
"This is really a disease management program that is built around the notion of health education and health literacy; of giving information and guiding [beneficiaries] on what they need," said William Fleming, Humana's vice president of pharmacy. "Our program is [designed] to reach beneficiaries where they live and to fully meet their needs."
Establishing MTM Programs
Although CMS has issued few guidelines, the industry has stepped in, introducing a variety of tools to help pharmacists deal with the most common challenges they face in creating an efficient, effective MTM program. These challenges range from physical space to communications skills, health literacy, and clinical competency, as well as establishing relationships and implementing the infrastructure necessary to support scheduling, documentation, and billing.
APhA and NACDS have released "Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service," a joint publication that provides pharmacists with a framework on which to base their programs, as well as the "Medication Therapy Management Implementation Manual." The associations also plan to offer training services to help pharmacists hone their clinical skills and expertise.
Other organizations are focusing on helping pharmacists work through the paradigm shift required to run a successful MTM program. This shift includes moving from a product-based business model to one that is service-based.
"Changing work flows and utilizing technicians and technology more effectively will free the pharmacists up to spend more time in patient care, but pharmacists must convert that patient care time into billable hours," said Tom Halterman, RPh, chief executive officer of Outcomes Pharmaceutical Health Care. The firm offers a Web-based documentation and billing system for MTM services, as well as training programs that are accredited by the Accreditation Council for Pharmacy Education.
Outcomes, which has contracts with CareFirst BlueCross BlueShield, a Region 5 PDP, and AvMed Health Plan, a Region 9 PDP, "has developed a business model focusing on what pharmacists do with their heads rather than their hands," added COO Patty Kumbera, RPh. "Our programs compensate pharmacists based on their ability to assist in more cost-effective therapies for patients, but, more importantly, they focus on quality issues such as making sure [patients are] on the right drugs, in the right combinations and appropriate strengths, and that they are taking [these drugs] properly. Our Web-based documentation and billing system also allows pharmacists to participate in our program without investing in costly computer hardware and software."
In fact, access to computerized billing and documentation systems plays a critical role in the success of MTM programs. For that reason, Humana has developed a pharmacist tool kit that, in addition to educating pharmacists on what MTM is and how it works, assists with setting up payment systems and claims-submittal processes.
"An entire payment system exists for pharmaceutical claims, but not for MTM claims," said Humana's Fleming. "The last thing we want to do is have pharmacists submitting paper reimbursement claims."
Also, for that reason, CCRx will be utilizing the Web-based communications infrastructure, clinical content, and policies and procedures system currently under development by Community MTM, which will serve as a conduit between plan sponsors and community pharmacists. In addition to providing the names of eligible patients, Community MTM will provide such critical information as medication history, clinical protocols, education materials, and patient-specific benefit design data"all the tools pharmacists need and probably don't have in their current system to conduct MTM," said Proctor.
A Year of Transition
Although the number of PDPs utilizing pharmacists for MTM services is lower than the profession believes that it should be, MTM services under Medicare Part D are an evolving process. Pharmacists still have the opportunity to gain widespread acceptance as the primary providers of MTM on the health care team.
"Pharmacists need to be patient and proactive," said NACDs' Staffa. "They need to be patient because, even though Medicare Part D MTM services provide a great opportunity for pharmacy, these services may take as long as 1 or 2 years before they evolve into a position of prominence within the health care system."
"Meanwhile, [pharmacists] need to be proactive," Staffa reiterated. "As CMS and other entities in health care assess the value of MTM services, community pharmacy must demonstrate through the services it has created that community pharmacists are the most effective providers of these important services."
Ms. Roop is a freelance writer based in Tampa, Fla.