Pharmacists: Be Proactive with MTM Programs
When the Medicare Part DPrescription Drug Benefitlaunched on January 1,2006, it ushered in a change for whichthe pharmacy industry has long advocated.That change was the opportunityfor pharmacists to be reimbursed forpatient counseling programs.
Since the initial focus will be onenrolling beneficiaries and collectingthe data necessary to determine eligibility,most Medication Therapy Management(MTM) programs will not startin any robust manner until at leastmidyear. Because of the time frameinvolved, many Part D prescription drugplans (PDPs) have opted to initially handleprograms in-house. Nonetheless,pharmacists may wish to strongly considersetting up programs—whether ornot they have contracted for services.
"We need to lookat 2006 as the yearfor pharmacists toget MTM services upand running and forencouraging pharmaciststo make contactwith plans to learnabout opportunitiesto contract for MTMservice delivery," said Anne Burns, RPh,group director, practice developmentand research, American PharmacistsAssociation (APhA).
Edward J. Staffa, vice president, pharmacypractice and communications,National Associationof Chain Drug Stores(NACDS), added: "Duringthe first year ofthe Part D benefit,community pharmacyhas the importantopportunity to deviseand implement MTMprograms that demonstrate effectiveoutcomes, so that, when CMS [Centersfor Medicare and Medicaid Services]becomes more prescriptive as to howplans must deliver MTM services, theagency will have had the opportunity tosee effective examples of communitypharmacy-delivered MTM programs."
What Constitutes MTM?
CMS requires MTM for beneficiarieswith multiple chronic diseases who aretaking multiple Part D-covered drugsand who are likely to incur annual costsin excess of $4000. In addition, CMS hasadopted a very broad definition of whatconstitutes MTM services. It includeselements designed to promote the following:
- Enhanced enrollee understandingof the appropriate use of medications
- Increased enrollee adherence toprescription medication regimens
- Detection of adverse events andpatterns of over-and underuse ofprescription drugs
The general consensus is that mostplans are providing services in-houseduring 2006. Some plans, however,such as Community Care Rx (CCRx), arerolling out pharmacy-based programs.
"Knowing [patients] and being ableto see their reactions and facialexpressions" is a benefitof pharmacist-drivenMTM, saidKurt Proctor, PhD,RPh, chief operatingofficer (COO) of CCRxand Community MTMServices LLC. "Youget a sense of whetherthey understandwhat you're talking about; they'remore comfortable asking questions.There isn't anything in any form ofhuman communication that canreplace that relationship." Other companies, such as Humana
Inc, are taking a multifaceted approach.This approach combines ongoing writtencommunications, outbound calls,and pharmacy-based consultations.
"This is really a diseasemanagementprogram that is builtaround the notion ofhealth education andhealth literacy; of givinginformation andguiding [beneficiaries]on what they need," said William Fleming,Humana's vice president of pharmacy."Our program is [designed] to reachbeneficiaries where they live and tofully meet their needs."
Establishing MTM Programs
Although CMS has issued few guidelines,the industry has stepped in, introducinga variety of tools to help pharmacistsdeal with the most commonchallenges they face in creating an efficient,effective MTM program. Thesechallenges range from physical spaceto communications skills, health literacy,and clinical competency, as well asestablishing relationships and implementingthe infrastructure necessary tosupport scheduling, documentation,and billing.
APhA and NACDS have released"Medication Therapy Management inCommunity Pharmacy Practice: CoreElements of an MTM Service," a jointpublication that provides pharmacistswith a framework on which to basetheir programs, as well as the"Medication Therapy ManagementImplementation Manual." The associationsalso plan to offer training servicesto help pharmacists hone their clinicalskills and expertise.
Other organizations are focusing onhelping pharmacists work through theparadigm shift required to run a successfulMTM program. This shiftincludes moving from a product-basedbusiness model to one that is service-based.
"Changing work flows and utilizingtechnicians and technology more effectivelywill free the pharmacists up tospend more time in patient care, butpharmacists must convert that patientcare time into billable hours," said TomHalterman, RPh, chief executive officerof Outcomes Pharmaceutical HealthCare. The firm offers a Web-based documentationand billing system for MTMservices, as well as training programsthat are accredited by the AccreditationCouncil for Pharmacy Education.
Outcomes, which has contracts withCareFirst BlueCross BlueShield, aRegion 5 PDP, and AvMed Health Plan,a Region 9 PDP, "has developed a businessmodel focusing on what pharmacistsdo with their heads rather thantheir hands," added COO PattyKumbera, RPh. "Our programs compensatepharmacists based on theirability to assist in more cost-effectivetherapies for patients, but, moreimportantly, they focus on qualityissues such as making sure [patientsare] on the right drugs, in the rightcombinations and appropriatestrengths, and that they are taking[these drugs] properly. Our Web-baseddocumentation and billing system alsoallows pharmacists to participate inour program without investing in costlycomputer hardware and software."
In fact, access to computerizedbilling and documentation systemsplays a critical role in the success ofMTM programs. For that reason,Humana has developed a pharmacisttool kit that, in addition to educatingpharmacists on what MTM is and howit works, assists with setting up paymentsystems and claims-submittalprocesses.
"An entire payment system exists forpharmaceutical claims, but not for MTMclaims," said Humana's Fleming. "Thelast thing we want to do is have pharmacistssubmitting paper reimbursementclaims."
Also, for that reason, CCRx will beutilizing the Web-based communicationsinfrastructure, clinical content,and policies and procedures systemcurrently under development byCommunity MTM, which will serve as aconduit between plan sponsors andcommunity pharmacists. In addition toproviding the names of eligible patients,Community MTM will provide such criticalinformation as medication history,clinical protocols, education materials,and patient-specific benefit designdata—"all the tools pharmacists needand probably don't have in their currentsystem to conduct MTM," said Proctor.
A Year of Transition
Although the number of PDPs utilizingpharmacists for MTM services islower than the profession believes thatit should be, MTM services underMedicare Part D are an evolvingprocess. Pharmacists still have theopportunity to gain widespread acceptanceas the primary providers of MTMon the health care team.
"Pharmacists need to be patient andproactive," said NACDs' Staffa. "Theyneed to be patient because, eventhough Medicare Part D MTM servicesprovide a great opportunity for pharmacy,these services may take as long as 1or 2 years before they evolve into aposition of prominence within thehealth care system."
"Meanwhile, [pharmacists] need tobe proactive," Staffa reiterated. "AsCMS and other entities in health careassess the value of MTM services, communitypharmacy must demonstratethrough the services it has created thatcommunity pharmacists are the mosteffective providers of these importantservices."
Ms. Roop is a freelance writer based in Tampa, Fla.