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Medication Therapy Management: If You Build It, They Will Come

Medication Therapy Management: If You Build It, They Will Come. Meghan K. Sullivan, Pharm.D . Assistant Professor University of New England College of Pharmacy July 27, 2012. Learning Objectives.

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Medication Therapy Management: If You Build It, They Will Come

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  1. Medication Therapy Management: If You Build It, They Will Come Meghan K. Sullivan, Pharm.D. Assistant Professor University of New England College of Pharmacy July 27, 2012

  2. Learning Objectives • Discuss the history of Medication Therapy Management (MTM): where have we been, and where we are going. • Describe the various core components of MTM, including: medication therapy review (MTR), personal medication record (PMR), medication action plan (MAP), intervention and/or referral, documentation, follow-up and billing.  • Discuss the current marketplace for MTM services. • Discuss the design, development, implementation, sustainability and measures for continuous quality improvement revolving around MTM services. • Evaluate current, and discuss future, reimbursement strategies for MTM services.

  3. Defining MTM “A service or group of services that optimize therapeutic outcomes for individual patients.” - Pharmacy Profession (2004) “A program of drug therapy management that may be furnished by a pharmacist and is designed to assure, with respect to targeted beneficiaries, that covered Part D drugs are appropriately used to optimize therapeutic outcomes through improved medication use, and to reduce risk of adverse events including adverse drug interactions.” – CMS (2005)

  4. MTM 101

  5. Core Elements of an MTM Service Model Medication therapy review (MTR) Personal medication record (PMR) Medication-related action plan (MAP) Intervention and/or referral Documentation and follow-up American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008. Available at: www.pharmacist.com/MTM. Accessed December 19, 2011.

  6. Medication Related Problems Unnecessary Drug Therapy Wrong Drug Incorrect Dose Adverse Drug Reaction Inappropriate Compliance Needs Additional Therapy American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008. Available at: www.pharmacist.com/MTM. Accessed December 19, 2011

  7. Testing Your Knowledge… • LB is a 72-year old female who presents to your pharmacy for a MTM consultation. During your visit, you discover that she only takes her hydrochlorothiazide “occasionally” when she notices swelling in her legs, as she experiences nocturia when taking it daily. When completing her MAP, how should this medication-related problem be classified? • Appropriateness of dose/dosing regimen • Therapeutic duplication • Untreated disease/condition • Adherence to therapy

  8. MTM Services Business Model American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008. Available at: www.pharmacist.com/MTM. Accessed December 19, 2011.

  9. Treatment Population “MTM services should be considered for any patient with actual or potential medication-related problems.” – MTM Core Elements 2.0

  10. Medication Therapy Management Services American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008. Available at: www.pharmacist.com/MTM. Accessed December 19, 2011. Medication Therapy Reviews Pharmacotherapy Consults Disease state management Pharmacogenomics Medication safety and surveillance Health and wellness Anticoagulation management Immunizations

  11. Medication Therapy Management Providers American Pharmacists Association. Medication Therapy Management Digest. Tracking the Expansion of MTM in 2010: Exploring the Consumer Perspective. March 2011. Available at: http://www.pharmacist.com/AM/Template.cfmSection=MTM&TEMPLATE=CMContentDisplay.cfm&CONTENTID=25712. Accessed: July 7, 2012.

  12. MTM Patient Care Settings American Pharmacists Association. Medication Therapy Management Digest. Tracking the Expansion of MTM in 2010: Exploring the Consumer Perspective. March 2011. Available at: http://www.pharmacist.com/AM/Template.cfmSection=MTM&TEMPLATE=CMContentDisplay.cfm&CONTENTID=25712. Accessed: July 7, 2012.

  13. MTM Payment: Not Just for Medicare Beneficiaries! Medicare Advantage plans Medicare stand-alone prescription drug plans HMO/managed care plans Specific employer benefit group Commercial insurance PPO plans State Medicaid programs Self-insured health or prescription coverate Health savings accounts American Pharmacists Association. Medication Therapy Management Digest. Tracking the Expansion of MTM in 2010: Exploring the Consumer Perspective. March 2011. Available at: http://www.pharmacist.com/AM/Template.cfm?Section=MTM&TEMPLATE=CMContentDisplay.cfm&CONTENTID=25712. Accessed: July 7, 2012.

  14. The MTM Movement

  15. The MTM Movement • 2006: Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) • Medicare Advantage-Prescription Drug Plans (MA-PD) • Prescription Drug Plans (PDP) • CMS mandated that MTM must “evolve and become the cornerstone of the Medicare Prescription Drug Benefit” Centers for Medicare and Medicaid Services. Medicare Prescription Drug Benefit; Final Rule. Issued January 28, 2005. Available at: http://www.access.gpo.gov/su_docs/fedreg/a050128c.html. Accessed December 17, 2012.

  16. The MTM Movement • Medication-related problems • Annual preventable medication ADRs: 1.5 million • Annual health care system expenditures: $178 billion • Medicare population • Average of 5 or more medications • Increased risk for medication-related problems

  17. Initial MMA MTM Beneficiary Requirements • Multiple chronic disease states • Medication therapy including multiple Part D covered drugs • Patient likely to incur annual costs for Part D drugs that exceed a predetermined level: $4,000 Centers for Medicare and Medicaid Services. Medicare Prescription Drug Benefit; Final Rule. Issued January 28, 2005. Available at: http://www.access.gpo.gov/su_docs/fedreg/a050128c.html. Accessed December 17, 2012.

  18. Enhancement of Medicare Part D MTM Programs • Affordable Care Act (2010) • Improved access to MTM services • Increased intensity of interventions • Provision of summaries to beneficiaries • Collection of robust data for outcomes analysis Centers for Medicaid and Medicare. 2011 Medicare Part D Medication Therapy Management (MTM) Programs. Issued June 30, 2011. Available at:https://www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet2011063011Final.pdf Accessed January 3, 2012

  19. Medicare Part D MTM Programs on the Horizon • Changes for 2013: MTM services and strategies MUST include: • Annual Comprehensive Medication Review • Follow-up interventions • Quarterly assessment of medication use • Automatic enrollment of targeted beneficiaries • Standardized format for comprehensive medication review, action plan and summary Centers for Medicaid and Medicare. CY 2013 Medication Therapy Management Program Guidance and Submission Instructions. Issued April 12, 2012. Available athttps://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/Memo-Contract-Year-2013-Medication-Therapy-Management-MTM-Program-Submission-v041012.pdf. Accessed July 7, 2012.

  20. Health Care Reform and More! American Pharmacists Association; APhA Pharmacy Law Matters 2010: Focus on Selected Provisions of the Affordable Care Act. Pharmacy Today. December 2010. Available at: http://208.40.175.32/cecity/components/util/pdf/docs/pdf/15288_print.pdf. Accessed July 7, 2012. Accountable Care Organizations Patient-centered Medical Home “Independence at Home” Transitions of Care Activities

  21. Testing Your Knowledge… • As per the Medicare Prescription Drug, Improvement and Modernization Act of 2003, how frequently are Medicare Part D plan sponsors required to offer a comprehensive medication review? • Quarterly • Bi-annually • Annually • Every 5 years

  22. Building Your Service

  23. Developing Your Business Plan Mission statement, goals, objectives Target population(s) Desired MTM services Implementation strategy Evaluation strategy

  24. MTM Implementation SWOT Analysis Strengths Weaknesses Opportunities Threats Internal Factors External Factors

  25. Setting Goals • SMART Goals • Specific • Measurable • Achievable • Realistic • Time-Limited

  26. Practice Site Operation Considerations • Space • Layout • Legal, regulatory and quality measures • Workflow • Assigned duties/tasks • Personnel • Time • Budget • Rent/Utility Costs • Software • Vendor contracts • Marketing/Advertising • Personnel

  27. Pharmacy Personnel Pharmacists Pharmacy Technicians • Manager, RPh, clinical pharmacy specialist • Training • APhA, ASHP, NCPA, ASCP, ACCP, CCGP, BPS • MTM, clinical skills, assessment and evaluation • MOTIVATION/Incentive Marketing Recruitment Scheduling Documentation/Data Entry Billing

  28. Testing Your Knowledge… • Which of the following MTM consultation activities are appropriate for pharmacy technicians to participate in? • Establishing appointments with patients • Billing third-party payers for MTM consultations • Faxing/mailing follow-up documentation forms to health care providers • All of the above

  29. Planning for MTM Consultations • Appointment Availability • Personnel • Pharmacist hours • Pharmacy technician hours • Admin/clerk hours • Workload • Daily script count • Interaction • Face-to-face • Telephonic

  30. Recruitment of MTM Patients • Local Initiative • Identifying standards • Sorting data • Contact patients • MTM Vendors • Pharmacy network • Contact patients • 30-90 day turn-around

  31. Documentation of MTM Consultations Paper patient charts Internal documentation system Electronic medical record (EMR) MTM vendor software • Available Electronic Documentation Systems: • Community CCRx • HealthMap Rx • MedKeeper • MirixaPro • MTMPath • Outcomes Pharmaceutical Health Care • Patient Tracker • PharmMD • PhillHelpWorks • RxPerise

  32. Marketing for MTM Services Media: TV, radio, newspaper Social Networking: Facebook, Twitter Fliers, bag-stuffers, buttons, vial caps, stickers Education!

  33. Testing Your Knowledge • List four ways that you can promote MTM services:

  34. MTM Consultations • Pre-appointment: • Review patient materials • Document initial findings • Identify points of clarity • Appointment: • Completion of MTR, PMR, MAP • Post-appointment: • Follow-up: how often?

  35. Billing for MTM Services • CPT Codes for MTM • 99605: Initial patient consultation: Max. 15 minutes • 99606: Follow-up patient consultation: Max. 15 minutes • 99607: Can be used in combination with either 99605 or 99606 to bill for any additional time spent with the patient, in 15 minute increments. • “Incident to” evaluation and management codes (E&M) codes • 99211 • Completing the process… • National Provider Identifier • Superbills

  36. Testing Your Knowledge… • Which of the following CPT codes should be used to bill for additional 15 minute increments during an initial or follow-up MTM consultation • 99604 • 99605 • 99606 • 99607

  37. Make it Work! IS it worth all of your effort?!

  38. Return on Investment • Sample Business Model: • Pharmacist: $130,000 • Base salary: $100,000 • Benefits: $30,000 • Full time employment: 2000 hrs/annually • Need to generate $65/hour if hired as MTM pharmacist • Is it worth it?! McDonough R. Making an MTM business plan work. Pharmacy Today. 2011;17: 48

  39. Institutional Pharmacy Study Medication Therapy Management: 10 Years of Experience in a Large Integrated Health Care System • Methods: retrospective review of 9,068 patients receiving MTM services from September 1998 to 2008 • Patients 21 years of age and older were eligible • Payment made out of pocket or via third party payer • Cost-savings calculations based on estimated costs of office visits, laboratory services, urgent care and emergency room visits and missed days of work Ramalho de Oliveira D, Brummel A, Miller D. Medication Therapy Management: 10 Years of Experience in a Large Integrated Health Care System. Journal of Managed Care Pharmacy. 2010;16:185-195

  40. Institutional Pharmacy Study Medication Therapy Management: 10 Years of Experience in a Large Integrated Health Care System • Results: • Patients: 9,068 • Documented encounters: 33,706 • Drug therapy problems identified: 38,631 • Patients not a goal: 4,849(12,851 conditions) • Improved: 7,068, No Change: 2956, Worsened: 2,827 • Cost Savings: $2,913,850 ($86/encounter) • Cost of MTM $2,258,302 ($67/encounter) • ROI: $1.29 per $1 spent Ramalho de Oliveira D, Brummel A, Miller D. Medication Therapy Management: 10 Years of Experience in a Large Integrated Health Care System.J Manag Care Pharm. 2010;16:185-195

  41. Community Pharmacy Study Analysis of Pharmacist-Provided Medication Therapy Mangement (MTM) Services in Community Pharmacies Over 7 Years Methods: MTM claims data from a multistate MTM vendor was analyzed: Reason, Action, Result, Estimated Cost Avoidance (ECA) Barnett J, Frank J, Wehring H, et.al. Analysis of Pharmacist-Provided Medication Therapy Mangement (MTM) Services in Community Pharmacies Over 7 Years. J Manag Care Pharm. 2009;15:18-30

  42. Community Pharmacy Study Analysis of Pharmacist-Provided Medication Therapy Mangement (MTM) Services in Community Pharmacies Over 7 Years • Results: • Number of claims in database: 100,000 • Claims analyzed: 76,148 (23,798 patient) • Average pharmacy reimbursement: $8.44/MTM service • Mean ECA: $93.78 • Trends resulted in higher pharmacy reimbursements and greater ECA per claim over time (P<0.001) Barnett J, Frank J, Wehring H, et.al. Analysis of Pharmacist-Provided Medication Therapy Mangement (MTM) Services in Community Pharmacies Over 7 Years. J Manag Care Pharm. 2009;15:18-30

  43. Questions?!

  44. Medication Therapy Management: If You Build It, They Will Come Meghan K. Sullivan, Pharm.D. Assistant Professor University of New England College of Pharmacy July 27, 2012

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