Medication Therapy Management: If You Build It, They Will

Report
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
 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.
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)
MTM 101
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.
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
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?
1.
2.
3.
4.
Appropriateness of dose/dosing regimen
Therapeutic duplication
Untreated disease/condition
Adherence to therapy
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.
Treatment Population
 “MTM services should be considered for any patient
with actual or potential medication-related
problems.” – MTM Core Elements 2.0
Medication Therapy Management Services
 Medication Therapy
Reviews
 Pharmacotherapy
 Medication safety and
surveillance
 Health and wellness
Consults
 Anticoagulation
 Disease state management
 Pharmacogenomics
management
 Immunizations
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 Management Providers
Contracted nurse
Disease management vendor
Contracted physicians
Other
2008
2009
2010
Nurses in-house
Contracted MTM provider organization
Contracted Pparmacists
Pharmacists in-house
0
20
40
60
80
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.
MTM Patient Care Settings
Other
Federal pharmacy
Managed care/PBM
2008
2009
2010
Acute care inpatient
Ambulatory care/outpatient
Independent pharmacy
Chain pharmacy
0
10
20
30
40
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.
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.
The MTM Movement
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.
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
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.
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/MTMFactSheet2011063011F
inal.pdf Accessed January 3, 2012
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-Year2013-Medication-Therapy-Management-MTM-Program-Submission-v041012.pdf. Accessed July 7, 2012.
Health Care Reform and More!
 Accountable Care
Organizations
 Patient-centered Medical
Home
 “Independence at Home”
 Transitions of Care
Activities
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.
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?
1.
2.
3.
4.
Quarterly
Bi-annually
Annually
Every 5 years
Building Your Service
Developing Your Business Plan
 Mission statement, goals, objectives
 Target population(s)
 Desired MTM services
 Implementation strategy
 Evaluation strategy
MTM Implementation SWOT Analysis
 Strengths
 Internal Factors
 Weaknesses
 External Factors
 Opportunities
 Threats
Setting Goals
 SMART Goals

Specific

Measurable

Achievable

Realistic

Time-Limited
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
Pharmacy Personnel
Pharmacists
 Manager, RPh, clinical
Pharmacy Technicians
 Marketing
pharmacy specialist
 Recruitment
 Training


APhA, ASHP, NCPA, ASCP,
ACCP, CCGP, BPS
MTM, clinical skills,
assessment and evaluation
 MOTIVATION/Incentive
 Scheduling
 Documentation/Data
Entry
 Billing
Testing Your Knowledge…
 Which of the following MTM consultation
activities are appropriate for pharmacy technicians
to participate in?
1.
2.
3.
4.
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
Planning for MTM Consultations
 Appointment Availability
 Personnel




Workload


Pharmacist hours
Pharmacy technician hours
Admin/clerk hours
Daily script count
Interaction
Face-to-face
 Telephonic

Recruitment of MTM Patients
 Local Initiative
 MTM Vendors

Identifying standards

Pharmacy network

Sorting data

Contact patients

Contact patients

30-90 day turn-around
Documentation of MTM Consultations
 Paper patient charts
 Available Electronic
Documentation Systems:
 Internal documentation
system


 Electronic medical record
(EMR)
 MTM vendor software








Community CCRx
HealthMap Rx
MedKeeper
MirixaPro
MTMPath
Outcomes Pharmaceutical
Health Care
Patient Tracker
PharmMD
PhillHelpWorks
RxPerise
Marketing for MTM Services
 Media: TV, radio,
newspaper
 Social Networking:
Facebook, Twitter
 Fliers, bag-stuffers,
buttons, vial caps,
stickers
 Education!
Testing Your Knowledge
 List four ways that you can promote MTM services:
1.
2.
3.
4.
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?
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
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
1.
2.
3.
4.
99604
99605
99606
99607
Make it Work!
IS IT WORTH ALL OF YOUR EFFORT?!
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
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
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)


Cost Savings: $2,913,850 ($86/encounter)


Improved: 7,068, No Change: 2956, Worsened: 2,827
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
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
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
Questions?!
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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