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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

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
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
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)

core elements of an mtm service model
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
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
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
mtm services business model
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
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 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

medication therapy management providers
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.

mtm patient care settings
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.

mtm payment not just for medicare beneficiaries
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 movement1
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 movement2
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
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
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

medicare part d mtm programs on the horizon
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.

health care reform and more
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

testing your knowledge1
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
developing your business plan
Developing Your Business Plan

Mission statement, goals, objectives

Target population(s)

Desired MTM services

Implementation strategy

Evaluation strategy

mtm implementation swot analysis
MTM Implementation SWOT Analysis

Strengths

Weaknesses

Opportunities

Threats

Internal Factors

External Factors

setting goals
Setting Goals
  • SMART Goals
    • Specific
    • Measurable
    • Achievable
    • Realistic
    • Time-Limited
practice site operation considerations
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
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

testing your knowledge2
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
planning for mtm consultations
Planning for MTM Consultations
  • Appointment Availability
    • Personnel
      • Pharmacist hours
      • Pharmacy technician hours
      • Admin/clerk hours
    • Workload
      • Daily script count
    • Interaction
      • Face-to-face
      • Telephonic
recruitment of mtm patients
Recruitment of MTM Patients
  • Local Initiative
    • Identifying standards
    • Sorting data
    • Contact patients
  • MTM Vendors
    • Pharmacy network
    • Contact patients
    • 30-90 day turn-around
documentation of mtm consultations
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
marketing for mtm services
Marketing for MTM Services

Media: TV, radio, newspaper

Social Networking: Facebook, Twitter

Fliers, bag-stuffers, buttons, vial caps, stickers

Education!

testing your knowledge3
Testing Your Knowledge
  • List four ways that you can promote MTM services:
mtm consultations
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
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 knowledge4
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
make it work
Make it Work!

IS it worth all of your effort?!

return on investment
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
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 study1
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

community pharmacy study
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 study1
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

medication therapy management if you build it they will come1

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