Insights into Pharmacist Provided MTM Services-Present and Future Anne Burns, RPh Vice President, Professional Affairs American Pharmacists Association
Learning Objectives • Describe the scope of MTM service delivery around the country. • Describe the APhA/NACDS Foundation MTM Core Elements Service delivery model. • Explain research findings on perspectives of providers and payers. • Discuss changes for 2010 Medicare Part D MTM programs and MTM opportunities under the health care reform bill.
Medication Therapy Management Services: Pharmacy Consensus Definition • Three inseparable elements: – Primary Definition: services that optimize therapeutic outcomes for individual patients … – Professional Service Components: MTM encompasses a broad range of activities and responsibilities within a pharmacist’s scope of practice… – Program Requirements: MTM Programs shall include ( core criteria for an MTM program )… Bluml, BM. Definition of medication therapy management: development of profession wide consensus. J Am Pharm Assoc. 2005;45:566-72.
MTM in Medicare Pharmacy Part D MTM Practice
Scope of MTM Delivery in Pharmacy Practice • Public Sector: Medicare Part D (PDP & MA-PDs) • Public Sector: State-based Medicaid Programs • Public Sector: Community Health Centers, VA, IHS • Private Sector: Self-insured employer groups or managed care/health plans
MTM Core Elements Service Model – v2.0 • APhA/NACDS: “baseline” service model for MTM providers • Supported by major national pharmacy associations • Based on the pharmacy profession’s MTM Definition
Goals of MTM Core Elements Version 2.0 • Improve collaboration among pharmacists, physicians, and other health care professionals • Enhance communication between patients and their health care team • Empower patients to optimize medication use for improved health care outcomes
MTM Core Elements • Medication Therapy Review (MTR) • Personal Medication Review (PMR) • Medication-Related Action Plan (MAP) • Intervention and/or referral • Documentation and follow-up
APhA MTM Digest • Highlights of pharmacist provider and payer surveys on MTM services • MTM Definition for survey = pharmacy profession consensus definition – MTM provided face- to-face and by phone • New trending graphs comparing survey data from 2007 and 2008
Survey Goals • Barriers to implementing MTM services and challenges that arise during service provision • Implementation strategies that have been used for providing MTM services • The value associated with pharmacist-provided MTM services to both providers and payers • Specific measure, if any, used to quantify MTM costs and benefits • The monitoring of the value of MTM services to providers and payers
Provider Perspectives on Offering MTM Services • Key factors affecting decision to implement MTM services: Consistent – Patient health needs theme since 2007 – Responsibility as a health care provider – Recognized a need to improve health care quality – Contribution to health care team • Providers’ reasons for offering services tended to be more professional and altruistic
Provider Perspectives on Financial Aspects of MTM • Most commonly reported investments were staff-related Consistent – Training staff, changing staffing patterns, and with 2008 increasing number of pharmacists data • An overwhelming majority of providers who received payment for providing MTM services did so as part of their standard pharmacist salary • 56% of provid ers who billed for MTM services used CPT codes
Value to Providers from MTM Services • Factors rated as significant to providers Consistent with 2008 – Improved professional satisfaction data – Improved patient satisfaction – Increased quality of care/outcomes • Factors rated as neither significant or insignificant – Revenue from MTM services – Increased patient traffic – Increase in prescription volume/sales
MTM Service Barriers: Providers Among Current MTM Providers Among Non-providers (n=168) (n=432) • Billing is difficult (3.5) • Pharmacists have inadequate time (4.0) Significant • Staffing levels insufficient (4.0) • Billing is difficult (4.0) • Dispensing activities are too heavy (3.9) • Documentation for services is difficult (3.7) • Payment for MTM services is too low (3.5) • Pharmacists have inadequate time (3.4) • Technology barriers (3.4) Neither significant • Dispensing activities are too heavy (3.3) • Inadequate training/experience (3.3) nor insignificant • Staffing levels insufficient (3.3) • Inadequate space available (3.2) • Documentation for services is difficult • Too difficult to determine patient eligibility (3.2) (3.2) • Payment for MTM services is too low (3.2) • Too few MTM patients to justify the start-up • Patients not interested or decline to cost (3.2) • Too few MTM patients to justify cost to participate (3.1)……… maintain the service (3.1)……. • Management does not support provision • Eligible patients do not really need it (2.4) Insignificant of services (2.1) Based on a 5-point rating scale where 5=very significant, 4=significant, 3=neither, 2=insignificant, 1=very insignificant .
Payers- Use of Providers and Methods of Delivery • MTM Services most often provided by Similar to – Pharmacists in-house (60%) 2008 – Contracted pharmacists (40%) – Contracted MTM provider organization (27%) • Primary Mode of MTM Service Delivery – Phone (74%) Similar to – Face to face (46%) 2008 – Multiple methods (18%)
Payers-MTM Service Value 5=Very significant, 0= Very Insignificant Significance of MTM Value
Payers-Outcomes Used to Assess Impact of MTM (n=42) • Medication Related Costs/Total Costs – Medication costs overall (62%) – Use of generics (60%) – Overall health care costs (36%) • Safety Issues – Drug interactions resolved (67%) – Medication over/under utilization (45%) – Number of high risk medications (45%) • Patient Focused – Member Satisfaction (67%) – Improved Compliance/Adherence (48%) • Quality of Care Issues – Treatment changed to align with guidelines (36%) – Quality Measure Scores (HEDIS) (33%)
Payers-Impact of MTM Improvements in Quality Measures Reported: • Inappropriate Medication Use in the Elderly (32%) • Pharmacy Quality Alliance (PQA) (20%) – 2009 is the first year this was measured • HEDIS (14%) • Patient Quality of Life/Satisfaction Surveys (11%) ROI: • Among 4 payer respondents: – Median ROI was 3:1 – Median ROI in 2008 was 3.5:1 – Median ROI in 2007 was 3.1:1
MTM Service Barriers - Payers Among Current MTM Payers (n=47) Among Payers Not Offering Services (n=6) • Patients are not interested or • Patients are not interested or decline Significant decline to participate (3.5) to participate (4.0) • Too few MTM patients to justify the cost (3.6) • Skeptical that these types of services • Insufficient MTM providers in the market Neither significant would produce tangible outcomes (3.0) area to meet needs (3.0) nor insignificant • Providers do not have the • Skeptical that these types of services training/experience (3.0) would produce tangible outcomes (2.8) • Insufficient MTM providers in the market • Too difficult to determine patient eligibility area to meet needs (2.7) (2.7) • Local physician resistance expressed • Local physician resistance expressed (2.6) (2.7) • Too few MTM patients to justify the cost (2.5) • Eligible patients do not really need it (2.3) • Providers do not have the Insignificant • Too difficult to determine patient training/experience (2.0) eligibility (2.0) • Eligible patients do not really need it (1.4) Very Insignificant (No items ranked in this category) Based on a 5-point rating scale where 5=very significant, 4=significant, 3=neither, 2=insignificant, 1=very insignificant .
CMS 2010 Part D MTM Requirements • Opt-out enrollment method only • New targeting criteria – No more than 8 chronic Part D medications (2-8) as a minimum number for eligibility – No more than 3 chronic diseases as minimum number for eligibility and must target 4 of 7 core chronic disease states (diabetes, heart failure, HTN, dyslipidemia, respiratory disease, bone disease – arthritis, mental health) – Minimum cost threshold is $3,000 (vs $4,000 in 2009)
CMS 2010 Part D MTM Requirements • Service requirements – Annual comprehensive person-to-person comprehensive medication review (CMR) • Must provide individualized written overview such as a personal medication record, an action plan, or a reconciled medication list – Quarterly targeted reviews • Does not have to be person-to-person – Interventions with prescribers • New plan reporting requirements
Patient Care in Health Care Reform • Coordination of care including care transitions • Integrated care models – Accountable Care Organizations (ACOs) • MedPAC: Set of providers associated with a defined population of patients, accountable for the quality and cost of care delivered to that patient – Medical Home Models • Team-based approach to comprehensive primary care coordinated by a personal physician • Receives performance-based incentives for achieving measurable health improvements www.pcpcc.net
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