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Medication therapy management: Commercial programs pick up speed
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Brian Bertha, senior vice president of marketing for McKesson U.S. Pharmaceutical, headquartered in San Francisco, is confident that, compared to three years ago, medication therapy management (MTM) programs have picked up speed.
He bases his opinion on three primary factors. The first is recognition that MTM need not be defined only by Part D guidelines developed by the Centers for Medicare & Medicaid Services (CMS). For example, Bertha refers to "focused MTM consultations," in which a plan using MTM leverages the expertise of a pharmacist to close a gap in care, as opposed to delivering comprehensive medication reviews. "Generally, the commercial plan populations do not have the same level of complexities as the Part D population, but do have a wide spectrum of simpler issues whose need for resolution is just as necessary; hence, the focused consultations," he said.
Second, commercial plans do not have the same formal MTM requirements as are found under Part D and thus are more flexible. And, finally, market pressures demand that health plans continue to innovate continually to keep avoidable medical costs at bay.
"Part of the strategy behind accomplishing the last goal involves optimizing medication regimens relative to patients' disease states," he said. "And then instilling appropriate behavioral change, such as good adherence to the optimized therapy."
In fact, Tom Halterman, CEO of Outcomes Pharmaceutical Health Care in Des Moines, Iowa, a provider of MTM services, believes that MTM programs in the commercial sector may be held to a higher standard than those under Part D. "Since commercial-sector plans have the option of not driving MTMPs at all, they must be able to prove quality improvement and cost control stemming from the pharmacist interventions," he said. "This means pharmacists must successfully consult with prescribers to resolve drug complications and influence patients to adhere appropriately to medication regimens."
The commercial sector, which includes pharmacies, insurance plans, and employers, is showing off its MTM programs - not only how they work, but eligibility requirements, reimbursement, what services are offered, and, in some cases, program results.
From pilot to program
What started in 2006 as a Part D MTM program sponsored by HealthPartners in Minneapolis, Minn., expanded into a pilot program with the State of Minnesota the following year and then into a program for all fully insured commercial members in 2008. This year, the health insurer is offering an MTM program to its employees.
In the pilot version, all state employees with diabetes were eligible to have their prescription copayments waived if they participated in a pharmacy counseling program and chose a HealthPartners' clinic for treatment. Members in the fully insured program had to be taking five or more unique medications and incurring more than $1,000 in pharmacy costs within a three-month period.
Initial consultations with clinical pharmacists were hour-long drug reviews, with subsequent 30-minute meetings to discuss potential cost savings, monitor conditions affected by medications, and help prevent side effects and adverse drug events. Meetings could take place in person or by phone. As many as 84 percent of visits were face-to-face, with 16 percent by phone. Studies show that through counseling, pharmacists have been able to identify an average of two drug-related problems for each patient.
According to Vyvy Vo, PharmD, clinical pharmacy program manager for HealthPartners, the keys to an effective MTM program are face-to-face interaction, use of an incentive, buy-in from members' physicians, and a collaborative practice agreement between pharmacists and prescribing physicians to change and modify therapies.
HealthPartners also designed eligibility requirements for clinical pharmacists. They must have graduated from a college of pharmacy after 1996, be licensed in the state, and offer a private place for consultations. Community pharmacists in the program bill fee-for-service; the rate is currently under renegotiation.
After the first year of the pilot, compared to nonparticipants the 300 patients in the program had 39 percent fewer emergency-room visits and 24 percent fewer hospital admissions, as well as a 137 percent improvement in meeting optimal blood pressure, cholesterol, and blood sugar levels, taking daily aspirins, and remaining tobacco-free. Cost savings revealed by a six-week study of some of the pilot participants revealed reduced expenses of $376 per patient through drug error intervention.
MTM goes corporate
Medication Management Systems (MMS), a Minneapolis company that designs and implements MTM programs, created its own pharmaceutical-care model, which it has used for the Minnesota Medicaid program and for General Mills, a leading food company also based in Minneapolis, among others. Both programs assess a patient's health status; formulate a medication treatment plan; monitor and evaluate a patient's response to therapy; conduct a comprehensive medication review to identify, resolve, and prevent medication-related problems; and provide information and support services to promote medication adherence.
"This personal relationship with a pharmacist will help participants better achieve therapeutic goals in coordination with physicians and other healthcare providers," said Jeanne Denz, director of global benefits at General Mills.
Although MMS's provider eligibility is similar to that of HealthPartners, its criteria for participants differ in that patients must be taking four or more prescriptions to treat or prevent two or more chronic conditions.
Tom Albers, RPh, vice president of sales and marketing at MMS, says that his company is able to hold its providers accountable and report outcomes back to the state or to General Mills, because it has the ability to maintain patient health information, link it to the drug and the intended outcome, and keep providers and participants in the loop. "Coordination with providers is critical to success," he added, reiterating Halterman's philosophy of what makes an MTM program effective. General Mills' employees who participate in the program, which is known as MyMedsManagement, may seek services at company headquarters, through MMS's Pharmaceutical Care Practice Network, or by telephone through MMS's call center.
Pharmacists are reimbursed only for face-to-face encounters, on the basis of CPT codes that reflect the time estimated to perform a service, as well as on the number of medications, drug-therapy problems, and medical conditions associated with a patient. For example, a first-time, face-to-face encounter with a patient lasting up to 15 minutes in duration merits $52, or $34 if it's a recurring problem. Additional increments of 15 minutes are billed at $24. Albers says the average amount reimbursed per visit in the Medicaid program is $100.
"Our model enables pharmacists to become part of a team of providers and be recognized as healthcare providers, while also linking patients and prescribers by sharing patients' drug histories and drug-therapy problems," Albers said.
The Asheville Project
Like other pharmacy stakeholders, Kerr Drug, a drugstore chain based in Raleigh, N.C., began by providing MTM services under Medicare Part D but has expanded into the community. "We have to be an integral part of the communities we serve and an active part of the healthcare system," said Rebecca Chater, RPh, MPH, president of KDI Health Solutions, the clinical services division of Kerr Drug.
"Multiple factors make up an effective MTM program: an employer or payer who understands the value of such a program; patients who have an incentive to participate, such as lower premiums/copayments or improved health; and early collaboration with the physicians in the community," said Lori Brown, PharmD, a clinical pharmacist and manager of clinical services for Kerr Drug. "An effective program also needs a knowledgeable, trained pharmacist who understands the clinical goals and is trained in the philosophy and workings of MTM and patient education."
The benefits to stakeholders are many, Brown said, pointing to patients who are empowered and educated to become active participants in their care and have access to an additional provider; pharmacists who have a chance to practice what they are trained to do; physicians who have additional support in monitoring patients' medication use; and payers who may realize lower healthcare costs as well as increased employee productivity and job satisfaction.
Together Kerr and KDI, along with pharmacy benefits manager HealthTrans, are offering a program to employers that combines a dispensing network, preferred pricing, copayment incentives, and access to a state network of clinical pharmacists specializing in MTM and other clinical pharmacy services. The underpinnings stem from the Asheville (N.C.) Project, a pharmacist-based, patient-centered chronic disease program in which Kerr's clinical pharmacists serve as care managers. In this program, employers have realized $2,000 savings per year per patient with diabetes, Chater said.
Mari Edlin is a freelance writer in Mill Valley, California. She writes frequently on pharmacy issues.
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