Medication Therapy Management (MTM) by Pharmacists

[onepharmer]

Thought I'd reply cause this post is interesting...

My background: I'm actually a pharmacist (resident) and practice in the community providing medication management to patients so the majority of the doctors I work with are family med/internal med. As part of my residency, I work closely with family med physician residents (we see patients together and I obviously focus on the meds.)

Anyways, I've thought about this sort of practice as a pharmacist but think a joint practice with a physician (or more than 1) would be interesting as well. I would want to have an onsite pharmacy that provided the meds (so I could work on adherence issues) along with having 30-45min appts with patients for med manag. With a physician, I think it would be great to see patients after their appt with you in order to talk more about their meds. Also-pharmacists are beginning to be paid for these services so there is potential for revenue outside of prescriptions. (just a sidenote)

A bit off topic but I do think this type of practice is an interesting idea and a great opportunity for both professions.

Take care =-)
onepharmer

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[sophiejane]

Anyways, I've thought about this sort of practice as a pharmacist but think a joint practice with a physician (or more than 1) would be interesting as well. I would want to have an onsite pharmacy that provided the meds (so I could work on adherence issues) along with having 30-45min appts with patients for med manag. With a physician, I think it would be great to see patients after their appt with you in order to talk more about their meds. Also-pharmacists are beginning to be paid for these services so there is potential for revenue outside of prescriptions. (just a sidenote)

OK, that is one really great idea. I love it. You can come work with me! Just think how much that could reduce polypharmacy and medication errors, and increase patient adherence/compliance/whatever....

So, like 30 minutes what, once every 6 months or so, or more frequently for people with med lists more than a page long (Ugh! I freak when I see that)....?

I don't know how this would work from a financial standpoint, though. I'm pretty sure the doc can't bill insurance companies for your time, so they'd have to be doing well enough from pharmacy revenues to not only pay your salary and a tech's, but include in that the time you spend with patients....could get expensive....

 

[onepharmer]

I'm glad you like the idea =-)

Well, I'm not an expert in pharmacy or medical billing but can provide a few more details..
As a resident, my primary practice site is a medication therapy management (MTM) service located within a pharmacy. I also spend time each week in the physician family med residency program clinic (they have their own pharm resident who is with them QD). Also each week, a med res comes with me to the pharmacy to learn more about MTM by seeing pts together, learn over the counters, etc. It's really fun =-)

So back to billing...MTM can be paid for if (in my understanding) it is affiliated with a pharmacy. The pharmacy I train at has a few contracts that allow us to bill 80-100/hour depending on the patient's insurance. Until more payer groups begin to cover MTM, this alone won't pay a full time RPh salary but it is a start and I am thrilled that our profession is finally making progress towards having the ability to help better care for pts! When in family med, I basically bill at the nurse level so payment is provided that way. Unfortunately, the amount of time required with these pts is likely worth more than that level of reimbursement (although I do not know the exact dollar figure)--closer to the rates we are seeing with MTM contracts.

The number of visits allowed vary by insurance company (unfortunately)..some are 45min Q 6 months, some are one visit every month initially...

And the things you listed (polypharm, med adherence, error reduction, etc) are *exactly* what we work on. I work with patients to figure out what I can do to help them to remember their meds...if they are having a side effect or difficulty with tolerance, we address that. We help pts save money by working the MD to sort through the pt's formulary, etc. One classic example: I see a patient who has multiple probs/meds etc and serious adherence issues. Data from first visit: BP-177/114, average glucose-199...most recent visit: BP~130/80 and average glucose-138....still not where we want it but much better. The great part is--the meds were all totally appropriate--he just needed to actually take them =-) It's situations like that that make me feel awesome as a pharmacist.

Anyhow, I'm off the subject....again, I'm certainly no expert in billing so please keep that in mind but I'm really pleased to see that physicians like the thought of working with pharmacists. Feel free to PM me if you want to draft a business plan =-)

take care,
onepharmer

 

[sdn1977]

OK, that is one really great idea. I love it. You can come work with me! Just think how much that could reduce polypharmacy and medication errors, and increase patient adherence/compliance/whatever....

So, like 30 minutes what, once every 6 months or so, or more frequently for people with med lists more than a page long (Ugh! I freak when I see that)....?

I don't know how this would work from a financial standpoint, though. I'm pretty sure the doc can't bill insurance companies for your time, so they'd have to be doing well enough from pharmacy revenues to not only pay your salary and a tech's, but include in that the time you spend with patients....could get expensive....

Actually...this is done in lots of places now, but it varies from state to state because it requires collaborative practice agreements (watch out for MacGyver!!!!).

But...one which has recently had a final study released is called the Asheville Project which is located in.....Asheville, NC. This is a small community, isolated & for the most part, upper-middle or higher in income & education. However, the city employees had tremendous expenses due to diabetes.

I think this project actuallly was started as a research project from a pharmacy resident from UNC, but it was collaboration with the IM/FM's in the community. These employees could receive free medication (a huge perk for a diabetic) IF they agreed to meet with a pharmacist every month. If they missed an appt, they had to go back to paying.

This project has gone on for 10 years & has saved more than $2000 in medical costs per patient per year. At the end of the first year, half the participants had their blood sugar under control, as defined by the physician's parameters & by the end of the third year, that number increased to two-thirds of the original group. By retrospective analysis, they found if they could keep just one patient from having to go on dialysis, the city could save $100,000 per year.

The cost of the medications were absorbed by Glaxo-Smith Kline & Sanofi-Aventis, but there were no formulary restrictions.

Anyway...more than you ever wanted to know & I'm not sure it can be reliably replicated in larger urban centers. However, it is done routinely in large clinics & clinic-type practice settings (Kaiser, VA, etc.)

As for reimbursement, currently Medicare Part D allows reimbursement for pharmacist medication management, when done with a physician directed agreement specifying parameters.

 

[raptor5]

Actually...this is done in lots of places now, but it varies from state to state because it requires collaborative practice agreements (watch out for MacGyver!!!!).

Please don't mention his name. I hear he searches daily for any post his name comes up in then posts in that thread.

 

[Faebinder]

I here by label Mac Guy ver as "He whose name we don't speak."

 

[RuralMedicine]

I actually think pharmacists doing medication management can be a real help towards getting BP, blood sugars, lipids etc at least moving within the same zip code as the patients goal. I spend a ton of time doing what I would happily delegate to you or one of your colleagues (and you'd probably do it better---plus if nothing else it would be someone else who doesn't really believe that insulin is the root of all evil ). You could also spend an enjoyable morning inputing the medicare formularies into our pharmacy computer system (ok several morning since we have 300+ Medicare Part D plans with new ones coming out nearly daily).

If I ever manage to turn my practice into an FQHC we will have an in office pharmacy and utilize our pharmacist(s) to educate as well as dispense (probably with tech assistance to allow you more time to do medication management). In an FQHC you may be able to write off some of the cost of your pharmacist/techs into your cost based reimbursement. As far as billing 99211s (brief visits physician presence not required, typical "nurse visit") these reimburse probably around $10-15 so they will not pay your salary if you're seeing only a few patients a day--now addressing a single issue per visit (so going for a 10 minute visit--which for some patients may work better) and perhaps rolled in with a pharmacy profit might get close to making it work financially. Obviously being able to some MTM rather than 99211 will help. There are also codes for education sessions/ group sessions that might be applicable. (My biller is exploring whether we could use these with a nutritionist (RD) who would like to contract with us.)

 

[onepharmer]

Actually...this is done in lots of places now, but it varies from state to state because it requires collaborative practice agreements (watch out for MacGyver!!!!).

But...one which has recently had a final study released is called the Asheville Project which is located in.....Asheville, NC. This is a small community, isolated & for the most part, upper-middle or higher in income & education. However, the city employees had tremendous expenses due to diabetes.

I think this project actuallly was started as a research project from a pharmacy resident from UNC, but it was collaboration with the IM/FM's in the community. These employees could receive free medication (a huge perk for a diabetic) IF they agreed to meet with a pharmacist every month. If they missed an appt, they had to go back to paying.

This project has gone on for 10 years & has saved more than $2000 in medical costs per patient per year. At the end of the first year, half the participants had their blood sugar under control, as defined by the physician's parameters & by the end of the third year, that number increased to two-thirds of the original group. By retrospective analysis, they found if they could keep just one patient from having to go on dialysis, the city could save $100,000 per year.

The cost of the medications were absorbed by Glaxo-Smith Kline & Sanofi-Aventis, but there were no formulary restrictions.

Anyway...more than you ever wanted to know & I'm not sure it can be reliably replicated in larger urban centers. However, it is done routinely in large clinics & clinic-type practice settings (Kaiser, VA, etc.)

As for reimbursement, currently Medicare Part D allows reimbursement for pharmacist medication management, when done with a physician directed agreement specifying parameters.

Just to clarify the above--Actually, MTM can be done independent of a formal state-board determined "collaborative practice agreement (CPA)." I provide MTM without such formal agreements. This is because MTM activities do not necessarily include anything that would necessitate a CPA (prescribing under protocol, etc.) We simply make recommendations and follow up with physicians/patients to take responsibility for med-management. Also, it is done in non typical clinic settings--we are located in a national chain pharmacy.

But regardless, Asheville certainly has been a great initiative and the profession (and many patients) has benefited as a result. One of the groups of patients we provide MTM for is based on a "spin off" of Asheville where again, employees with a certain insurance carrier receive DM supplies at no cost while participating.

Not to be nit picky--just thought I'd share my experiences with MTM =-)

 

[sdn1977]

Just to clarify the above--Actually, MTM can be done independent of a formal state-board determined "collaborative practice agreement (CPA)." I provide MTM without such formal agreements. This is because MTM activities do not necessarily include anything that would necessitate a CPA (prescribing under protocol, etc.) We simply make recommendations and follow up with physicians/patients to take responsibility for med-management. Also, it is done in non typical clinic settings--we are located in a national chain pharmacy.

But regardless, Asheville certainly has been a great initiative and the profession (and many patients) has benefited as a result. One of the groups of patients we provide MTM for is based on a "spin off" of Asheville where again, employees with a certain insurance carrier receive DM supplies at no cost while participating.

Not to be nit picky--just thought I'd share my experiences with MTM =-)

Yeah...but, these kinds of "recommendation" things are nothing other than what you do everyday as a pharmacist & really are not MTM. I, honestly, would have a hard time billing for them...

and rural MD - they are separate coding - I'd have to look at the table, but these are separate codings than what you have in Part B. They are billed under Part D therefore tied to a drug - not a drg - altho we have to put in a drg qualifier.

Each one has to choose their own course, I understand. But...I've worked with physicians a long time & they expect me to refer someone to them who is a diabetic & who wants something "stronger" than Neosporin for the sore on their foot and that's what I've done for decades. Likewise, if a pt is taking more xanax, pain medication, trazodone, seroquel, whatever...than the rx indicates - its my job & always has been to communicate with the prescriber - just to update & clarify the directions. We've also always been in the position of reinforcing the need to continue to take medications, particularly those (antihypertensives) in which the pt doesn't "feel" any different & can in fact feel worse. Thats not MTM either - its just our job.

But....my interpretation, my corporate structure & my state's requirements all involve more extensive management than that kind of example. The kind that involves therapeutic change...which means...I need to know the physician - he/she needs to know me - I need to understand the parameters they want to function by & with so the therapy can be definitely be changed & that information communicated in a rapid & complete way with the primary care giver so everyone stays on the same page. That's why - in my state, we require a CPA.

IMO - this whole thing can go off the track if its just handing out "advice" - which, unless you have communication back & forth - can cause more harm than good, particularly if you've billed for it.

The whole point of this is & should be easier & more complete access to care by the pt - not reimbursement for advice we already give.

But...again...everyone has their own opinions. My own experience is respect & trust takes a long time to gain & can rapidly be dissolved if misguided. I am very, very careful not to ever cross the line outside of my practice area & I only venture into gray areas with those physicians whom I already have an agreement. Fortunately...the corporations I work with (two) agree.

 

[deleted87716]

I've put the MTM posts into their own thread, since it's an interesting subject for discussion, but not related to the original thread on concierge practices.

Carry on.

 

[Faebinder]

I think pharmacists will be disappointed by how much medicare will reimburise them for this...

 

[sophiejane]

I think pharmacists will be disappointed by how much medicare will reimburise them for this...

I don't know...most pharmacists I've met tell me the most satisfying part of their job is helping patients. Sometimes the satisfaction you get for something is worth a lower reimbursement, as long as they are making a competitive salary.

I mean, this is the family medicine forum, so it's not like many of us are gold diggers.

 

[MacGyver]

YOu guys are aware that if Medicare starts paying pharmacists for all this stuff, they are going to divert those funds from elsewhere, namely FP reimbursement in particular or primary care reimbursement in general. The AMA RVU committee is dominated by specialists and trust me they wont let their reimbursements get cut, they'll shift it to you folks.

Medicare does not have a blank check to reimburse everybody for everything. The more people who try to take a chunk out of the healthcare reimbursement pie means that less goes to everybody.

Eventually we'll have a system where every single patient has a pharmacist, doctor, NP/PA, dietitician, and PT/OT. All those people have to be paid from a fixed pie, meaning that the amount going to any one individual is going to fall drastically.

So think about that next time you hear that Medicare is cutting your 30 minute office visit fee by another 10% while simultaneously adding new reimbursements for pharmacists, dieticians, "care coordinators", etc

 

[iatrosB]

YOu guys are aware that if Medicare starts paying pharmacists for all this stuff, they are going to divert those funds from elsewhere, namely FP reimbursement in particular or primary care reimbursement in general. The AMA RVU committee is dominated by specialists and trust me they wont let their reimbursements get cut, they'll shift it to you folks.

Medicare does not have a blank check to reimburse everybody for everything. The more people who try to take a chunk out of the healthcare reimbursement pie means that less goes to everybody.

Eventually we'll have a system where every single patient has a pharmacist, doctor, NP/PA, dietitician, and PT/OT. All those people have to be paid from a fixed pie, meaning that the amount going to any one individual is going to fall drastically.

So think about that next time you hear that Medicare is cutting your 30 minute office visit fee by another 10% while simultaneously adding new reimbursements for pharmacists, dieticians, "care coordinators", etc

 

[iatrosB]

Please don't mention his name. I hear he searches daily for any post his name comes up in then posts in that thread.

 

[Faebinder]

Ya, unfortunately, he is correct about the evil medicare part.... it takes from one thing and gives to the other... the overall medicare funding does not increase... it gets cut.

 

[iatrosB]

Ya, unfortunately, he is correct about the evil medicare part.... it takes from one thing and gives to the other... the overall medicare funding does not increase... it gets cut.

I wouldn't know if he is correct or not because I honestly don't even read his posts anymore. I'm just laughing because raptor basically said if you use his name, he will be brought forth. Sure enough, look what happened, hillarious.

 

[sdn1977]

I wouldn't know if he is correct or not because I honestly don't even read his posts anymore. I'm just laughing because raptor basically said if you use his name, he will be brought forth. Sure enough, look what happened, hillarious.

How does that happen? I mean....is it like a bird call, or pheromones (sp??) or something ???

Well...I guess that's the end of any rational disucussion - good to talk to all of you !

 

[sdn1977]

I've put the MTM posts into their own thread, since it's an interesting subject for discussion, but not related to the original thread on concierge practices.

Carry on.

As much as I can appreciate & understand your motives....I think you just made this thread a bit more obvious for ....well...those who choose to see if the sky is falling (altho I'm very much in favor of everyone having their own opinion!!!!)

But....as for carrying on...well...not so much now. It was easier to have this discussion when it was "hidden" which made it appear less inflammatory - but, that's just my opinion.

 

[sophiejane]

If I can see more patients and do a better job at it, I am going to make more money, regardless of whether or not Medicare reimbursement declines.

Let's see...would I rather spend 30 minutes dealing with med issues with one patient, or be able to see three in the same time period, because their med issues have been dealt with by an expert?

Using ancillary staff, pharmacists, nurses, PAs (oh lord here we go), PTs, etc to the best of their ability will save money in the long run.

 

[deleted87716]

As much as I can appreciate & understand your motives....I think you just made this thread a bit more obvious for ....well...those who choose to see if the sky is falling (altho I'm very much in favor of everyone having their own opinion!!!!)

But....as for carrying on...well...not so much now. It was easier to have this discussion when it was "hidden" which made it appear less inflammatory - but, that's just my opinion.

Please tell me that you don't seriously care what MacGyver thinks.

And you know about SDN's "ignore" feature, right?*

* Click on his user name, then on the "View Forum Profile" option, then click on "Add User to your Ignore List."

 

[McDoctor]

Thought I'd reply cause this post is interesting...

My background: I'm actually a pharmacist (resident) and practice in the community providing medication management to patients so the majority of the doctors I work with are family med/internal med. As part of my residency, I work closely with family med physician residents (we see patients together and I obviously focus on the meds.)

Anyways, I've thought about this sort of practice as a pharmacist but think a joint practice with a physician (or more than 1) would be interesting as well. I would want to have an onsite pharmacy that provided the meds (so I could work on adherence issues) along with having 30-45min appts with patients for med manag. With a physician, I think it would be great to see patients after their appt with you in order to talk more about their meds. Also-pharmacists are beginning to be paid for these services so there is potential for revenue outside of prescriptions. (just a sidenote)

A bit off topic but I do think this type of practice is an interesting idea and a great opportunity for both professions.

Take care =-)
onepharmer

I've always felt that having an on-site pharmacy in which the physician has some stake in ownership would be a serious conflict of interest. As a physician, you would have more of a tendency to prescribe medication when perhaps it is not indicated, and you would have a financial incentive to prescribe brand name over equally effective generics, and thereby needlessly inflate healthcare costs for your patients and the public in general.

This is already a problem in physician owned cancer centers. I think it just escapes scrutiny because most of the general public holds this baseless notion that oncologists are somehow more ethically pure and more compassionate than other specialties in the medical field.

 

[MacGyver]

If I can see more patients and do a better job at it, I am going to make more money, regardless of whether or not Medicare reimbursement declines.

True to a certain point, but we are quickly reaching the vanishing point of no returns. There are only 24 hours in a day. Your ability to see more and more patients is starting to reach the upper limit.

"doing a better job of it" means nothing in the current american system. Until pay for performance is implemented, it will have nothing to do with how much money you make. The UK recently instituted P4P, and guess what. Docs were so successful at it, increasing their revenues by 30%, that now the UK has started talking about putting an absolute cap on doctor income. Docs thought that P4P would give them a lot of extra money, but that was true only in the short term. Once govt saw the bottom line of these P4P efforts, thyey immediately sought to keep the docs bills in check with caps. Another option they excercised was to vastly lower the P4P rates. At first, a doc could get an extra $20 per visit by meeting BP guidelines. Now the UK cut that down to $5 per visit. They will just keep cutting that number down until they reach a "revenue-neutral" P4P scheme.

You see, the govt wont let docs make more money over the long term. They control all the access points, they are holding all the keys. In the name of the "balanced budget" they are going to put a hard cap on overall doctor expenditures. The SGR formula ALREADY does this and forces doctors to bicker among themselves who gets to split up the fixed pie that govt gives every year.

You have zero leverage against the govt. You will make what they let you make, and any efforts to game the system are only temporary. Resistance is futile.

Let's see...would I rather spend 30 minutes dealing with med issues with one patient, or be able to see three in the same time period, because their med issues have been dealt with by an expert?

No evidence that pharm involvement would increase your throughput by that much.

Using ancillary staff, pharmacists, nurses, PAs (oh lord here we go), PTs, etc to the best of their ability will save money in the long run.

You mistakenly assume that more cooks for the broth = better healthcare outcomes = saved money down the line. AGain, no evidence to support this. It WILL greatly increase costs though. We used to have only 2 or 3 people bill Medicare for any given patient. Wtih all of these "collaboration" efforts that number will skyrocket. When we start paying 20 "providers" for each patient, the govt is going to clamp down on individual reimbursement.

Its not just midlevels and pharms though its also other doctors. Now every patient has 5 or 6 specialists, whereas in previous eras the GP would try to manage many of those issues. Of course that creates a vastly inflated healthcare bill.

 

[deleted87716]

 

[MacGyver]

This is already a problem in physician owned cancer centers. I think it just escapes scrutiny because most of the general public holds this baseless notion that oncologists are somehow more ethically pure and more compassionate than other specialties in the medical field.

Rules were recently changed to clamp down on this abuse on chemo drugs by oncologists. Forecasted salaries for them will plummet by at least half. Its clearly unethical to script for hte same drugs you sell. Japan utilizes this approach, and their doctors are the 2nd highest paid in the world. Expect that gravy train to stop eventually though.

 

[deleted87716]

A bit off topic but I do think this type of practice is an interesting idea and a great opportunity for both professions.

Unfortunately, this thread seems to be getting more off-topic with every post. Closing.

There's already a similar thread going in Topics in Healthcare, if anyone's interested.