Medication Therapy Management Services: Perceptions, Processes and Models for Compensation Hoai-An Truong, PharmD, MPH Assistant Director, Experiential Learning Clinical Assistant Professor University of Maryland School of Pharmacy Baltimore, MD Eastern Medicaid Pharmacy Administrators Association (EMPAA) Conference November 9-12, 2008 White Sulphur Springs, WV 1
Learning Objectives By the end of the presentation, participants will be able to: � Explain different perceptions of MTM from the perspectives of the provider, payer, and patient � Describe the five core elements of an MTM service model � Describe the process for obtaining compensation for MTM services � Identify existing MTM service models from the public and private sectors and available resources for implementing MTM services 2
What Do Pharmacists Do? � CAPE Educational Outcomes 2004 � Organizing Framework � Integrating science, professional attributes, inter- professional practice, and professionalism across new major areas of…as they are in the practice of pharmacy � P_ _ _ _ _ _ _ _ _ _ _ _ _ C _ _ _ � S _ _ _ _ _ M _ _ _ _ _ _ _ _ _ � P _ _ _ _ _ H _ _ _ _ _ � ACPE 2007 Standards and Guidelines 3
Role of Pharmacists in Public Health � American Public Health Association (APHA) � Policy Statement � Statement of the Problem � Product-oriented functions evolved to patient- oriented, administrative and public health functions � Pharmacist’s unique expertise including pharmacotherapy, access to care, and prevention services � Pharmacist’s accessibility as resource for health and medication information � Desired Actions 4
Perceptions of MTM � Provider � Payer � Patient 5 APhA MTM Digest: Perspectives on MTM Service Implementation. March 2008.
6 Perceptions of MTM: Provider
7 Perceptions of MTM: Provider
8 Perceptions of MTM: Provider
9 Perceptions of MTM: Provider
Perceptions of MTM: Provider 10
POP Quiz – MTM Challenge 1 � According to the MTM Digest on survey findings among providers, which of the following is/are the most important reason(s) for pharmacists NOT implementing MTM services? � A) Recognized need to improve health care quality � B) Professional satisfaction � C) Billing is difficult � D) Patient needs � E) All of the above are important reasons for NOT implementing MTM services 11
12 Perceptions of MTM: Payer
13 Perceptions of MTM: Payer
Perceptions of MTM: Payer Contract and Billing Details (n=7; fees varied by organization; in most cases fees are determined by a combination of factors: time, level of complexity, and/or type of service) $90.50 per encounter State Medicaid program $86 per encounter Program administrator/contract vendor $70 per initial; $20-$60 per follow-up Self-insured employer $50.57 per initial; $34.35 for follow-up; Insurer of children $24.74 for additional follow-up time $2 per minute flat fee 2 of 7 respondents APhA MTM Digest: Perspectives on MTM Service Implementation. March 2008. 14
Perceptions of MTM: Patients APhA MTM Digest: Perspectives on MTM Service Implementation. March 2008. 15
Perceptions of MTM: Patients � Patients had a favorable opinion of pharmacists providing MTM services. � Patients with prior exposure to practices where MTM was provided by pharmacists have a more favorable opinion of such services. “Data suggest that increasing patient awareness about MTM may increase their appreciation of and desire for these services.” – APhA MTM Digest 2008 16
POP Quiz – MTM Challenge 2 � According to the MTM Digest on survey findings among payers and patients, which of the following is/are NOT potential barriers for implementing MTM services? � A) Costs to implement exceed expected benefits � B) Lack of acceptance by physicians and other HCP � C) Skeptical that services would produce tangible outcomes � D) Lack of perception of need by patients � E) Patients with prior exposure to MTM services have less favorable opinion of such services 17
MTM Definition � “a distinct service or group of services that optimize therapeutic outcomes for individual patients” � “independent of, but can occur in conjunction with, the provision of a medication product” � “broad range of professional activities and responsibilities within the licensed pharmacist’s, or other qualified health care provider’s, scope of practice” MTM Definition. Consensus statement on July 27, 2004 by 11 national pharmacy organizations. 18
Five Core Elements of MTM Service Model � Medication Therapy Review (MTR) � Personal Medication Record (PMR) � Medication-Related Action Plan (MAP) � Intervention and/or Referral � Documentation and Follow-up 19
Medication Therapy Review (MTR) � A systematic process of: � collecting patient-specific information � assessing medication therapies to identify medication-related problems � developing a prioritized list of medication-related problems � creating a plan to resolve them � Comprehensive versus Targeted 20
Personal Medication Record (PMR) � A comprehensive record of the patient’s medications including: � Prescription meds � Non-prescription meds � Herbal products � Dietary supplements 21
Prime Questions for Patient Counseling • What Is My Medication For? • How Do I Take It? • What Are Some Side Effects? 22
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Medication-Related Action Plan (MAP) � A patient-centric document containing a list of actions for the patient to use in tracking progress for self-management 24
A Collaborative Effort Between the Patient and the Pharmacist • What the Patient Need to Do Now? 25
Intervention and/or Referral � The pharmacist: � provides consultative services � intervenes to address medication-related problems � refers the patient to a physician or other healthcare professional when necessary � Referral circumstances � Evaluation and diagnosis of new problems � Chronic disease management and education � Monitoring for high-risk medications 26
Documentation and Follow-up � Consistent manner for evaluating patient progress and sufficient for billing � Purposes, including but not limited to: � Facilitating communication � Improving patient care and outcomes � Enhancing continuity of patient care � Ensuring compliance with laws and regulations � Protecting against professional liability � Justifying billing or reimbursement � Demonstrate the value of pharmacists-provided MTM service � Demonstrate clinical, economic, and humanistic outcomes 27
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POP Quiz – MTM Challenge 3 � Which of the following five core elements of the MTM service model differentiates between patient counseling and MTM service? � A) Medication Therapy Review (MTR) � B) Personal Medication Record (PMR) � C) Medication-Related Action Plan (MAP) � D) Intervention and/or Referral � E) Documentation and Follow-up 30
Learning Objectives By the end of the presentation, participants will be able to: � Explain different perceptions of MTM from the perspectives of the provider, payer, and patient � Describe the five core elements of an MTM service model � Describe the process for obtaining compensation for MTM services � Identify existing MTM service models from the public and private sectors and available resources for implementing MTM services 31
MTM Reimbursement Criteria � All Medicare PDPs must reimburse health care providers for MTM services � Reimbursement rates are determined by PDPs � CMS cannot dictate rates or fees � CMS does require PDPs to explain fees � Pharmacists are eligible for reimbursement only for services covered by their states’ practice acts Acknowledgement: Slide from the APhA and ASCP Kostick J. Medscape Pharmacists . 2006;7(1). MTM National Certificate Training Program. 32
MTM Reimbursement: PSTAC and CPT � Pharmacist Services Technical Advisory Coalition (PSTAC) � National pharmacy initiative addressing and supporting billing and payment issues for pharmacists’ services � Development of CPT codes specifically for MTM services billing � Approval from AMA to reclassify MTM service codes from Category III to Category I � Current Procedural Terminology (CPT) � Coding system for documentation of medical services (i.e. diagnosis or reason for visit) on a superbill � Most CPT codes used for billing by prescribers � 3 new CPT codes for pharmacists’ billing of MTM services � Payers’ decision regarding the preference and use of codes Source: Pharmacist Services Technical Advisory Coalition Website. Available at: www.pstac.org 33
MTM Reimbursement: CPT Codes for MTM � 99605 (0115T) � Initial encounter MTM service performed face-to-face with a NEW patient in a time increment of up to 15 minutes � 99606 (0116T) � Subsequent or follow-up encounter with ESTABLISHED patient in a time increment of up to 15 minutes � 99607 (0117T) � Add-on code for additional increments of 15 minutes for use in conjunction with either of the preceding codes (99605 or 99606) Source: Pharmacist Services Technical Advisory Coalition Website. Available at: www.pstac.org 34
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