Medication Therapy Management Services: Perceptions, Processes and - - PowerPoint PPT Presentation

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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,

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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

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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

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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

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Role of Pharmacists in Public Health

American Public Health Association (APHA)

Policy Statement Statement of the Problem Product-oriented functions evolved to patient-

  • riented, 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

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Perceptions of MTM

Provider Payer Patient

APhA MTM Digest: Perspectives on MTM Service Implementation. March 2008.

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Perceptions of MTM: Provider

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Perceptions of MTM: Provider

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Perceptions of MTM: Provider

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Perceptions of MTM: Provider

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Perceptions of MTM: Provider

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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

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Perceptions of MTM: Payer

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Perceptions of MTM: Payer

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Perceptions of MTM: Payer

Insurer of children $50.57 per initial; $34.35 for follow-up; $24.74 for additional follow-up time Self-insured employer $70 per initial; $20-$60 per follow-up Program administrator/contract vendor $86 per encounter State Medicaid program $90.50 per encounter 2 of 7 respondents $2 per minute flat fee

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)

APhA MTM Digest: Perspectives on MTM Service Implementation. March 2008.

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Perceptions of MTM: Patients

APhA MTM Digest: Perspectives on MTM Service Implementation. March 2008.

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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

  • f and desire for these services.”

– APhA MTM Digest 2008

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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

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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

  • ther qualified health care provider’s, scope of practice”

MTM Definition. Consensus statement on July 27, 2004 by 11 national pharmacy organizations.

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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

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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

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Personal Medication Record (PMR)

A comprehensive record of the patient’s

medications including:

Prescription meds Non-prescription meds Herbal products Dietary supplements

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Prime Questions for Patient Counseling

  • What Is My

Medication For?

  • How Do I Take It?
  • What Are Some

Side Effects?

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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

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A Collaborative Effort Between the Patient and the Pharmacist

  • What the Patient

Need to Do Now?

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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

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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

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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

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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

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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

Kostick J. Medscape

  • Pharmacists. 2006;7(1).

Acknowledgement: Slide from the APhA and ASCP MTM National Certificate Training Program.

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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

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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

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POP Quiz – MTM Challenge 4

AZ is a 66 y/o Caucasian man who comes to the Pharmacy PCC

for an initial MTM session and receives a CMR. He has 4 disease-states/med conditions and currently takes 12 meds, including 4 OTC meds and dietary supplements. You spent 30 minutes for his MTR and provided him with a PMR and MAP.

If the PCC’s fee-for-service is a flat rate of $2 per min, what

CPT code(s) should you use to bill and for how much?

A) 0115T and 0117T for a total of $60 B) 0116T and 0117T for a total of $60 C) 99605 and 99607 for a total of $60 D) 99606 and 99607 for a total of $60 E) 99607 for a total of $60

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MTM Reimbursement: NPI

National Provider Identifier (NPI)

Unique 10-digit provider number required for

electronic billing

Both the individual pharmacist AND pharmacy must

have a unique number

Does NOT indicate provider status (under Medicare

Part B) OR guarantee payment from payer

Applying for an NPI number:

Pharmacists may apply online at the National Plan and

Provider Enumeration System at: https://nppes.cms.hhs.gov/NPPES

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MTM Reimbursement: The Superbill

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MTM Reimbursement: Sample Billing Forms

CMS-1500 Form

OutcomesTM Pharmaceutical Health Care. Available at: www.getoutcomes.com.

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MTM Reimbursement: Sample Payment Rates

Source: Medication Therapy Management Services: A Critical Review. The Lewin Group Report. J Am Pharm Assoc. 2005;45:580-7.

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  • Public Sector: Medicare Part D (PDP & MA-PDs)

Member Health (CCRx), Humana, Outcomes*, Walgreens Health Initiative Managed-care based services

  • Public Sector: State-based Medicaid Programs
  • Public Sector: Community Health Centers*
  • Private Sector: Self-insured employer groups or managed care plans

Asheville project/APhA Foundation projects Outcomes Pharmaceutical Health Care* Kaiser – Clinics* Hospitals – medication reconciliation

* Public and Private

Scope of MTM Delivery in Pharmacy

Acknowledgement: Slide from Jim Owen, PharmD, Director of Professional Practice at the APhA.

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Exploratory Research on MTM: Final Report for CMS on July 8, 2008

CMS contracted with Abt Associates to explore MTM in 2007-2008 Reviewed 59 publications on MTM Interviewed 60 individuals from 46 different organizations Conducted 4 in-depth case studies Key Findings MTM Organizational Practices and Models Targeted Patients, Eligibility Criteria and Enrollment Mechanism MTM Components and Services MTM Service Providers Coordination of MTM with Disease/Care Management MTM for Nursing Home Patients Reimbursement and Documentation Outcomes and Evaluations

Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.

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Final Report for CMS: Organizational Practices and Models

Variety of practice models in the literature and in current

MTM programs

Not yet appear to be an identifiable set of clearly defined

models that are reasonably stable and mutually exclusive

Variations of Practice Models Primary focus MTM service providers Intervention frequency Service delivery mod Reconciliation with prescribers Additional education and support Disease-state monitoring

Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.

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Final Report for CMS: MTM Program Funding

Medicare Part D Prescription Drug Plans

Required to provide MTM to targeted beneficiaries Administer MTM programs as part of CMS contracts

State Pharmacy Assistance Programs and Medicaid MTM Programs

Funded through respective state budgets

Employer-sponsored MTM Programs Nursing Homes Contract with Consultant Pharmacists VA Salaried Pharmacists Pharmacy Association Foundations Research Grants or Institutional Support Third Parties (PBM or MTM vendors) Patient Out-of-pocket Purchase from Some Community Pharmacy

Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.

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Final Report for CMS: Provider Reimbursement

Fee Schedules – Fee-for-service (FFS)

Employer-sponsored Medicare Medicaid

Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.

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Final Report for CMS: Provider Reimbursement

Resource-based Relative Value Scale (RBRVS)

and CPT Codes

Minnesota Medicaid Program

Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.

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Final Report for CMS: Some Challenges and Opportunities

Challenges Opportunities

Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.

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MTM and Future of Pharmacy Practice

Joint Commission of Pharmacy Practitioners (JCPP) Future Vision of Pharmacy Practice 2015 Consensus document on vision for pharmacy,

pharmacy practice and benefits to society

Pharmacy education will prepare pharmacists to promote

health improvement, wellness, and disease prevention

Pharmacists will practice as experts regarding

medication use and be responsible for promotion of health improvement, wellness, and disease prevention

Pharmacy practice’s benefits to society – medications-related

public health goals are more effectively achieved

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MTM Initiatives and Resources: National and State (Maryland)

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MTM Initiatives and Resources: National

  • MTM Definition – 11 National Pharmacy Organizations
  • APhA-NACDS – Core Elements of MTM Service Model
  • APhA Lewin Group Report – Findings on Existing MTM

Programs, Models for Payers, and Benefits of MTM

  • APhA-ASCP MTM Certificate Training Program
  • APhA-NACDS MTM Pharmacist Training CD-ROM
  • APhA MTM Self-Assessment Tool
  • APhA-NACDS MTM Implementation Manual
  • APhA MTM Resources at: www.pharmacist.com/mtm
  • APhA MTM List-serv and e-Communities
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MTM Initiatives and Resources: Maryland

MTM Training Initiative for Pharmacists and Preceptors Goals: Optimizing medication use and improving public

health

Providing certificate training for pharmacists,

preceptors and student pharmacists

Helping to advance pharmacy practice in the

community and long-term care settings

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MTM Initiatives and Resources: Maryland

MTM Faculty Trainers: Chanel Agness (UM SOP) Nicole Brandt (MD-ASCP) Kristen Fink (MPhA) Jennifer Hardesty (MD-ASCP) Nayab Hussain (MPhA) Hoai-An Truong (UM SOP) Student Assistants: Katherine L. Lodowski Janet E. Shaw Thao N. Vuong

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MTM Initiatives and Resources: Maryland

Maryland P3 Program APhA Foundation Ten City Challenge Trained pharmacists provide diabetes self-management

education/training for patients

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References and Acknowledgement

APhA MTM Digest: Perspectives on MTM Service

  • Implementation. March 2008.

MTM in Pharmacy Practice: Core Elements of MTM Service

  • Model. Version 2.0. March 2008.

American Pharmacists Association MTM Resources Center.

Available at: www.pharmacist.com/mtm

University of Maryland School of Pharmacy Continuing Education

  • Website. Available at: www.pharmacy.umaryland.edu/ce

Acknowledgement to the APhA for the data and information

from MTM Digest 2008 in this presentation.

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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

E-mail: htruong@rx.umaryland.edu

Eastern Medicaid Pharmacy Administrators Association (EMPAA) Conference November 9-12, 2008 White Sulphur Springs, WV