Medication Therapy Management LT Scott Raisor, PharmD Indian Health Service, Phoenix Area, Colorado River Service Unit Medication Therapy Management

Legacy of Innovation in IHS 1962: Shift from distribution to clinical services 1969: Pharmacists provide direct patient care as primary care providers

Legacy of Innovation in IHS 1996: RADM Michael Trujillo codifies Pharmacists as Primary Care Providers (PCPs) with prescriptive authority 1997: National Clinical Pharmacy Specialist (NCPS) certification established 2011: PHS Pharmacy Report to the Surgeon General and the Surgeon General’s Support Letter

Justification for Expanding Services “Advance beyond discussion of the value of expanded roles of pharmacists and move towards health system support and implementation of these roles.” 1.5 billion preventable medication related problems occur each year The United States health care system spends over $177 billion dollars annually on medication related problems

What is Medication Therapy Management? Medication Therapy Management services are patient centered assessment and evaluation of the patient’s full medication regimen and not only individual medications Goals: Optimize medication use Improve collaboration Enhance communication Empower patients

What is Medication Therapy Management? MTM is separate and distinct from pharmacist managed disease state clinics Pharmacist managed clinics require and provide a higher level of care

What is Medication Therapy Management? Medicare Part D sponsors are required to provide MTM services to their patients 42 CFR 423.153 (d)

42 CFR 423.153 (d) (d)Medication therapy management program (MTMP)— (1) General rule. A Part D sponsor must have established a MTMP that— (i) Is designed to ensure that covered Part D drugs prescribed to targeted beneficiaries described in paragraph (d)(2) of this section are appropriately used to optimize therapeutic outcomes through improved medication use; (ii) Is designed to reduce the risk of adverse events, including adverse drug interactions, for targeted beneficiaries described in paragraph (d)(2) of this section; (iii) May be furnished by a pharmacist or other qualified provider; and (iv) May distinguish between services in ambulatory and institutional settings. (v) Must enroll targeted beneficiaries using an opt-out method of enrollment only. (vi) Must target beneficiaries for enrollment in the MTMP at least quarterly during each plan year. (vii) Must offer a minimum level of medication therapy management services for each beneficiary enrolled in the MTMP that includes all of the following: (A) Interventions for both beneficiaries and prescribers. (B) Annual comprehensive medication review with written summaries. The comprehensive medication review must include an interactive, person-to-person, or telehealth consultation performed by a pharmacist or other qualified provider unless the beneficiary is in a long-term care setting and may result in a recommended medication action plan. (C) Quarterly targeted medication reviews with follow-up interventions when necessary. (D) Standardized action plans and summaries that comply with requirements as specified by CMS for the standardized format.

Who is Eligible? Medicare criteria Medicaid Private plans Employers Multiple chronic disease states Multiple medications High drug costs Medicaid Florida, Iowa, Maryland, Minnesota, Missouri, Mississippi, Ohio, Virginia Private plans Employers Self-pay

Medicare Eligibility Chronic disease states CMS requires 3 or less Sponsors must include the 7 core chronic diseases Diabetes Hypertension Dyslipidemia Heart failure Respiratory disease Bone disease Mental health disorder 2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at https://www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet2011063011Final.pdf. Accessed on May 16th, 2012

Medicare Eligibility Multiple medications High drug costs CMS requires 8 or less High drug costs $3,000 or higher in annual medication costs Average $250 per month 2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at https://www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet2011063011Final.pdf. Accessed on May 16th, 2012

MTM Best Practices CMS regulations established a general framework that allows for best practices 10 pharmacy organizations collaborated to develop the core elements of an MTM visit APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

Five Key Elements Medication Therapy Review (MTR) “is a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them” Personal Medication Record (PMR) “is a comprehensive record of the patient’s medications” Medication-Related Action Plan (MAP) “is a patient-centric document containing a list of actions for the patient to use in tracking progress for self-management” Interventions or Referrals “The pharmacist provides consultative services and intervenes to address medication-related problems; when necessary, the pharmacist refers the patient to a physician or other healthcare professional” Documentation and Follow Up “MTM services are documented in a consistent manner, and a follow-up MTM visit is scheduled based on the patient’s medication-related needs, or the patient is transitioned from one care setting to another” APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

Best Practice Flow Chart APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

MTM Services Medicare sponsors must provide a minimum level of MTM services Comprehensive Medication Review (CMR) Annually Targeted Medication Review (TMR) Quarterly

Comprehensive Medication Review (CMR) Comprehensive annual review of all medications Interactive person to person Phone call Pharmacy visit Affordable Care Act standardizes the content and format of the CMR starting January 1, 2013 Components Cover Letter Medication Action Plan Personal Medication List

Targeted Medication Review (TMR) TMR must be provided at least quarterly TMR is meant to address specific or potential medication-related problems Does not have to be face-to-face

Who can provide MTM services? Pharmacists Only provider specifically mentioned Registered Nurses Physicians Non-physician providers 2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at https://www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet2011063011Final.pdf. Accessed on May 16th, 2012

IHS Pharmacy Electronic Health Record (EHR) IHS mode of counseling Allows for comprehensive reviews Physician notes, lab work, and medication lists IHS mode of counseling New Three prime questions Refill Show and tell Open dialogue about disease not just medicine

10 Steps to Your Medications: Why the Wait? Five Key Elements to an MTM visit: Medication Therapy Review (MTR) Personal Medication Record (PMR) Medication-related Action Plan (MAP) Intervention or referral Documentation and Follow Up 1. After your appointment, the doctor enters your prescription into the computer 2. The pharmacy receives the order signed by the doctor 3. The pharmacist checks the prescription for errors 4. The pharmacist looks at your lab results 5. The pharmacist reviews your chart for drug interactions and allergies 6. The pharmacist may call your doctor for questions 7. The medications are counted and packaged 8. The pharmacist does a final check for safety and accuracy 9. The pharmacist counsels you on your medications 10. You receive your medications and can ask any questions you have Document MTR Review EHR Document MAP Intervention Document PMR Medication List

Best Practice Flow Chart IHS Prescription Processing Chart Meds ordered in EHR Meds dispensed and patient counseled APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

IHS is Leading Again Our legacy of innovation has allowed PHS pharmacists to lead the profession Providing clinical services since 1962 We are already providing MTM for our patients Potential reimbursement opportunities?

Reimbursement Process

Part D Prescriptions Filled in 3 months Number of Prescriptions Medicare Part D Plans

Part D Reimbursement The largest Part D provider does not allow for reimbursement to community pharmacists for MTM services The second largest provider only has four patients who qualify for MTM reimbursable services

Part D reimbursement Part D sponsors determine payments for MTM services Considered administrative costs 80% allow external personnel 31% use vendors 25% use community pharmacists Plans require contracts with pharmacies Separate from medication dispensing There is not much published on reimbursement  Limited to vendor’s published numbers

MTM Vendors MirixaPro® MirixaEdge® Outcomes® Others: Mirixa.com No cost for participation MirixaEdge® Pay Provides documentation to submit to non-contracted part D plans or for out of pocket billing Outcomes® Getoutcomes.com No cost for participation Others: PharmMD® Pharmmd.com Employ pharmacists Can make $2,000/month

Reimbursement Rates MirixaPro® Comprehensive medication review $60 Welcome review $40 Medication adherence 15 minute initial $30 10 minute follow up (2) $20 Cardiovascular risk 45 minute initial $90 Follow up $30 www.mirixa.com

Reimbursement Rates Outcomes® Comprehensive Medication Review $50 to $75 Prescriber Consultation Cost Efficacy Management $20 Drug Therapy Problem $20 Patient Compliance Consultation $20 Patient Education/Monitoring $10 Prescriber Refusal $2 Patient Refusal $2 www.getoutcomes.com

Is MTM the future of pharmacy? Providing MTM services improves outcomes Reimbursement for pharmacist-delivered patient care is a step forward, BUT: Part D pays the pharmacy not the pharmacist Pharmacists are not the only providers Right now, MTM does not look to prevention Eligible patients are already a burden on health system

Pharmacists are Patient Care Providers “Pharmacist-delivered patient care services fit most definitions of “primary care” services (with the exception of diagnosis) as defined by major medical and health organizations” “Compensation … should reflect the level of care provided” Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.

MTM Conclusion Potential reimbursement for actions that PHS pharmacists engage in currently Create time to make appointments, proper documentation, and provide opportunities for reimbursement and reporting Work with Tribes Provide presentations on correct medication habits MTM should not prevent PHS pharmacists from continually leading with new and innovative patient care practices

Citations APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008. Lee MP, Giberson S. Implementation of the Indian Health Service National Clinical Pharmacy Specialists (NCPS) Program. Available at www.usphs.gov/corpslinks/pharmacy/clinpharm/doc/ncps.ppt. Accesses May 16th, 2012. 2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at https://www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet2011063011Final.pdf. Accessed on May 16th, 2012. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011. Schupbach R. Insights from the bizarre perspective and mind of Ryan Schupbach. Presented at the Oklahoma Area IHS Pharmacy Chief’s Meeting, February 17th, 2012.

Questions LT Scott Raisor thomas.raisor@ihs.gov Colorado River Service Unit 12033 Agency Road Parker, AZ 85344 928.669.3330