Thursday, March 3, 2011

Journal club- Medication therapy management: Gator style

I'm a little bit late on this, but better late than never.

The February issue of Pharmacy Today has an article about a project going on down at the University of Florida. Quick summary- pharmacy students are conducting comprehensive medication reviews with WellCare patients over the phone.

After reading the article over lunch today, I can only think one thing: Why in the hell is the University of Florida giving away pharmacist services?

I say that because there was no mention of reimbursements for the MTM services that were provided. Articles like this do absolutely no good for practicing pharmacists who are trying to develop a business model for medication therapy management because reimbursements are not discussed.

Maybe WellCare is reimbursing the Gators. Maybe not. The article doesn't say. But if the article doesn't say that pharmacists are getting paid, then I assume that they aren't.

The article discusses how, over the course of a standard day at the call center, a total of 25 MTM calls are made by 12 pharmacy students. That's two calls per day, per student.

Now this is just my opinion, but two MTM calls per day per pharmacist is not going to pay the bills for any operation. Based on the reimbursements I've personally seen from Outcomes, those 25 calls wouldn't even cover the costs of labor and benefits for two licensed pharmacists.

Doesn't look like the type of business model that we should try to recreate in the real world.

Maybe it's time for pharmacy to stop looking at academia for ways to advance the profession. Academia doesn't need to make a profit. In the real world, no profit means no more business. about featuring a real business that is successfully billing for MTM services? That's what real pharmacists want to see. Not all of us are fortunate enough to have 12 students to provide the labor for an operation that still can't operate in the black.

Just some thoughts from a frustrated pharmacist out on the front lines.

* * * * *

As a side note. Today I received a letter from a local medical insurance carrier that said that they were denying my application to be a provider for their company. The reason... they don't cover the type of services that I offer (medication therapy management and pharmacotherapy consults).

Instead of promoting happy-go-lucky-yea-for-us-we-do-MTM-for-free stories, how about getting an insurer or two to recognize us as providers straight up? Forget trying to show how pharmacists can save money and enhance patient care.

Get us recognized as providers so we can prove it.


Anonymous said...

MTM is nothing more than what we do each & every day - counsel patients!

When did our practice "model" ever change?

Perhaps it came with "clinical pharmacy", in which I was one of the initial classes of UCSF. I thought it was a crazy idea at the time to delinate differences - we are all, each & every one of us clinical when we work. In practice, I knew that was not the case since prescribers at that time could check a box & indicate "no label". Really - can you imagine now a label indicating the patient's name, prescriber & date - no drug name, strength or sig??? Yes - in the late 70's that was commonplace. Pharmacists at the time didn't think that was wrong nor did they feel it was their responsibility to educate patients so they could be engaged in their own health. I was taught to change that thinking & I'm proud to have been a part of that change.

Although we did make huge strides in improving pharmacy care, we also alienated a large group of pharmacists who were deemed "not clinical", even if they graduated only 4 years before I did with a BS rather than a PharmD. It created a divide that lasted until all pharmacy schools adopted the PharmD as the entry level degree. With that change, there was also the expectation of increased responsibility.

Since then I've witnessed the rise & fall of "clinical pharmacy", "pharmaceutical care" & mow "MTM" labels. Each decade it seems, there needs to be a need to redefine what we do rather than continue to move forward with increased responsibilities. We now have prescribing authority (in some states like mine), therapeutic interchange authority, anticoag review & now are taking on being the primary source of adult vaccination services for adults.

We are & always will be sources of drug knowledge. Since access to primary care providers is so scarce, we are often the first one the public comes to as a source of medical advice.

If you became a provider of "MTM" for an insurer, what would you do for your cash or uninsured patients? Would you not provide that same service?

I am an Outcome pharmacist & honestly, it doesn't take that long to review the patient's current regimen. Since I only work at one location, I know the patients, their medical issues, the multiple providers they see, the drugs that have worked & those that haven't - and....I listen, advise, communicate with prescribers. It doesn't matter to me who their insurer is. If I have time, I do the Outcomes paperwork (cumbersome - written by some PGY2 probably!) & my employer gets the $50 initial consult or the $10 subsequent consult. Mostly, I just do my job - listen, advise & communicate. AND, I do it for every patient - not just for those whose insurer has a contract with Outcomes.

I've only been a pharmacist fot 30-some years, but I'm betting MTM will follow the path of "clinical pharmacy" & "pharmaceutical care" labels . Its something we should be doing each & every day we work and a label won't change that for most of us.

IMO - Univ. of Florida is only teaching its students methods of communication. That is a good thing since there are lots of people who go into pharmacy without communication skills.
Certainly, when I was a student, we needed to go on rounds with the medical team because pharmacists didn't know disease processes at that time. Now that it is incorporated into the curriculum, we have pharmacists who can enter non-academic hospitals in which there are no "rounds" because there is no house staff & provide the same excellent clinical skills as could be found in any academic hospital.

Why should you have to prove what you already do? Is the $10 fee that attractive? Is it the "label" you want to have?

Time to ask yourself the hard question - would labeling what you do change what you do & who you do it for?

Eric, RPh said...

As I've said before, we give away our professional knowledge every day for free.

Lawyers don't. Accountants don't.

We do.

Look at this previous post on the issue

Anonymous said...

UF is getting money out of the deal:

Anonymous said...

The applications to become a provider are all going to be denied simply because the insurer has no reason to pay. There is no physician demand for their patients to have mtm services and patient's certainly are not demanding paid mtm services, so why the hell would an insurer pay for it?

The demand just isn't there and the current practice model is to give cognitive services away for free, so what is the incentive to pay?
Answer: Patient outcomes can be improved by pharmacist delivered mtm right....?
Well the PBM has pharmacists on staff, if they want to lower patient expenditure through mtm, they will have their own pharmacists do it! Look at Humana and CVS, they are both launching growing phone based mtm service programs.

I am a proponent for pharmacists being reimbursed for their services but the patient and prescriber support is not there because we do not advertise the benefits of our services well enough. Hell, the pharmacists support is not even there, especially among community pharmacists.

Retail chains are not trying to figure how to expand pharmacist services in their stores or give their pharmacists the time to provide these services on their own. They are trying to figure out how they can staff less pharmacists and still do same number of scripts.

Anonymous said...

Bringing up accountants and lawyers...those are business professionals. Retail pharmacy sold out professionalism years ago.

Drive thrus, 15 minute scripts, flu shots in store aisles, pharmacists on the cash register, counseling patients in public area with every other patient there to listen in, etc. There is a little left in community pharmacy that can be considered professional.

Anonymous said...

I take it your answer is no, meaning you would not do your job by reviewing the patient's profile prior to doing your counseling - which is required by law!

You've now just put yourself in the position of filling an rx for a pharmacy shopper or the position of a floater pharmacist, who might - just might have an excuse to break a law.

But, you - the responsible pharmacist?????

When did we get people like you in the profession who got hung up on titles & labels?


Oh - btw...I have been given free advice by my lawyer on many occasions. Of course, if I need his services for a product - will, trust, (god-forbid) litigation - yep, I pay by the hour. My dad as an accountant gave away tons of information with the caveat its only as good as his signature since the tax code is so huge. Likewise, I can call our accountant anytime & get information on the phone. He knows we take him our taxes though & don't go to H&R Block.

My dh, a dentist, has made it a policy to give away a certain $$$ amount in services since there is no Medicaid for dentistry in our area. His core group of consultants do the same. No one walks in off the street needing an opinion without him giving one - nor does a child ever go without care, despite the ability of the parents to pay.

Eric - can you look at yourself in the mirror every morning and really not consult that 80yo who has been put on Humira because the mtx & prednisone no longer are adequate for her rh? Are you going backwards & relying on the physician to impart drug information?

Is it truly your belief that a complete consultation & review can only be done if you are paid your $10? What happened to us encouraging patients to keep rxs in the same pharmacy so we could really review them like we should? What happened to the idea that by having us educate patients about their medications & how they impact their diseases, we make a better, more engaged pharmacist?

What happened to you?

Txpharmguy said...

Honestly, I don't have the time to do any MTM cases. What type of volume do you do to allow to do ANY MTM cases? We generally fill 500-600 rxs per day with way less staffing than we did even a year ago. I feel lucky just to get my lunch break. We also do compounding, immunizations, health testing, etc. I could fill 5 zpacks for a fraction of the time and make the same gross profit to perform an initial MTM consult. I'm all for the advancement of the profession, but it seems more and more work is poured on us with little to help to provide these "value-added services"

Anonymous said...

Txpharmguy - MTM is so time consuming right now because the paperwork is cumbersome & repetitive.

I really do believe it was written by some PGY2 as a project & their only written form of communication they knew was SOAP notes.

If a techy-pharmacist would streamline it like a prior auth format & have it be an online form to be sent for adjudication just as the claims are done, then it might have a chance of taking off.

Right now - its just too much paperwork.

I do 200 rxs/day, 1 pharmacist & 1 tch (double coverage on Mon), no compounding, but adult immunizations daily - hep a&b, adacel or decvac, zostavax, MMR, etc.. I get lots of time to interact with patients & help to facilitate better therapy.

I just hate paperwork!!!!

btw - my employer gets the profit from these expanded duties, so I don't get the $10 directly from an Outcome. But, my hourly wage has always gone up, in spite of the economy. So, indirectly, I am getting paid to do all this stuff. I'd much rather have it be incorporated into my hourly rate than be on a commission basis. I think all my patients would suffer if that were the case.

Anonymous said...

All this boils down to a simple fact.

The people do not want our help.

They want the pills and whatever makes that happen faster is all that matters. The laws attempt to protect them by requiring us to counsel. The only way MTM will ever be anything is if some law mandates it. Then imagine how the people will feel when they are forced to pay us for something they never wanted in the first place.
Folks it's a horrible job, the "profession" is dead and will never be back. Get used to it or get out. I'll stick with it until the pay starts dropping.

Anonymous said...

To "Anonymous the profession is dead"

You may be right when it comes to retail pharmacy, it has been going down hill for years, getting worse and worse with no sign of getting better. Rite aid has their 15 minute guarantee now and pharmacy schools are pumping out grads like crazy, with more schools opening every year.

Just because retail is where most pharmacists work does not mean it defines the profession. Managed care pharmacists and hospital pharmacsts have been thriving. We have strong pharmacist led management and services are expanding faster than we can staff them adequately. I think the profession has a strong chance of surviving with the strong business/clinical pharmacy minds that go the hospital route/managed care route. Retail is a sad case. The only way to practice retail professionally is as an Independent!

Billrx561 said...

To all "anonymous": If you really feel strongly about something, you should either put you name proudly next to it, or keep it to yourself. My name is Bill. I am a Pharmacist working in south Florida.

Part of the fundamental issue with payment to Pharmacists for cognitive services is that many patients view us as nothing more than overpriced human pill-o-matics. They do not view us as legitimate healthcare providers. Perhaps that is because so many of our colleagues are nothing more than "pour, count, pour, cap, label, bag, staple, hand to tech" kind of Pharmacists.

Before you judge me to be one of those, I will let you know I've been an Outcomes provider since 2005, and have more than 700 claims in that time. I was very active within the now-defunct Medicaid of Florida MTM program. I see what these programs attempt to do, and commend them.

I have a comment for Mr. anonymous who wanted to berate him for "not doing he is legally required to do". I see nowhere in his comment that he's refusing to counsel/educate/perform DURs. I take his comments to be more directed at getting our profession paid for the services we render. Sure, your attorney or accountant give you've probably paid well above and beyond for their cognitive services. But lets keep this within medicine for this discussion.

When is the last time you simply called up or walked into your doctor's office for some friendly advice? "We need to see you first" is the most likely answer you will get for anything. And for the most part, you won't get that from the'll get it from the secretary at the front desk.

THE FIRST thing that a Physician will determine is your ability to pay for his it via insurance or pre-paid cash/credit/check. I have been turned away for a Physical for my daughter because I forgot my debit card and checkbook at home, even though I had a 6 year relationship with that office and had never been either late or delinquent in any way when it came to payment.

How many times are we all asked questions that border on practicing medicine? How many office/ER visits do we prevent through the things we do (often for patients who do not even use our Pharmacy)? People view us as free doctors. We're behind the counter where they can walk right up and show their rash/spot/mark and ask us what to put on it for FREE.

I have a problem with people who come in and get upset with me when I am not absolutely sure that the "spot" on their arm (that happens to look like a severely infected boil of some sort) is and refer them to their Physician.

I don't see what's wrong or unethical to expect payment if we are providing services that are above and beyond the norm.

I think some of our colleagues need to wake up.

Anonymous said...

So, Bill - I'm the anonymous & I'm Linda. Why don't I put my name - I don't have a google account, a URL or use Open ID. But, you can call me Linda. Does that satisfy?

We are PAID to provide counseling services for the prescriptions we give. THAT is what MTM (or pharmaceutical care) or whatever else the pharmacy people come up with. Why don't we charge for this information? Because we are bound by law to provide it!

Beyond that - counseling for prescriptions - you don't have to provide anything else. Also - you can't charge for anything else, like how much acetaminophen to give for a child because that very same information can be obtained from the label. If you are advising treatment for some rash & WANT to charge for it - it now becomes a diagnosis. That is NOT what we do. We are not professionally trained to diagnose - period! We are more experienced & educated in illnesses than the general public, but to receive compensation for information that is based on our "medical" judgement is wrong. I wouldn't do it nor would I pay it as an individual.

Now, we can do all sorts of therapeutic adjustments, but they are done within collaborative practice agreements or other arrangements (like Kaiser, VA, anticoag clinics, etc). Those can be charged services. But, they follow a strict protocol.

If you had a pt diaphoretic, scapula pain, not "feeling well" & thought he might be having a cardiac event - it is the ethical & right thing to advise an ER visit. But, to charge for that is unprofessional. You would have to put a name to that charge & that walks the fine line of diagnosis. The "norm" for us is to advise when to see a Dr & when an OTC product would do the same. Frankly, the checker does the same thing when the pharmacy is closed. The patient may or may not feel that information is valid or not, but that checker is stating an opinion - not making a diagnosis. That, often, is what we do as well - state an opinion that the matter can be treated with an OTC product or should be seen by a physician.

I too have been an Outcome pharmacist & have done many, many interventions. Most of them were absolute nonsense & not worth the $10 fee my company was paid. It was wasted paperwork. The structure of MTM is not viable - period. It needs to be revamped & done in real time. All this paperwork is cumbersome & doesn't do the patient or prescriber any good at all, IMO. 90% of the "interventions" actually non-interventions - I "made" them into a payable intervention.

Oh, & what kind of a Dr are you going to? Yes, I can & have just walked in or called & asked for advice many times & have not had to make an appointment. I've never, ever, ever had to pay up front or not be seen. You need a new Dr!!! - MTM will go the way of "pharmaceutical care"...............

All the best,

Linda of Oregon!

Billrx561 said...

Well, Linda, it's nice to have a name to put with the opinions.

I'm sure you think I'm sort of unprofessional person who is just looking for money. I'm actually not. I've provided the same service both with and without reimbursement for it. I have a very loyal patient base who rely on me for my advice. I at many times do help treat things in manners that border on diagnosis (yes, telling someone what the rash on their stomach is or what the spot on their leg is DOES qualify as a diagnosis and treatment).

I'd like to be an idealist and say that we all do this job solely for the love of the patient, but lets live in the real world for a second. Every single one of us (you included) went into this field to make a living. You have a desire to help people, but wanted a good, stable income you can support a family (or just yourself) on. There's nothing wrong with making money at it. Being great at patient care is fantastic as well, and is commendable.

But we don't pay the bills with smiles and thank yous. As any of us in the retail game can attest to, we're seeing less and less reimbursement from every direction...what with Walmart/Target and their $4.00 lists, Publix and their free antibiotics (you wouldn't know about this unless you live down here)....Humana and their $1.50 above cost on branded items. All of this means less money to keep the lights on, provide help, and yes, pay us Pharmacists. If costs get cut enough and we're not doing something other than just verifying and counseling, then what will stop one of the big Pharmacy chains from replacing you and I with a robot to fill and a computer to identify patient issues and provide "counseling"?

If we don't look out for our profession and try to come up with some new things to justify our existence, what's to stop us from being "gone"? Why do you think we're pushing to do immunizations? Because we like needles? Hell No! It's to pay the bills. Wake up, girl! You can't keep a Pharmacy open if you're doing 400 scripts a day and only averaging $2.00 in GP per script unless you want to take a huge pay cut.

As for my doctor, I live in South FL. I don't know if you've ever lived here, but it's probably remarkably different from Oregon (It certainly is from my humble hometown in central NY). Everyone down here is out for theirs...and that includes the Doctors...just take a look at all the pill mills there are down here.

I'm confused as to where you stand on this. Why bother with MTM if you think it's garbage? Why say that MTM s nothing more than counseling (which we're legally required to do), then flip and say that MTM needs to be revamped and done in real time? If it's irrelevant in "past" time, it's irrelevant now. Pick an argument and stay with it.

Well, I'd like to say it's been nice talking to you, but I'd be lying. You're extremely condescending and quite a bit combative.

Perhaps I should call my good buddy Dan Rodriguez (at Outcomes) and let him know there's a Linda in Oregon potentially perpetuating fraud. You act condescending toward me and then admit that you received payment for you employer (or yourself) by "making something fit". Please!

Anonymous said...

Wow... I'm a first year pharmacy student and considering quitting due to the battle within. I think pharmacists need to agree accross the board and move forward otherwise there will be no progression within this so-called evolving career. Its all starting to sound like BS where I'm standing.

Hator said...

Yes, there is a huge battle within pharmacy schools about the future. The old timers don't want to change and think they can impose their will on the 'social media' generation. The new crowd gets kicked out for saying anything innovative or opening a discussion. I can tell you Walgreens gets paid for MTM. You can bill the patients for it, but may not get paid. The problem isn't the pay, it is the people. When pharmacists pronounce they hate this and hate that and make up things when doctors ask them questions and tell frank lies that you catch them telling, the profession becomes a joke. The profession needs people like Eric who speak up in something they believe and pursue their cause. Thanks Eric!

Anonymous said...

Regarding 24 MTM/day and 12 students (UF Pharmacy MTM student training).
2 MTM per day per student.
I am an MTM specialist myself, BCPS and MTM certified. I have my private practice of MTM services. The average MTM per day, to be profitable, is a minimum of 6-10 MTM sessions per day. Technically, divide MTM sessions in 20 minutes each. Some first time MTM will take 2 to 3 sessions each (20 to 60 minutes), but the average is 20 minutes. Insurance companies and Medicaid will pay $50 to $75 per MTM per year. You need practice experience, not only as a pharmacist, but as a clinician. You can not do it if you are a student, and you can not do it if out of school, without experience either. You need to constantly study pharmacology, every day and every minute. Read articles of all sorts, and be up -to-date in guidelines, etc. Once you develop speed and experience, and an analytical pharmacology eye, them you can make from 2 MTM per day, to 4 , to 6, to 10 per day. You will be called an analytics/therapeutics consultant. Average is 6 MTM/CMR per day. Sometimes you can very well do 10 to 12 if they are repeat patients from prior years. Regarding profit, you should be able to get from $1 to $2/hour of work. If not possible, them do not try to do MTM's at all. Remember that some pharmacists are PILL COUNTERS and others are CLINICIANS. Sometimes they can be both, but this combination rarely exist. You have to have a vocation. It is like a musician or an artist, you have the talent, or you do not. You can not learn it in school. You are an MTM pharmacist or not. However, you deserve to give yourself the chance to know if you are for it or not. Just try it and then decide it! Good luck!

Note: I was reading an article recently were the author recommends a CMR/MTM for every patient to improve adherence on a monthly basis. My opinion of this article. The author is simply crazy! Have no idea of what a "realistic" idea is. Have no idea what an MTM is and basic MTM reimbursement logistics. Here is the article from PharmQD 12/23/2013......

Monthly Pharmacist Appointment Improves Adherence.
Patients are more likely to take chronic medications when they meet monthly with pharmacists to coordinate medication schedules and treatments, according to a new study. Read more....

Basel Hakim said...

^^ Dear Anonymous above who has a private MTM practice, is it possible to contact you privately and learn from your experience how I could set up such a practice?? Please email me at baselhakim30 at gmail dot com