MTM... a personal history

Medication Therapy Management..... MTM for short. That's been the buzzword at the APhA for the last few years. Supposed to be the future of pharmacy practice. Pharmacists won't be associated with the product they are dispensing, but the information.

If you are like me, these first few years of Medicare Part D and the MTM "opportunities" that have been made available to retail pharmacists have left a bad taste in my mouth about the whole MTM idea. And now that the health care bill may be getting pared down in order to get passed, the whole concept of pharmacist-provided MTM may be lost.

But is it?



I graduated from college in 1995 with my BS in Pharmacy. I joined Rite Aid and took a position at a store near one of our state's universities. The neighborhood that I worked in wasn't the greatest. Several houses that I passed every day were boarded up. Fights in the parking lot were common. It was a rough neighborhood in a city that had seen its better day.

I had been at the store for about nine months when one of our regular patients came up to me looking like crap. He stated that he was only getting three solid hours of sleep each night. We talked for a few minutes and he shared the reason why. He was taking a pill at the top of the hour for 20 of the 24 hours of the day.

You see, six months prior he was diagnosed as being HIV-positive. I remember the day of his diagnosis. It was a Saturday. He came from the local teaching hospital with some discharge scripts. Nothing too remarkable except that on the discharge paper he handed to my tech there was a note stating that he was HIV-positive and that he was to follow-up with the infectious disease clinic on Tuesday.

Over the prior six months I had followed his treatment plan, mostly so I could see how he was being treated. I had refilled his scripts several times, but had never been there when a new medication was being picked up.

Anyhow, as we talked he told me that the pharmacy manager had told him to separate taking each of his pills by an hour. He was doing so, and not getting much sleep. After getting some details on his typical routine, I told him that I would do some checking and see if I could make his life a little better.

A couple weeks later he came into the pharmacy again. By this time I had worked up a regimen that had him taking his medications seven times a day, including giving him a seven hour span at night where he could get some decent sleep. I handed him the sheet that I had worked up and sent him on his way.

There it was. My first MTM session. Didn't know what to call it then. But it felt good doing it.

I stayed at that pharmacy for a few more months before transferring to a different town that was closer to my family. But every time I saw him, he thanked me for what I had done for him.


Go forward another year. My father was fighting lung cancer. Had a lung removed and was undergoing radiation and chemotherapy. With the regimen of chemo medications that he was on, he had a rough time on days 5-9 after each round. Dad was taking Oxycontin to try to alleviate the pain that he was experiencing in his lower legs. I lived 50 miles away so I didn't see him in his pain during these days.

One weekend I went over to visit and it just happened to be between days 5 and 9. I could see my father wince in pain if anything jarred his legs. He told me that it felt like his legs were on fire. I asked a few questions to get more details and to see what his oncologist was doing for the pain.

My father was a man who didn't like you to see that he was in pain. Because of this, he hadn't said anything specific to his oncologist about the pain. I grabbed an envelope off of the end table and wrote down the names of a couple medications, with the instructions to call his doctor and request one of these meds to try to calm down the burning in his feet.

Three weeks later, after his next round of chemo, he was playing on the floor with my infant son when previously he would have been confined to his recliner for a few days because of the pain. The physician ordered the first medication on my list and, after one dosage adjustment, had knocked out the pain in my dad's feet. Another MTM success.


Shortly after that, I had a young mother come into the pharmacy with a mountain of prescriptions for her two year-old son. He had just been released from the local children's hospital with a diagnosis of diabetes. She was scared and wasn't afraid to talk about her fears. Over the course of several years, we had been through the wringer with his medical ups and downs. When it was Saturday evening and his blood sugars were bouncing up, down, left, and right she would call me to see what to do. Many times I had to tell her to pack her bags for another week at the hospital, but there were other times when we were able to identify the cause of his blood glucose fluctuations and control them without the need for hospitalization. Some MTM wins and losses.


And there have been many more patients. From the heart-lung transplant woman to the mother of a six-week old infant with RSV to the mother who was caring for her 25 year-old daughter with cervical cancer. All of these patients came up to me with problems about their therapy that we were able to sit down and work out. There have been many others along the way, but for each of them I have conducted what would be considered MTM counseling by today's definition.



Why do I bring these patients up? Because I personally believe that if we want to survive as medical professionals we need to show our value to the health care system. We have specific knowledge that can improve patient therapy outcomes and improve their quality of life. The days of making a decent living off of the profits from the product that we sell are long gone, so we need to take our profession to the next level.

For me personally, I'm trying to set up an MTM consulting business for self-insured employers in my area. It's been rough so far. Employers are laying off people left and right. I've sent dozens and dozens of contact letters and only received a handful of responses. I have had some interest from one of the largest employers in my region, but the state of the economy has kept them from committing so far.

So I plug on.

In a couple weeks, I'm heading out to Washington DC to attend the Delivering MTM in the Community session at APhA 2010. Hopefully I can learn what it takes to get an MTM consulting business up-and-running.

I'm not looking at having a full-time job as an MTM consultant, but I believe that in order to impact patient lives and show the value that pharmacists have in our health care system, we need to get out of the pharmacy and away from counting, pouring, licking, and sticking.

We are in a unique position to change lives. We just need to step up to the plate to show it.

Too much

That's too damn much. I just won't take the shit.


Then patient storms away from the pick-up area. Boy, he's shown us. He's a big boy and isn't going to take his medicine.

Most of the time, I don't care if a patient picks up their medication or not. I'm not the one with the illness that required the call to the doctor in order to get a prescription to clear up a common cold. Heck, thirty percent of our return-to-stocks are antibiotics that weren't picked up.

But when the medication is for a chronic condition, I tend to care a little bit more. Based on the patient's behavior, I may offer to call the prescriber to see about a more reasonably priced alternative. If you act like an adult and can have a somewhat intelligent conversation about the options that are available to us, I will do my best to help you out. If you behave like a two year-old and make a big scene, don't expect a lot of help from me. I didn't select your medication (the doctor did) and I didn't set your copay (your insurance company did).

This scenario plays itself out several times a week at the pharmacy. Normally it doesn't phase me. I help some of the people while letting the ones throwing their tantrums storm off. But lately I've been starting to get upset......no mad, at the people who just won't take the shit.

Why?

Because they are the older patients who get their medications covered by Medicare Part D. These patients just had a stay at one of our local hospitals where they received excellent medical care. The physicians and medical staff stabilized the patients' conditions to the point that they can return to a normal life in American society. The patients have been returned to health because Medicare has footed the bill for the hospital stay.

So now, when the responsibility for medical care falls back onto the patient's shoulders in the form of an elevated copay and the patient decides that they don't need the medication, it makes me mad.

But it's not surprising. The people who are covered by Medicare have grown up in a society that has promised to take care of them when they are old. Social Security will send you money, Medicare will cover your medical issues. These people have basically been told for the last 45 years that everything would be taken care of, that the government would take care of them once they retired.

Part of me feels bad for the patients. But there also has to be some personal responsibility involved. If a patient is not willing to pony up fifty bucks for the copay on their steroid inhaler, why should I have to pay for the ER visit and subsequent hospitalization when the patient's lung condition goes haywire and needs to be stabilized.

I don't know what the answer is. I have some ideas, but they would be seen as being cruel. One of them is to set up a database that records the discharge diagnoses for Medicare/Medicaid patients, as well as the discharge prescriptions. If the patient is admitted again within six months for a similar diagnosis and they have not filled or refilled their prescriptions, tough luck Charlie. It's cruel. But I'm getting tired (as a taxpayer) of footing the bill for people who have no interest in taking responsibility for their own health care.

Of course part of the problem could be avoided if the prescribers would consult with pharmacists about the costs of medications. Hospital pharmacists (I'm talking about those of you on the floor) need to step up to the plate on this. It doesn't matter if you recommend medication X for the patient if they can't afford it. Maybe you should (gasp) call the patient's insurance carrier before they are discharged to make sure the medications are covered and find out what the copay would be. If the patient isn't able to afford it, you could recommend an affordable alternative. Then a lot of the noncompliance could be averted.



I guess that I'm just tired of being the bad guy who gets stuck in the middle. All I'm trying to do is provide excellent patient care in a retail setting. But instead I'm the mean pharmacist who charges too damn much for the medications.

An insurance override I'd like to see

Between the end of last week and the start of this week, there has been a considerable run on the pharmacy by people wanting to get stocked up on their medications. My pharmacy is in a small town of 15,000. A majority of my pharmacy's customers live in the outlying towns and villages or out in the country.

Since we are not near a major metropolitan area, the state highways don't receive the greatest attention. In fact, the county highways were in better shape than most of the state routes during this most recent snow event. Most of my patients live either on county roads or township roads (you know, those roads that are slightly bigger than a goat path). These roads might be buried for days or weeks after a major winter storm. In the summer, they are inaccessible due to flooding.

So when a major weather event is known to be on its way, the people run to town to get supplies for the next couple of weeks. They don't know how long they may be cut off.

When a little old lady comes into the pharmacy as the storm is getting started, it would be nice to be able get an over-ride for an early refill so that Mrs Johnson can get her heart medication. That way our local EMS crews won't be risking their lives to run Mrs Johnson to the hospital because she just had a heart attack in the middle of a blizzard.

I'm just saying that maybe the insurance providers should implement a system to allow early fills in these situations. Base it off of the patient's postal ZIP code.