Tuesday, August 30, 2011

I hope I'm wrong about the future of MTM

As a pharmacist, it is my duty to be correct one-hundred percent of the time. Correct medication, correct strength, to the correct patient at the correct time. If I am not correct, there may be some serious consequences.

Well today I am writing to say that I hope that I am not correct with what I am thinking, but from what I have been reading and researching, I just may be correct.

What is it that I hope I am incorrect about? It’s the thought that medication therapy management (MTM) is the model for the future of pharmacy. I’m afraid that the profession has gone all-in on this one practice model before the cards have even been dealt. Let me explain.

For the past twenty years, pharmaceutical care/ medication therapy management has been touted to be the future of pharmacy practice. There have been a few projects that have shown how interventions by pharmacists can improve the quality of health care and decrease expenses for employers and insurers (Ashville, Diabetes Ten City). But these have not been able to be duplicated and rolled out across the country.

In fact, after twenty years all we have are three CPT codes that we can bill our services under, but the insurers and Medicare do not recognize individual pharmacists as providers of medical services. We are still viewed by the product that we dispense instead of the services that we provide. It has only been in the recent past that the profession has been able to get language written that provides for grant money for MTM services. No funding yet, just language that might provide funding.

So where does that leave us today? Right now the only MTM that is being provided (and compensated for) is to patients who are enrolled in Medicare Part D Prescription Drug Plans. When the Medicare Modernization Act was passed several years ago, one of the selling points to pharmacists was that we were going to be able to provide MTM services to the Medicare Part D patients. At least with this community pharmacists should be able to provide the MTM services to a segment of the population who should be able to benefit.

The 2011 CMS Fact Sheet on Medicare Part D MTM (dated 6-30-11) provides some insight on how the MTM services are being provided. According to the fact sheet, all of the Medicare D PDPs offer telephonic consultations. And 27 percent of the plans offer face-to-face consultations. Only 27 percent. That is sad. The Medicare D plans are not allowing their patients to receive MTM services from the pharmacists that they know and trust.

The service that is being compensated is a comprehensive medication review (CMR). For those of you who have never provided a CMR consultation, it’s basically a medication reconciliation with a Q & A session afterwards. After twenty years of hoopla, the future of pharmacy is a med-rec and a Q & A?

Since I began writing my blog, I have had the opportunity to talk with several national-level pharmacists who are in the know about MTM. Folks who are higher up the national organizations. From these conversations I have learned that there aren’t any pharmacists who have been able to create a business model that is able to stand on its own financially. I have talked to a couple pharmacists who have been able to bill for their services and collect enough from insurers to cover their salaries and benefits. But these pharmacists have done so using billing codes that are “incident to” physician services, not utilizing the CPT codes that have been established for pharmacists.

If you have paid attention to recent articles, medication therapy management hasn’t been talked about as a service to be provided by community pharmacists. It’s now being thrown in as the pharmacist’s role in the medical home models and accountable care organizations (ACOs). It’s almost as if the national organizations have realized that medication therapy management as it was originally envisioned isn’t going to come to fruition so now they are trying to find a way to incorporate MTM into the ACOs to they can say that they were successful.

Like I said at the beginning, I hope I’m wrong about this. I want to see pharmacists able to bill for MTM services as individual providers. I want to see pharmacists recognized as individual practitioners by Medicare/insurers and not as extensions of the buildings that they work in. I want to see pharmacists reimbursed for the knowledge in their heads, not the pills in the bottle.

By embracing medication therapy management as the future of the profession of pharmacy, it seems to me that the national organizations and the pharmacy educators have gone all-in on this before the cards have even been shuffled, let alone dealt.


Anonymous said...

You want to be incorrect but you know you are correct.

David Cousino said...

I couldn't agree more! I have been a practicing consultant pharmacist and "wannabe" MTM provider for quite a few years. Ever since I graduated pharmacy school I have read study after study confirming the fact that pharmacists can improve patient outcomes across the spectrum of care and save money in the process. Yet, reimbursement for these services remains scarce.

Recently there seem to be efforts from professional organizations trying to oppose pharmacist conducted MTM. The AMA is looking into such a role for pharmacists as "expanding into the practice of medicine". http://bit.ly/kpYWgD

It is all rather discouraging.

Anonymous said...

A group of "Doctors", recent diplomates from one the multitudes of pharmacy programs spawned in the last decade, wondered......... who could provide MTM. After much study they discovered there is already a group dedicated to this endevour which has been in receipt of reimbusment of said services for decades. This new group of doctors discovered a more qualified group of individuals called physicians has filled this perceived gap for decades and is not going to give it up to another group of doctors with watered down credentials. With student loans over their heads the majority of recent Pharm D graduates lowered their collective heads and headed off to the land off 4 dollar generics, and mandatory flu shots. 6 figures in the bank, a Mcmansion on the horizon, and the keys to their German auto in their hand. "Doctors" on their way to well earned indentured servitude.

James Notaro said...


In your blog post you seem to take a negative perspective based on a minimum of evidence. Here's a few examples:

1. You contend that the Asheville Project has not been able to be duplicated. This comment is patently wrong. In fact, the Ten City Challenge was the national roll out of the Asheville Project. In addition if you conduct a medline search you will find a good deal of pharmacists conducting medication management in various environments.

2. You lament the fact that only 27% of PDPs provide face to face consultation. Yet you provide no evidence that MTM with a face to face interaction provides a better medication therapy management result than one with a telephonic interaction. It is interesting, that while other clinical professionals are working with insurers to obtain the ability to bill for e-mail consulations, telehealth and virtual interactions, you are advocating that pharmacists embrace the old way of face to face interaction.

3. I would recommend that you review the CMS 2010 call letter with regard to MTM. I believe you will find that a CMR as specified by CMS is a bit more comprehensive than as you say "a med rec and Q&A".

4. You claim that nobody has been able to develop MTM as a stand-alone business. I think this comment demonstrates a bit of business nietivity. Have you ever considered that MTM is not a stand alone business, but rather a product-line? A pharmacy has a dispensing product line, a DME product line, an compounding product line - all these products are synergistic and form a business. Have you considered that MTM is one product in a consulting pharmacist practice, and ACO's and PCMH's are simply client types?

Every day I see innovative pharmacists advancing the profession in the area of drug regimen review and MTM, and sincerely believe that your post minimizes these efforts.

Finally, I refer you to your blogs mission: Eric Durbin, RPh, discusses the challenges that pharmacists face today, and what is needed to advance the profession.

I have to say I didn't see you propose much of "what is needed to advance the profession" in this post.

Anonymous said...

Can you give more information about how those pharmacist (based on your comments in point #4 above) have started their MTM business? What are the steps they have to take in order to have MTM business?

Anonymous said...

James, your response......*crickets*

I only wish I had the luxury of being as disconnected with reality as James is. *sigh*

Anonymous said...

Medical Doctor is not allowed to dispense drugs, while pharmacist is not to prescribe. This was how to define the advanced health care of the developed countries. Long time ago such as your great grandpa, I do not think there were such distinction btw pharmacy and medicine for them.

However, if now pharmacist is getting more and more away from dispensing, such differential roles btw dispensing and describing should be re-defined at regulatory and system level. It is true, pharmacist will be in very difficult position for a while, it will be a battle for pharmacy profession before a comfortable new role obtained. it would not be easy for pharmacists. 20 years means nothing. 100 years or so usually necessary for system to adapt total changes.