Wednesday, September 14, 2011

More concerns about MTM

The internet is an amazing thing. It allows us to share thoughts and ideas with a wide spectrum of people and receive feedback almost instantaneously. This is one of the reasons that I enjoy writing on-line. I receive emails and comments from people who I will probably never meet in real life, but we are able to share our experiences. Hopefully for the betterment of our lives and, since I write almost exclusively on pharmacy issues, our profession.

After my last post, I had a few people contact me to challenge the statements that I made. I appreciate this. It allows me to strengthen my argument if needed. It can also open my mind to points of view that I may not have considered. For today’s post, I’m going to address some of the issues that were brought up to challenge my thoughts on medication therapy management being the future of pharmacy.

First, let me remind you that I believe that pharmacists are not utilized to the fullest extent of their potential in the community setting. Heck, community pharmacists aren’t even being used for ten percent of their potential. That’s why the concept of medication therapy management is appealing. In theory it gives the community pharmacist the opportunity to utilize his or her skill sets to have a positive impact on the health of patient. That’s why we became pharmacists…to help people.

But the reality of the situation is that MTM isn’t going to happen. At least not to the level that pharmacists would like to see. Sure, there may be an individual here and there who is able to generate a revenue stream from MTM-style services. But when it comes down to it, insurers aren’t paying for the services. And if insurers aren’t paying, people aren’t going to use the services.

I’ll use the Diabetes Ten City Challenge to make my point. Now this was to be the national rollout of MTM services following the Ashville Project. I printed off a copy of the article that reported the results of the DTCC from the Journal of the American Pharmacists Association (J Am Pharm Assoc. 2009:49:e52-e60) and did my own analysis of the results.

Firstly, when the results were published, two of the ten cities didn’t have their data included in the results. For whatever reason, Chicago and Los Angeles didn’t get counted. So in effect we have the Diabetes Eight City Challenge.

To be included in the DTCC certain criteria were required:
· Participating groups had to be self-insured with a patient base of at least 5000
· Incentives for insured persons to participate were to be provided
· The insurer had to have strong internal support for the program
· The Ashville model was to be followed

I pulled some information from the DTCC website to see how many people took advantage of the programs. Only six of the reporting cities had data on the number of patients enrolled in the plans that took part in the DTCC. These six cities had approximately 43,200 potential patients. Not diabetic patients, just overall patients. From the eight cities that were included in the final statistical analysis, only 832 patients with diabetes started the program. And from these patients, only 572 completed at least one year and were included in the final analysis. That’s less than 2 percent of the insurer’s patients who took part in the program.

The insurers gave incentives for the people to participate. Things like discounted or free copays on their medications. No out-of-pocket expense for testing supplies or lab work. Credits towards their deductibles.

All of this incentive and less than two percent enrolled in the program. Granted, the data does not say how many patients were actually diabetic, but remember I’m using the number of patient who enrolled from eight cities divided by the number of eligible patients from six cities and I still come in at under two percent. People aren’t beating down the doors for these services like some would have you believe.

When I looked at the final results of the study, I wasn’t impressed. The DTCC did report that there was a savings versus projected costs. Not against a control group, but against the insurers’ projected costs for the patients. My fuzzy math skills calculated that the insurers expected the costs of medical care to increase 13.5 percent, but the actual increase in cost from baseline was only 5.3 percent. That’s how you can report cost savings of 7or 8 percent.

The claims of success for the DTCC were base on improvements on some lab tests. Wanna know what the improvements were? A1c dropping from 7.5 to 7.1. LDLs going from 98 to 94. Systolic BP dropping from 133 to 130. The average patient saw their pharmacist every other month for MTM services and this is the impact that the pharmacists had? Was it really the pharmacists’ interventions that had an impact? Or was it the impact of generic drug prices falling upon the release of Wal-Mart’s $4 list? Or how about some new medications that came out around the time of the DTCC (Byetta/ Januvia)?

We are basing the future of our profession on a couple of studies. Just two. Ashville and the Diabetes Eight City Challenge. Would you agree that the FDA approve a medication based on two studies? But you are banking on the future of your profession on two studies.

Another criticism of my previous post centered on my pointing out that only 27 percent of Medicare Part D plans cover face-to-face comprehensive medication reviews. The point was made that other health care providers are searching for methods to bill for these tele-medicine services. One point was over-looked. The physicians already have an established relationship with the patient. They have met face-to-face previously. They are simply expanding their access and creating another billable service. Billable service? Aside from three CPT codes that offer Level I reimbursements, pharmacists don’t have billable services. And even if we did have more billable services, insurers don’t recognize pharmacists as individual health care providers. After 20 years of pharmaceutical care/MTM, we are still seen as an extension of the building that holds the drugs.

I found an article summary online from the American Journal of Geriatric Pharmacotherapy on the impact of telephonic MTM. In a nutshell, telephone MTM did help resolve medication health-related problems, but did not have an impact on medication adherence or on total drug costs. That doesn’t make the case to me that telephone MTM has an impact on the quality of care delivered.

I receive messages from the APhA listserv for pharmacists who have completed the MTM training session. On July 27th there was a message asking for real-life examples of pharmacists who have been able to incorporate MTM into their business model for inclusion in a guidebook/workbook for MTM. One of the organizations championing medication therapy management has to ask for examples of pharmacists who have been successful at the professions future? Twenty years after Hepler and Strand and we are looking for success stories?

On August 17 the Center for Disease Control and Prevention announced that they were going to award the AphA Foundation a purchase order to “identify and engage a consortium of key stakeholders who have knowledge of, experience in, or can facilitate the adoption and implementation of collaborative medication therapy management policy” and also to educate policymakers. I could save the CDC a lot of money if they float a PO my way. I’d tell them to have CMS give us status as primary-care providers and about thirty billable codes and see the impact that we can make.

As a profession, we’ve sat around for the past twenty years hoping to get reimbursed for services that we can provide. It’s time that organizations that purportedly represent the profession either put-up or shut-up with regards to MTM. In the twenty years since Hepler and Strand advanced the idea of pharmaceutical care/MTM we’ve seen the profession devolve to a three-ring retail circus with a $4 charge.

As always, share your comments either here or as an email to me. I appreciate the feedback. We need to speak up as professionals, while we still have a profession to speak up for.


Anonymous said...

Great post brother. Wil forward this and book-mark out as well

Anonymous said...

Anticipating the enlightened response of the educated elite to your post has merely served to put me to sleep. Then again I have always appreciated the crickets serenade.

Anonymous said...

"" allows many kinds of billable clinical interventions. Do you know how to get those CPT codes approved?

Eric Durbin, RPh said...

The problem with Outcomes, at least in my area, is that you can only bill for interventions on patients who have been pre-approved, for lack of a better term, for services. I am able to submit TIPS claims for the pre-approved member of an Outcomes-contracted plan, but many of the plans in my area keep the CMRs away from the local pharmacists (they prefer to use in-house staff to conduct tele-CMRs).

Whenever I had a billable intervention for a patient whose plan was contracted with Outcomes, I would log-on to see if I could add the patient to my list of patients. Ninety percent of the time the patient was not eligible for so much as TIPS services, let alone CMRs. A major disappointment.