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Medication Therapy Management Services: Perceptions, Processes and Models for Compensation
Hoai-An Truong, PharmD, MPHAssistant Director, Experiential Learning
Clinical Assistant ProfessorUniversity of Maryland School of Pharmacy
Baltimore, MD
Eastern Medicaid Pharmacy Administrators Association (EMPAA) Conference
November 9-12, 2008White Sulphur Springs, WV
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Learning Objectives
By the end of the presentation, participants will be able to:
Explain different perceptions of MTM from the perspectives of the provider, payer, and patient
Describe the five core elements of an MTM service model
Describe the process for obtaining compensation for MTM services
Identify existing MTM service models from the public and private sectors and available resources for implementing MTM services
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What Do Pharmacists Do?
CAPE Educational Outcomes 2004Organizing FrameworkIntegrating science, professional attributes, inter-professional practice, and professionalism across new major areas of…as they are in the practice of pharmacy
P_ _ _ _ _ _ _ _ _ _ _ _ _ C _ _ _
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P _ _ _ _ _ H _ _ _ _ _
ACPE 2007 Standards and Guidelines
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Role of Pharmacists in Public Health
American Public Health Association (APHA)Policy StatementStatement of the Problem
Product-oriented functions evolved to patient-oriented, administrative and public health functionsPharmacist’s unique expertise including pharmacotherapy, access to care, and prevention servicesPharmacist’s accessibility as resource for health and medication information
Desired Actions
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Perceptions of MTM
ProviderPayerPatient
APhA MTM Digest: Perspectives on MTM Service Implementation. March 2008.
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Perceptions of MTM: Provider
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Perceptions of MTM: Provider
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Perceptions of MTM: Provider
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Perceptions of MTM: Provider
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Perceptions of MTM: Provider
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POP Quiz – MTM Challenge 1
According to the MTM Digest on survey findings among providers, which of the following is/are the most important reason(s) for pharmacists NOTimplementing MTM services?
A) Recognized need to improve health care qualityB) Professional satisfactionC) Billing is difficultD) Patient needsE) All of the above are important reasons for NOT implementing MTM services
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Perceptions of MTM: Payer
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Perceptions of MTM: Payer
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Perceptions of MTM: Payer
Insurer of children$50.57 per initial; $34.35 for follow-up; $24.74 for additional follow-up time
Self-insured employer$70 per initial; $20-$60 per follow-up
Program administrator/contract vendor$86 per encounter
State Medicaid program$90.50 per encounter
2 of 7 respondents$2 per minute flat fee
Contract and Billing Details (n=7; fees varied by organization; in most cases fees are determined by a combination of factors: time, level of complexity, and/or type of service)
APhA MTM Digest: Perspectives on MTM Service Implementation. March 2008.
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Perceptions of MTM: Patients
APhA MTM Digest: Perspectives on MTM Service Implementation. March 2008.
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Perceptions of MTM: Patients
Patients had a favorable opinion of pharmacists providing
MTM services.
Patients with prior exposure to practices where MTM was
provided by pharmacists have a more favorable opinion of
such services.
“Data suggest that increasing patient awareness about MTM may increase their appreciation of and desire for these services.”
– APhA MTM Digest 2008
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POP Quiz – MTM Challenge 2
According to the MTM Digest on survey findings among payers and patients, which of the following is/are NOT potential barriers for implementing MTM services?
A) Costs to implement exceed expected benefitsB) Lack of acceptance by physicians and other HCPC) Skeptical that services would produce tangible outcomesD) Lack of perception of need by patientsE) Patients with prior exposure to MTM services have less favorable opinion of such services
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MTM Definition
“a distinct service or group of services that optimize therapeutic outcomes for individual patients”
“independent of, but can occur in conjunction with, the provision of a medication product”
“broad range of professional activities and responsibilities within the licensed pharmacist’s, or other qualified health care provider’s, scope of practice”
MTM Definition. Consensus statement on July 27, 2004 by 11 national pharmacy organizations.
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Five Core Elements of MTM Service Model
Medication Therapy Review (MTR)
Personal Medication Record (PMR)
Medication-Related Action Plan (MAP)
Intervention and/or Referral
Documentation and Follow-up
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Medication Therapy Review (MTR)
A systematic process of:collecting patient-specific informationassessing medication therapies to identify medication-related problemsdeveloping a prioritized list of medication-related problemscreating a plan to resolve them
Comprehensive versus Targeted
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Personal Medication Record (PMR)
A comprehensive record of the patient’s medications including:
Prescription medsNon-prescription medsHerbal productsDietary supplements
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Prime Questions for Patient Counseling
• What Is My
Medication For?
• How Do I Take It?
• What Are Some
Side Effects?
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Medication-Related Action Plan (MAP)
A patient-centric document containing a list of actions for the patient to use in tracking progress for self-management
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A Collaborative Effort Between the Patient and the Pharmacist
• What the Patient
Need to Do Now?
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Intervention and/or Referral
The pharmacist:provides consultative servicesintervenes to address medication-related problemsrefers the patient to a physician or other healthcare professional when necessary
Referral circumstancesEvaluation and diagnosis of new problemsChronic disease management and educationMonitoring for high-risk medications
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Documentation and Follow-up
Consistent manner for evaluating patient progress and sufficient for billingPurposes, including but not limited to:
Facilitating communicationImproving patient care and outcomesEnhancing continuity of patient careEnsuring compliance with laws and regulationsProtecting against professional liabilityJustifying billing or reimbursementDemonstrate the value of pharmacists-provided MTM serviceDemonstrate clinical, economic, and humanistic outcomes
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POP Quiz – MTM Challenge 3
Which of the following five core elements of the MTM service model differentiates between patient counseling and MTM service?
A) Medication Therapy Review (MTR)B) Personal Medication Record (PMR)C) Medication-Related Action Plan (MAP)D) Intervention and/or ReferralE) Documentation and Follow-up
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Learning Objectives
By the end of the presentation, participants will be able to:
Explain different perceptions of MTM from the perspectives of the provider, payer, and patient
Describe the five core elements of an MTM service model
Describe the process for obtaining compensation for MTM services
Identify existing MTM service models from the public and private sectors and available resources for implementing MTM services
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MTM Reimbursement Criteria
All Medicare PDPs must reimburse health care providers for MTM servicesReimbursement rates are determined by PDPsCMS cannot dictate rates or feesCMS does require PDPs to explain feesPharmacists are eligible for reimbursement only for services covered by their states’ practice acts
Kostick J. MedscapePharmacists. 2006;7(1).
Acknowledgement: Slide from the APhA and ASCP MTM National Certificate Training Program.
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MTM Reimbursement: PSTAC and CPT
Pharmacist Services Technical Advisory Coalition (PSTAC)National pharmacy initiative addressing and supporting billing and payment issues for pharmacists’ servicesDevelopment of CPT codes specifically for MTM services billingApproval from AMA to reclassify MTM service codes from Category III to Category I
Current Procedural Terminology (CPT)Coding system for documentation of medical services (i.e. diagnosis or reason for visit) on a superbillMost CPT codes used for billing by prescribers3 new CPT codes for pharmacists’ billing of MTM servicesPayers’ decision regarding the preference and use of codes
Source: Pharmacist Services Technical Advisory Coalition Website. Available at: www.pstac.org
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MTM Reimbursement: CPT Codes for MTM
99605 (0115T)Initial encounter MTM service performed face-to-face with a NEW patient in a time increment of up to 15 minutes
99606 (0116T)Subsequent or follow-up encounter with ESTABLISHED patient in a time increment of up to 15 minutes
99607 (0117T)Add-on code for additional increments of 15 minutes for use in conjunction with either of the preceding codes (99605 or 99606)
Source: Pharmacist Services Technical Advisory Coalition Website. Available at: www.pstac.org
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POP Quiz – MTM Challenge 4
AZ is a 66 y/o Caucasian man who comes to the Pharmacy PCC for an initial MTM session and receives a CMR. He has 4 disease-states/med conditions and currently takes 12 meds, including 4 OTC meds and dietary supplements. You spent 30 minutes for his MTR and provided him with a PMR and MAP.
If the PCC’s fee-for-service is a flat rate of $2 per min, what CPT code(s) should you use to bill and for how much?
A) 0115T and 0117T for a total of $60B) 0116T and 0117T for a total of $60C) 99605 and 99607 for a total of $60D) 99606 and 99607 for a total of $60E) 99607 for a total of $60
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MTM Reimbursement: NPI
National Provider Identifier (NPI)Unique 10-digit provider number required for electronic billingBoth the individual pharmacist AND pharmacy must have a unique number Does NOT indicate provider status (under Medicare Part B) OR guarantee payment from payer Applying for an NPI number:
Pharmacists may apply online at the National Plan and Provider Enumeration System at: https://nppes.cms.hhs.gov/NPPES
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MTM Reimbursement: The Superbill
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MTM Reimbursement: Sample Billing Forms
CMS-1500 Form
OutcomesTM Pharmaceutical Health Care. Available at: www.getoutcomes.com.
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MTM Reimbursement: Sample Payment Rates
Source: Medication Therapy Management Services: A Critical Review. The Lewin Group Report. J Am Pharm Assoc. 2005;45:580-7.
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Public Sector: Medicare Part D (PDP & MA-PDs)Member Health (CCRx), Humana, Outcomes*, Walgreens Health InitiativeManaged-care based services
Public Sector: State-based Medicaid Programs
Public Sector: Community Health Centers*
Private Sector: Self-insured employer groups or managed care plansAsheville project/APhA Foundation projectsOutcomes Pharmaceutical Health Care*Kaiser – Clinics*Hospitals – medication reconciliation
* Public and Private
Scope of MTM Delivery in Pharmacy
Acknowledgement: Slide from Jim Owen, PharmD, Director of Professional Practice at the APhA.
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Exploratory Research on MTM:Final Report for CMS on July 8, 2008
CMS contracted with Abt Associates to explore MTM in 2007-2008Reviewed 59 publications on MTMInterviewed 60 individuals from 46 different organizationsConducted 4 in-depth case studies
Key FindingsMTM Organizational Practices and ModelsTargeted Patients, Eligibility Criteria and Enrollment MechanismMTM Components and ServicesMTM Service ProvidersCoordination of MTM with Disease/Care ManagementMTM for Nursing Home PatientsReimbursement and DocumentationOutcomes and Evaluations
Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.
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Final Report for CMS:Organizational Practices and Models
Variety of practice models in the literature and in current MTM programsNot yet appear to be an identifiable set of clearly defined models that are reasonably stable and mutually exclusiveVariations of Practice Models
Primary focusMTM service providersIntervention frequencyService delivery modReconciliation with prescribersAdditional education and supportDisease-state monitoring
Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.
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Final Report for CMS:MTM Program Funding
Medicare Part D Prescription Drug PlansRequired to provide MTM to targeted beneficiariesAdminister MTM programs as part of CMS contracts
State Pharmacy Assistance Programs and Medicaid MTM ProgramsFunded through respective state budgets
Employer-sponsored MTM ProgramsNursing Homes Contract with Consultant PharmacistsVA Salaried PharmacistsPharmacy Association FoundationsResearch Grants or Institutional SupportThird Parties (PBM or MTM vendors)Patient Out-of-pocket Purchase from Some Community Pharmacy
Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.
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Final Report for CMS:Provider Reimbursement
Fee Schedules – Fee-for-service (FFS)Employer-sponsoredMedicareMedicaid
Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.
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Final Report for CMS:Provider Reimbursement
Resource-based Relative Value Scale (RBRVS) and CPT Codes
Minnesota Medicaid Program
Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.
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Final Report for CMS:Some Challenges and Opportunities
Challenges Opportunities
Source: Exploratory Research on MTM. Final Report for CMS by Abt Associates Inc.; July 8, 2008.
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MTM and Future of Pharmacy Practice
Joint Commission of Pharmacy Practitioners (JCPP) Future Vision of Pharmacy Practice 2015Consensus document on vision for pharmacy, pharmacy practice and benefits to society
Pharmacy education will prepare pharmacists to promote health improvement, wellness, and disease preventionPharmacists will practice as experts regarding medication use and be responsible for promotion of health improvement, wellness, and disease preventionPharmacy practice’s benefits to society – medications-related public health goals are more effectively achieved
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MTM Initiatives and Resources: National and State (Maryland)
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MTM Initiatives and Resources: National
MTM Definition – 11 National Pharmacy OrganizationsAPhA-NACDS – Core Elements of MTM Service ModelAPhA Lewin Group Report – Findings on Existing MTM Programs, Models for Payers, and Benefits of MTMAPhA-ASCP MTM Certificate Training ProgramAPhA-NACDS MTM Pharmacist Training CD-ROMAPhA MTM Self-Assessment ToolAPhA-NACDS MTM Implementation Manual APhA MTM Resources at: www.pharmacist.com/mtmAPhA MTM List-serv and e-Communities
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MTM Initiatives and Resources: Maryland
MTM Training Initiative for Pharmacists and PreceptorsGoals:
Optimizing medication use and improving public healthProviding certificate training for pharmacists, preceptors and student pharmacistsHelping to advance pharmacy practice in the community and long-term care settings
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MTM Initiatives and Resources: Maryland
MTM Faculty Trainers:Chanel Agness (UM SOP) Nicole Brandt (MD-ASCP)Kristen Fink (MPhA)Jennifer Hardesty (MD-ASCP)Nayab Hussain (MPhA) Hoai-An Truong (UM SOP)
Student Assistants:Katherine L. LodowskiJanet E. ShawThao N. Vuong
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MTM Initiatives and Resources: Maryland
Maryland P3 ProgramAPhA Foundation Ten City ChallengeTrained pharmacists provide diabetes self-management education/training for patients
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References and Acknowledgement
APhA MTM Digest: Perspectives on MTM Service Implementation. March 2008.MTM in Pharmacy Practice: Core Elements of MTM Service Model. Version 2.0. March 2008.American Pharmacists Association MTM Resources Center. Available at: www.pharmacist.com/mtmUniversity of Maryland School of Pharmacy Continuing Education Website. Available at: www.pharmacy.umaryland.edu/ceAcknowledgement to the APhA for the data and information from MTM Digest 2008 in this presentation.
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Medication Therapy Management Services: Perceptions, Processes and Models for Compensation
Hoai-An Truong, PharmD, MPHAssistant Director, Experiential Learning
Clinical Assistant ProfessorUniversity of Maryland School of Pharmacy
Baltimore, MDE-mail: [email protected]
Eastern Medicaid Pharmacy Administrators Association (EMPAA) Conference
November 9-12, 2008White Sulphur Springs, WV