Establishing a Successful Collaborative
Medication Therapy Management
Service
Thomas Buckley, RPh, MPH
Assistant Clinical Professor
University of Connecticut School of Pharmacy
Faculty Disclosure
Thomas Buckley has no actual or potential
conflict of interest associated with this
presentation.
Learning Objectives
1. Describe the value of medication therapy
management and collaborative drug therapy
management within the patient centered
medical home model
2. Illustrate the opportunities of MTM practice
initiatives in Connecticut
3. Identify reimbursement options for
pharmacist services
Making Health Care Reform Sausage
Health reform goal:
Reduced cost through improved quality
• Can pharmacists reduce costs through MTM
services’ ability to improve outcomes?
• Can pharmacists improve incentives for payfor-performance?
– Shared savings?
– Aligned incentives?
– Integration of systems?
– . . . end/reduction of fee-for-service?????
“Why Pharmacists Belong In The
Medical Home”
•
•
•
•
Marie Smith (UConn)
David Bates (Brigham&Women’s)
Thomas Bodenheimer (UCSF)
Paul Cleary (Yale)
Health Affairs, May 2010; 29(5): 906-913
Pharmacists in Medical Home
• Pharmacists “are well trained health professionals, yet they
are often underused.”
• “…the complementary knowledge and skills of pharmacists
and prescribers can lead to improved patient care and
medication use – especially for chronic conditions.”
• “The medical home movement provides an opportunity to
examine innovative approaches to expanding patientcentered pharmaceutical care in a collaborative, teambased practice model.”
Source: Marie Smith, David W. Bates, Thomas Bodenheimer, and Paul D. Cleary. “Why
Pharmacists Belong In The Medical Home. Health Affairs, May 2010; 29(5): 906-913.
Patient-Centered Primary Care
Collaborative
“In primary care practices
that offer a patientcentered medical home,
comprehensive
medication management
by a "clinically oriented
pharmacist"
is needed for patients
with complex regimens
who are not at their
therapeutic goal or are
having adverse effects”
Medication Facts
• 75% of all healthcare costs are related to chronic
disease
• After lifestyle interventions, medications are the
primary weapons used to prevent disease and
effectively control chronic disease
• Proper use of medications can lead to improved
health, enhanced quality of life, and increased
productivity when directly related to clinical
outcome goals
So why a quality gap?
www.pcpcc.net
Medication Facts
• Four out of Five leave with at least 1 prescription¹
• One-third of all Americans take at least 5 medications
• Medicare beneficiaries with multiple illnesses:
–
–
–
–
–
–
See an average of 13 different physicians
Have 50 different prescriptions filled each year
Account for 76% of hospital admissions
Account for 88% of all prescriptions filled each year
Account for 72% of physician visits
Are 100 times more likely to have a preventable
hospitalization than someone without a chronic condition²
Why is medication management
needed in the PCMH?
• Comprehensive medication management has
facilitated the efficiency and effectiveness of
the PCMH team in improving clinical
outcomes, reducing morbidity/mortality, while
lowering total healthcare costs
• Medication management is even more
essential when multiple providers are involved
with complex patients
Comprehensive medication
management in the PCMH
•
•
•
•
•
•
•
Elements of comprehensive
medication management:
Assessment:
Reveal the patient’s
medication experience
Identify drug-therapy
problems
Care Plan:
Personalized goals of therapy
Resolve drug problems
Personalize interventions
Follow-Up:
Effectiveness and safety
Determine patient outcomes
www.pcpcc.net
Core principles of PCMH
In addition to cost & quality –
Why is MTM needed?
Adverse Drug Reactions
• ADRs are the 4th leading cause of death in the US:
– 106,000 deaths per year
• ADR cost per year
– $ 76.6 billion in US per year
– The cost of drug-related morbidity and mortality
exceeds the annual expenditure for drug therapy
in the United States!
• 28% of ADR’s are preventable
Primary Care Med Use and Safety Issues
 175,000 visits/yr to US emergency depts for adverse
drug events (ADEs) in the elderly
 32% adverse events leading to hospital admission
attributed to medications
 49% patients with unexplained med discrepancies
between home to hospital discharge;
 29% patients with unexplained med discrepancies between
hospital discharge and 30-days post discharge
SOURCES:
National Ambulatory Medical Care Survey: 2006 Summary. Natl Health Stat Report. 2008 Aug 6;(3):1-39.
Arch Intern Med. 2005;165:1842-1847; Ann Pharmacother 2008;42:1373-9.; JAMA. 2008;300(24):28672878. Ann Intern Med. 2007;147(11):755-765.; Arch Intern Med. 2006;166:565-571; Int J Med Informatics
2008:153–60; Jt Comm J Qual Patient Saf 2007 May:33(5):286-292.
Primary Care Med Use and Safety Issues
 71% of physician office visits involve medication therapy with 15%
of visits having 4 or more prescriptions
 Only 47% of meds used at home were documented in EMRs;
 89% of prescription medications and 76% of OTCs/herbals had
discrepancies with EMR
 30% patients taking prescription meds and 48% patients taking
OTCs/herbals had actual meds used at home that were not
recorded in EMRs
Arch Intern Med. 2005;165:1842-1847; Ann Pharmacother 2008;42:1373-9.; JAMA. 2008;300(24):2867-2878.
Ann Intern Med. 2007;147(11):755-765.; Arch Intern Med. 2006;166:565-571
Outcomes of MTM Studies
Self-insured employer:
The Diabetes 10 City Challenge
• Decrease in A1C (5.2%), LDL (32%), SBP (16%),
DBP (9%)
• Increase in nutrition, exercise and weight loss
• Employer savings of $918/employee of total
health costs
• ROI > 4:1 beginning in the 2nd year
• 50% reduction in absenteeism and fewer
worker’s compensation claims
• 97.5% of patient satisfaction with diabetes care
http://www.diabetestencitychallenge.com/
JAmPharmAssoc 2009; 49:383-91.
MTM return on investment
• Asheville Project: $1200/patient/year diabetes
patients with improved outcomes
• Minnesota Medicaid MTM: resolved 3.1 drug
therapy problems per recipient generating
average cost savings $403/patient/year
– Reduction in total annual health costs exceeded
cost of providing MTM by 12:1
J Am Pharm Assoc 2006; 46:133-47
J Am Pharm Assoc. 2008;48:203–11
Pharmacist Care MTM Practice Model*
1. Develop a comprehensive, active medication profile (CAMP)
2. Perform a systematic assessment of each medication for appropriateness,
efficacy, safety, and adherence (in this sequence) to achieve optimal
treatment goals;
3. Identify, resolve, monitor , and prevent drug therapy problems in
collaboration with the PCP and other prescribers:
drug therapy problems include: allergies, inappropriate medication
selection, omissions, duplications, low or excessive dosages, drug
interactions, adverse events, cultural competency and health literacy
challenges, adherence issues, and costly regimens
4. Collaborate with the patient’s PCP, specialists, and health care
professionals to optimize medication therapy and achieve treatment goals
* APhA/NACDS MTM in Pharmacy Practice Core Elements 2.0 (2008)
Pharmacist Care MTM Practice Model (cont’d)
5. Provide the patient with a personal medication record that can be shared
with caregivers, prescribers (PCPs and specialists), and across care
transitions
6. Providing the patient with a medication action plan to empower them to
work on medication self-management goals and share decision-making
7. Sending the patient’s PCP (and other providers, as needed) the
pharmacists’ care plan with evidence-based recommendations on
identified drug therapy problems for review and action prior to inclusion
in the patient’s medical record;
8. Schedule follow-up patient visits, as needed, to resolve drug therapy
problems and to evaluate the patient’s progress toward achievement of
medication self-management goals.
Patient and PCP Reports
Personal Medication Summary (Patient)
• printed for patient at end of each visit
• list of meds and conditions
• patient medication action plan with
self-management goals for continued follow-up
MTM Summary Report (PCP)
• med list (Rx, OTC, herbal) – directions & prescriber
• drug therapy problems – linked to med & condition
• comments to physician – SOAP note format
Critical Perspective: CDTM vs. MTM
(CDTM as a “tool” of MTM)
Medication Therapy Management
Service Description
Collaborative Drug Therapy Management
Practice Model
(Provider Arrangement)
Any service, regardless of intensity,
Provided by a pharmacist to a patient.
Practice relationship between the
pharmacist, physician, and patient that
provides enhanced management of care
and improved health outcomes
CDTM Definition (ACCP)
• Collaborative practice agreement between
physicians & qualified pharmacists whereby
pharmacists work within the context of a defined
protocol, permitting them to assume the
professional responsibility for:
–
–
–
–
Performing patient assessments
Ordering drug therapy-related labs
Administering drugs
Selecting, initiating, monitoring, continuing, and
adjusting drug regimens
Numerous types of CDTM agreements
• Smoking cessation
• Emergency
contraception
• Immunization
• HTN/hyperlipidemia
• Diabetes
• Pain
• Depression/PTSD
•
•
•
•
Refill protocol
Anticoagulation
Asthma/COPD
UTI, pneumonia,
antibiotics
• STDs
• Antiemetics
• IV to oral therapy
What is a Connecticut Model of
Providing MTM?
Pharmacist’s Network
(Independent Practice Association)
1. CT Pharmacists Association
2. UConn School of Pharmacy faculty
Contract with Health
Plans/Payers, Employers,
Providers, Health Systems
for Pharmacist Services
Recruit
Qualified
Pharmacists
for contract
services
NETWORK SERVICES
Negotiate Contracts
• Administrative and billing service
 Direct payments to Pharmacists
• Coordinate network of pharmacists
 Competency/skill-based qualifications
Not dependent on pharmacists’ workplace
• Validate credentials of pharmacists involved
• Provide standardized pharmacist
documentation tool
HIPAA compliant
 Web-based , secure access
Standardized reports
• Systematic approach to all services offered
Pharmacists
Collaborate with
Health Care
Professionals &
Provide PatientCentric Care
Improved
Patient
Care and
Outcomes
PHARMACIST MTM:
• Pharmacist at Point-of-Care (Primary Care
Office/Telemedicine)
• Perform Comprehensive Medication Review
 Develop a Personal Medication Record
• Assess Medication-Related Problems (MRPs)
 Duplicate therapy/ Drug interactions
Adverse events and side effects
Adherence
• Develop Patient Medication Action Plan
• Document /Follow-up Plan
• Communicate with Primary Care Provider
CT DSS Medicaid Transformation Grant
Building a Medicaid HIE and ERx Med Info Exchange
UConn School of Pharmacy
EHealthCT
EDS
Build/ Evaluate ERx Med Info Exchange
Build Health Info Exchange
Medicaid Data Transfer
CT Pharmacist Network
MEDICAID
HEALTH INFO EXCHANGE
Pharmacists conduct patient interviews,
MTM and Adherence projects
Inpatient and ED
Discharge Info
Hospitals
Updated Med Info
MTM
DOCUMENTATION TOOL
MTM and
Adherence Reports
Patient Medical Info
Physician Offices
Pharmacies
Medicaid Ptnt Eligibility
Preferred Drug List
Sub-project: Medication Info Exchange Project
2008, UConn School of Pharmacy/Marie Smith, PharmD; Written permission required for any use including copying, modifying, duplication, or distribution
17
Medicaid Project - Objectives
1. Network Pharmacists build a comprehensive, active medication
profile (CAMP – prescriptions, OTCs, herbal products,
nutriceuticals) for Medicaid patients that can be accessed by
health care providers via the Health Information Exchange.
2. Network Pharmacists assess primary care drug-therapy problems
(DTPs) using the CAMP and communicate findings to primary
care providers.
3. Advance the medical home concept through pharmacists’
collaboration with primary care providers
4. Improve medication adherence for Medicaid patients utilizing Rx
fill data to alert prescribers on patient adherence trends.
CT Medicaid MTM Results
• 9 pharmacists providing MTM in PCP office; EHR access
• 89 patients; 51 yo; 9.5 medical conditions; 15 meds; 4.5 visits/6
months
• Medication discrepancies: >3200 between DSS claim, EHR med list,
patient report
• Drug Therapy Problems (DTPs):
– 918 DTPs; mean 10.3 DTPs/patient
– 83% resolved within 4 pharmacist/patient visits
– Categories: Indication/Appropriateness(30%); Effectiveness(23%);
Safety(20%); Adherence(26%)
– 78% DTPs resolved through pharmacist/patient interaction (without
PCP visit)
• Illustrates pharmacists can improve PCP efficiency
CT Medicaid MTM Results
• Patient med therapy goals: 63% to 91% 1st to last visit
• Cost analysis: using Medicaid drug & visit claims from previous year
compared to project period
– Approximate $1600/patient/year savings . . . ROI > 4:1
• Patient feedback - Overwhelmingly positive, 2 themes:
• Improved patient empowerment: “answered questions not
addressed in busy pharmacy”, “in control of my life”, “can now
speak to my doctor”
• Improved care coordination: “pharmacist communicated with
my doctor and they are all on the same page”
– PCP feedback
• 82% PCPs made med change based on pharmacist
recommendation
• 90% wanted pharmacist MTM services for eligible patients
Leveraging the Medicaid MTM experience
Medication Optimization Grant from Center for
Technology & Aging
– Utilize CT Medicaid MTM model in high-risk,
underserved Cambodian American communities
– Pharmacist as member of Cambodian American
Medical Home team – CT, MA, CA
Benefits:
– Patient outcomes – traditional MTM outcomes
– Identification & resolution of social determinants
– Cultural competency: cross-cultural teams with
Community Health Workers
“Delivering Culturally Appropriate Care to
Optimize Medication Use in the Elderly”
Use of telemedicine,
videoconferencing, &
spoken-format technologies
Student involvement:
Culturally-appropriate MTM
Eliminating Barriers to Care Using Technology
http://www.youtube.com/user/TechandAging?blend=7&ob=5
Project Need
• Cambodian-Americans have exceptionally high prevalence
of chronic mental and physical disease due to torture and
trauma experienced during the Khmer Rouge regime.
– escalating rates of life-threatening chronic disease
• 6x rate of DM, 4x rate of stroke, 70% PTSD/depression
• Lack of access to health care
–
–
–
–
Language
Culture
Socioeconomic conditions – social isolation
Lack of understanding of trauma issues
• MTM research has not addressed individuals of
ethnic/racial minorities
– Particularly those afflicted with chronic disease from exposure
to torture or trauma
– Opportunity for pharmacists to impact health disparities
Project Design
• Goal of reaching:
– 50 patients in Connecticut/Western Massachusetts (face-to-face
consultation in home or clinic setting)
– 50 patients in Long Beach, California (local CHW in their home or clinic
and pharmacists in Connecticut via telemedicine)
• Population identification
– Connecticut/Western Massachusetts: case finding in the KHA provider
network.
– California: Mount Carmel Cambodian Project, an affiliate organization
within the National Cambodian American Health Initiative
– CHWs screen elderly patients to determine their use of chronic
medications (risk assessment & medication history screening)
– Patients matching the criteria (at least 2 chronic conditions and 3 chronic
medications) will be eligible for participation in the project
– Patients randomly selected and asked if they would like to participate in
the project until the site number reaches 50 patients
Project Design
• Initial visit (pharmacist & CHW):
– Developed comprehensive medication record of prescription and nonprescription therapies
– Identification and potential resolution of drug-therapy problems (including
medication adherence)
– A medication action plan for the patient
– MTM report for the patient’s provider, and f/u with provider if needed.
• Follow-up visits occurred quarterly (with a goal of 4 total visits) to monitor
progress with the plan
• Patient received written report at each visit:
– Med list (drug picture) matched to condition
– List of medication-related problems (MRPs) – drug to condition
– Medication action plan (what they need to do prior to next visit)
• Primary care provider receives MTM report after each visit:
– Med list matched to condition
– MRPs match drug with condition
– Pharmacist recommendations to patient and provider
Results
• 96 total patients (627 screened), 217 total visits
(2.3/patient) over 8 months
• The average patient had 6.6 medical conditions and
was on 10.3 medications
– 73% CVD, 72% depression/PTSD, 68% pain, 53% diabetes
• 604 drug therapy problems (DTPs) were identified, or
6.3 per patient
• 81% of DTPs involved medication appropriateness,
effectiveness, or safety; 19% were due to nonadherence
– DTPs are systems rather than patient issues
Clinical Results
• 93% of DTPs were resolved during the study
period (with < 4 hours of MTM/patient)
• Therapy outcomes goals improved 24% (69% to
93%) from initial to final MTM visit
• Inappropriate medication use decreased 34.5%
• Depression screen (mean Hopkins score)
improved 24.5% (p=0.022) from initial to final
MTM visit
Clinical Results
• Medication adherence behavior (Modified Morisky
Survey) improved 22.5% (p=0.027)
– Significantly more high adherers identified than low
adherers (p=0.022) from first to final visit
• Relating adherence to beliefs about medicine:
– Low adherence correlated with overall negative health
beliefs (p=0.015); low adherence strongly correlated with
how they felt about meds in general (not their specific
meds), and how prescribers use meds (p<0.001)
– Reinforces importance of communication/relationship
Financial Results
• Cost avoidance was estimated using evidencebased analytics from Assurance© software
• Calculating the costs of providing MTM:
– Pharmacist & CHW costs for each patient
– Compared to total of direct cost savings (drug changes or
drug prevention costs) and cost avoidance (health care
costs & prevention savings).
– Health expenditure savings included clinic, ED, urgent
care, lab, and specialty office visits avoided; work days
saved, and drug therapy changes
Summary of Service Savings and Costs
Savings
Cost
Net
Health Care:
$329,263
$5,747
$323,516
Drugs:
$13,820
$3,507
$10,313
Pharmacist & CHW
$42,715
Totals:
$343,083
$51,969
$291,114
(5.6 : 1)
Per Encounter:
$1581.03
$239.49
$1,341.54
Per Patient:
$3573.78
$541.34
$3,032.44
Hospital/ER Utilization Rate Comparison
5
4.5
4.7
4
p=0.046
3.5
3
2.5
2
Non-MTM
1.75
p=0.032
1.5
p=0.032
1.5
1
0.5
0
Hospital visits
Hospital LOS
ER visits
Survey of 140 Cambodian Americans during MTM study period
Matched controls of conditions: MTM patients vs non-MTM patients
MTM
Culturally Appropriate MTM
Conclusions
• Empowered high-risk trauma patients
– Realized value of health for the 1st time
– Overcame mistrust of health care system
– Revealed information to pharmacists never given
to PCPs or family members
• Reduced the burden on caregivers and the
need for higher cost medical care
• Identified & addressed social determinants
that impact med use & overall health
Culturally specific medical home
Khmer Health Advocates Inc.
How are MTM services recognized
through payment?
• Private & public sector payment approaches
– State vs federal provider recognition
• Consistent w/primary care payment reform
• 3 approved time-based CPT codes for MTM
– Document service delivery & bill any health plan
(including Medicare Part D)
– Federal provider recognition of pharmacists: pending
legislation in Congress – would allow Part B billing
• Capitation approaches for payment
– PMPM; or annual capitated basis for receiving service
(? model for ACO or PCMH)
Credentialing Requirements of Payers
• Varies widely by payer – with regard to:
– Pharmacist credentials
– Service delivered to patient
– Recipient eligibility
– Electronic documentation
– Space to provide service
– Billing & reimbursement
Credentialing Requirements of Payers
• To submit a claim, 2 things need to be in place:
– Practitioner needs to be recognized as a provider by the payer
• Payer specific provider ID, issued by the payer
• National Provider Identification (NPI) – issued by federal gov’t
http://www.cms.hhs.gov/NationalProvidentStand
– Facility that submits claim must also be recognized as a facility by
the payer
• Licensed health care facility ID (clinic, hospital, etc)
• Licensed pharmacy ID
• NPI
• If all payer credentials are met & when both of above are in
place, you submit claim to any payer who has ability to accept
claims for pharmacy services using a CMS 1500 claim form (for
Medicare or Medicaid claims)
Compensated Services of Current
Payers
• Clearly defining & understanding the service
you are being asked to perform is critical
– MTM services have not been well defined
– Some payers define MTM clearly
– Each payer may set a definition of services
– Compensation rates vary by payer, important you
understand services you perform & rate to be paid
for that service
MTM as a Health Care Service
• Medicare Modernization Act & Health
Information Portability and Accountability Act
(HIPAA) have assisted in providing guidance for
MTM reimbursement
• HIPAA requires that all health care service
billing done through CMS 1500 form
– ICD-9 codes have specific reimbursement eligibility
– Most CMS 1500 is electronic, but can use paper
Medicare Part D
Required MTM forms (as of 1/1/13)
• Medicare Part D requires use of CMS
Standardized Format:
– Cover letter
– Medication Action Plan (MAP)
– Personal medication list for the comprehensive
medication review
Can be downloaded at:
http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/MTM.html
MTM documentation/billing systems
•
MirixaPro, founded by the National Community Pharmacists Association
(www.mirixa.com)
•
OutcomesMTM System (www.getoutcomes.com)
•
ConXus MTM, from Protocol Driven Healthcare, Inc. (www.pdhi.com)
•
Medication Management Systems/Assurance Pharmaceutical Care
Documentation Software, from the University of Minnesota Peters Institute of
Pharmaceutical Care (www.medsmanagement.com)
•
Medication Pathfinder, from Clinical Support Software
(www.medicationpathfinder.com)
•
MTM 360, from Elsevier Clinical Decision Support
(www.goldstandard.com/product/medication-therapy-management/mtm-360)
•
PharmMD, from PharmMD (www.pharmmd.com)
•
IQ Ware (www.iqwareinc.com)
Billing Strategies for MTM
• Outside of Medicare/Medicaid
• Must have private pay rate defined to use as
measuring stick for complexity of patients
• CPT Codes for MTM as of January 2008
Differentiating Product from Service
Medication Therapy Management
Drug Regimen Review
Patient Care
Patient Education
Prescriptions
Product
AMA Current Procedural Terminology (CPT)
Medication Therapy Management (MTM)
MTM describes face to face patient assessment and intervention as appropriate, by a
pharmacist, upon request. MTM is provided to optimize the response to medications or
to manage treatment related medication interactions or complications.
MTM includes the following documented elements: review of the pertinent patient
history, medication profile (prescription and nonprescription), and recommendations for
improving health outcomes and treatment compliance. These codes are not to be used to
describe the provision of product specific information at the point of dispensing or any
other routine dispensing related activities.
99605
Medication therapy management service(s) provided by a pharmacist,
individual, face to face with patient, with assessment and intervention if
provided; initial 15 minutes, new patient
99606
initial 15 minutes, established patient
99607
each additional 15 minutes (List separately in addition to code for primary
service)
MEDICATION THERAPY MANAGEMENT SERVICES:
Level of
Service Provided
Assessment of
Drug -related
Needs
Identification
Drug Therapy
Problems
Complexity of
Care Planning
& Follow -up
Evaluation
CPT
Category III
Codes b
Level #1
Level #3
Level #4
Level #5
Detailed
Expanded
Detailed a
Comprehensive
2 Medications
3-5 Medications
6-8 Medications
=9 Medications
Problem -focused
Expanded
Problem
Detailed
Expanded
Detailed
Comprehensive
0 Drug Therapy
Problems
1 Drug Therapy
Problem
2 Drug Therapy
Problems
3 Drug Therapy
Problems
=4 Drug Therapy
Problems
Straightforward
Straightforward
Low Complexity
Moderate
Complexity
High
Complexity
1 Medical
Condition
1 Medical
Condition
2 Medical
Conditions
3 Medical
Conditions
=4 Medical
Conditions
99605 initial
encounter with a
new patient c
99605
(or 99606
99605
(or 99606
99605
(or 99606
99605
(or99606)
Problem -focused
Level #2
Resource -based Relative Value Scale
Expanded
Problem
a
1 Medication
(or 99606 for all
follow -up
encounters)
and
and
and
and
99607
2 X 99607
3 X 99607
>4 X 99606
Face -to-face
Time
15 minutes
16-30 minutes
31-45 minutes
46-60 minutes
>60 minutes
Amount
$32
$25
$76
$58
$100
$82
$124
$106
$148
$130
Mechanisms for Reimbursement
•
•
•
•
•
•
•
Fee-for-Service
Contracted Service
Prescription Drug Plan (Medicare Part D)
Health Plan (fee schedule)
Physician Practice (“Incident-To” – Level 1)
At Risk Contracts (Point of Service)
Currently cannot bill Medicare Part B as
independent provider
Additional Billing Strategies
• Dependent on practice model
• “Incident to” billing – i.e. Medicare Part B, use
MD CPT codes – requires direct supervision of
MD, “integral but incidental” to MD care
– Not guaranteed, may be lower level of payment
• Per member per month (PMPM) or Per
Enrollee (or utilizing member) per month
– Working with employers
– At risk contract (capitated)
Critical Goal: Medicare Part B Eligible
Provider Status
Report to the Surgeon General
“The 2011 Report provides rationale and
compelling discussion to support health
reform through pharmacists currently
delivering expanded patient care services.”
Report to the Surgeon General
• Focus Point 1: “pharmacists are already
integrated into primary care as health care
providers
– However, pharmacists may be the only health
professionals (that manage disease through
medications and provide other patient care
services) that are not recognized in national
health policy as health care providers or
practitioners.”
Report to the Surgeon General
• Focus Points 2 & 3: “pharmacists must be
recognized as health care providers by statute via
legislation and policy, and compensated
commensurate with level of services provided”
• Focus Point 4: “thousands of articles, systematic
reviews and meta-analyses of positive patient
and health system outcomes have been
published that validate this model as evidencebased”
Objectives of Surgeon General Report
• Obtain advocacy from the U.S. Surgeon General to:
– Acknowledge pharmacists that manage disease through
medication use and deliver patient care services, as an
accepted and successful model of health care delivery
in the United States
– Amend the Social Security Act to include pharmacists
among health care professionals classified as “health
care providers.”
– Have pharmacists recognized by CMS as Non-Physician
Practitioners in CMS documents, policies, and
compensation tables
Keys to Reimbursement Success
• Build relationships!!!
– Provider & patient relationships critical
– Offer yourself as a resource to providers, payers, legislators
– Learn strategies from other providers
• The only thing harder than taking care of patients is billing for
the service – look for resources that can assist you.
• Reimbursement texts:
– ASHP Guidelines for Implementing & Obtaining
Compensation for Clinical Services by Pharmacists
www.ashp.com/bestpractices/pharm-mgmt
– “The Pharmacist’s Guide to Compensation for Patient Care
Services” Michael D. Hogue, PharmD
• Released by APhA www.pharmacist.com
– “How to Bill for Clinical Pharmacy Services”
• ACCP publication www.accp.com/strhowtobill
Conclusions
• Pharmacists can be valuable members of PCMH, but are
underutilized resource
• MTM services improve outcomes, reduce health costs
• MTM services are eligible and capable of being reimbursed with
and without a CDTM agreement.
• CDTM agreements may enhance reimbursement options for
MTM services.
• Federal recognition of pharmacist provider should reduce
confusion of payers toward reimbursement
• There are no limitations on the delivery of MTM services to
patients by pharmacists; but liability increases
Thank You!
Questions . . . and some answers?
thomas.e.buckley@uconn.edu