MEDICATION THERAPY Management (MTM) services introduced in 2006 under Medicare Part D have prompted pharmacists to adopt expanded roles in the commercial setting, such as performing a comprehensive medication review and monitoring a patient's response to therapy. One of the main caveats, however, is the lack of standardized reimbursement for pharmacists' services.
According to the American Society of Health-System Pharmacists, patients who need MTM may not have access to those services when third-party payers do not provide adequate reimbursement. Although the role of the pharmacist has grown well beyond that of pill dispenser, Stacey Swartz, senior director, pharmacy affairs, National Community Pharmacists Assn. (NCPA), is not convinced pharmacists are living up to their full potential.
"We would see more pharmacists offering these services if they were supported by a business model," she says. "In the long run, MTM programs improve overall outcomes. MTM is more than monitoring drug interactions but is not yet quite at the level of disease state management."
"Pharmacists are learning new duties, away from just educating patients about products, and moving more toward clinical application of drugs and how to communicate and work with patients," says Mark Petruzzi, RPh, president of SecurityRx, a consulting firm in Hartford, Conn. "The physician serves as the general contractor, while pharmacists deliver a specific therapy, much like a physical or occupational therapist."
Marissa Schlaifer, director of pharmacy affairs for the Academy of Managed Care Pharmacies (AMCP), is concerned that MTM is not taking off as quickly as expected in the commercial world because not enough pharmacists are embracing the new role.
Compliance with drug therapy is an issue that concerns Brad Tice, PharmD, chief clinical officer for Nashville-based PharmMD, an MTM provider.
"Many companies send edits and other messages to pharmacies and letters to physicians, but they do nothing to follow-up and see that the action is carried out," he says.
Well before the Medicare Modernization Act went into effect, the Asheville Project-a disease management and pharmacy program piloted in 1996 between the city of Asheville, N.C., a self-insured employer, and Mission-St. Joseph's Diabetes and Health Education Center-showed that drug therapy management was a viable option for educating and monitoring patients with chronic disease. NCPA's Swartz, however, is concerned that insurers may not adopt the Asheville model until there is recognition of MTM programs as professional services.
Asheville invites employees with diabetes to participate in a wellness and education program with specially trained pharmacists. In turn, if employees attend on a regular basis, copayments on all diabetes-related medications and supplies are waived. The city pays the entire cost of the program and reimburses community pharmacists for their role as consultants and advisors.
Kerr Drug based in Raleigh, N.C., has been in on the ground floor of the Asheville Project by providing services to its participants. Many of Kerr's 102 pharmacies now house healthcare centers that are staffed by one of 15 clinical pharmacists available to provide patients with services.
Rebecca Chater, PharmD, director of clinical services for Kerr, says that the ROI for employers using the community pharmacy-based services is as high as 4-to-1. Pharmacists are receiving reimbursement on a fee-for-service basis but the model is moving toward capitation.
The Midwest Business Group on Health (MBGH), which represents 85 employers, rolled out the Asheville model in November 2006. President Larry Boress says the group's role includes negotiating with and training pharmacists, promoting the program, and overseeing implementation, orientation and enrollment. As of late 2007, MBGH had trained about 80 pharmacists.
Boress admits that implementing the model has not been easy. "As a large metropolitan area, we are replicating a program that first started in a small community," he says. "We do not have enough pharmacists, and few have facilities for confidential meetings. Most employers do not want to host the counseling sessions onsite." In addition, he notes, waiving a copayment does not guarantee compliance.
The overwhelming statistic-a loss of $177 billion from drug non-compliance and its consequences, as reported in the Journal of the American Pharmacists Association-certainly makes a strong argument for finding more solutions to the inappropriate use of drugs.
Mari Edlin is a frequent contributor to MANAGED HEALTHCARE EXECUTIVE. She is based in Sonoma, Calif.