When Congress created the Medicare Part D drug benefit program as part of the Medicare Modernization Act of 2003, lawmakers acknowledged within the language of the bill that some elderly beneficiaries would require additional counseling about their often-complicated drug regimens, and additional oversight by a health professional of their long-term medication therapy.
By elevating the concept of Medication Therapy Management into law and calling for some level of reimbursement for that level of patient care, the U.S. government effectively endorsed a message that pharmacy leaders have been pushing out to the nation’s health plan sponsors, pharmacy benefit managers and patients for years. The message: that pharmacy services like disease management, clinical oversight and patient education go way beyond drug dispensing, and as such deserve compensation.
That’s all to the good. But Congress left many aspects of MTM vague when it mandated that the Centers for Medicare & Medicaid Services implement the program as part of the Part D package of benefits. In turn, CMS left many aspects of the program up to the hundreds of prescription drug plans administering Part D—including which seniors qualify for the additional counseling and monitoring, who actually delivers it to those patients, and how it’s paid for.
It’s up to the pharmacy community to step firmly into the breach. MTM could represent one of the greatest opportunities still left to community pharmacies to prove their worth as front-line, fully qualified and patient-focused health care practitioners, rather than just dispensers of pharmaceutical products. But, as pharmacy’s leaders have warned repeatedly over the past year, the profession must step up quickly and decisively with a bold and thoughtful plan for delivering MTM—or some other group of health professionals will.
Indeed, some PBM-owned Medicare Part D plans appear to show little interest in enlisting retail pharmacies within their plan provider networks in their still-evolving MTM service models, opting instead for the services of nurses, HMO or PBM staff pharmacists or other professionals.
Somebody will be delivering MTM services to millions of Medicare patients,” said one Rite Aid pharmacy executive. “Let’s be certain it’s community pharmacists.
“I urge all pharmacy opera-tors…to develop MTM programs with a ‘build it, and they will come’ approach. If we don’t, in a few years we will look back and realize we missed a major patient-care opportunity,” he added.
“One of our primary challenges with the Medicare Modernization Act is that it stated that MTM services can be delivered by pharmacists—and ‘others.’ It could be stated that MTM services can be delivered by pharmacists—and ‘others.’ It could be doctors or nurses, or it could be some faceless voice over the telephone from a call center in another part of the world,” warned Bruce Roberts, executive vice president and chief executive officer of the National Community Pharmacists Association. “That’s no way to deliver patient care.”
Addressing NCPA members at the group’s last annual meeting, Roberts passed along a warning from Mark McClellan, former administrator of the Centers for Medicare & Medicaid Services. “Shortly after the passage of MMA,” Roberts noted, “Mark McClellan said to me: ‘If pharmacy wants to be paid for services, you better develop a systemized way to deliver MTM and be able to clearly demonstrate the outcomes of your efforts.’ I’ll never forget those words.”
The challenge, said Roberts, “is to demonstrate that community pharmacists are ready, willing, and able to deliver medication therapy management, that face-to-face MTM is dramatically superior to any cut-rate alternative, and that we can and will produce better outcomes for the plan and our patients.”
Equally important, said the group’s chief executive officer, is that any successful pharmacy-based MTM program has to “recognize the reality of the community pharmacy setting: busy pharmacies, busy pharmacists, workflow issues.”
Chain and independent operators nationwide are scrambling to establish at least some their pharmacies as MTM destinations and stake a claim in the emerging field before other groups pre-empt the initiative. And, within the dictates of their busy dispensing workflow requirements, they continue to push their own pharmacists into broader roles as clinical care specialists and members of a broader health team.
The effort to deliver on the MTM promise at the retail pharmacy can’t be made in a vacuum. “Community pharmacists must be integrated into physician and consumer e-Health initiatives if we are going to reduce administrative costs and improve the quality of care delivered,” said Donald Hackett, chief executive officer of Community MTM Services, which was organized by NCPA as a Web-driven communications and information toolkit to help pharmacists provide MTM and other patient-care services. Big chains like Walgreens and CVS, both of which are emerging as power players in pharmacy benefit management with their own PBM operations, may be best-positioned to capture and define the delivery of MTM services to their own patients.
Walgreens, for instance, has developed an MTM program though its PBM subsidiary, Walgreens Health Initiatives, aimed at the patients enrolled in WHI who are most in need of the additional clinical services. Those patients account for just 5 percent of WHI’s total membership but 29 percent of total prescription costs for their health plan sponsors, according to new company research.
By focusing on those high-cost patients, WHI’s MTM program produced a client return on investment of 2.5-to-1 for MTM interventions throughout 2006, Walgreens reported recently. Pharmacy savings shared between members and clients were more than $50 per member per month for members receiving interventions, according to Walgreens.
“MTM is proving to be a valuable program for creating better patient therapeutic outcomes while also controlling overall healthcare costs,” said Jim Langman, vice president of clinical services for WHI. “By combining our…technology and clinical expertise, our MTM program creates true coordination of care for patients with complex pharmaceutical needs.”