Integrating MTM Services into the Patient-Centered Medical Home

Sylvia Jenkins

Atlanta—In providing medication therapy management (MTM) services, local pharmacists become a valuable resource for case management programs and patient-centered medical home (PCMH) models. Pharmacist–physician collaboration promotes resolution of medication-related problems between primary care office visits and creates continuity of care among healthcare providers. At a Contemporary Issues session titled Integration of Medication Therapy Management into the Patient-Centered Medical Home, at the AMCP meeting, presenters provided an in-depth discussion of MTM and the ways MTM services have been integrated into case management and 2 care coordination models.

Brand Newland, PharmD, MBA, vice president, Outcomes Pharmaceutical Health Care, opened the session with an overview of MTM services. Since 1999, these services have evolved into a systematic network-based approach designed to improve patient understanding of prescription medications through coordination with pharmacists. Initially adopted by self-insured employers and other innovators, and greatly expanded through the Medicare Part D mandate, these services not only enhance enrollee understanding and adherence to medication therapies, but also reduce adverse drug events and patterns of misuse.

Currently, more plans are using a pharmacy-based approach, requiring interactive services including comprehensive medication review (CMR), prescriber consultation, patient compliance consultation, and patient education and monitoring. Dr. Newland characterized a CMR as an interactive person-to-person consultation between the patient and/or caregiver and the pharmacist, designed to empower patients to self-manage their medications and health conditions.

Dr. Newland also discussed the importance of program consistency, including network requirements, policies and procedures, covered services, documentation and billing, and quality assurance expectations. He emphasized that covered services have a dual approach, either pharmacist-initiated or plan-initiated. Outcomes’ MTM system analyzes prescription claims data from contracted plans to direct targeted intervention programs (TIPs) to the plan’s pharmacy networks. TIPs focus on both cost and quality interventions.

In concluding his presentation, Dr. Newland emphasized the growth of provider networks in all 50 states, now including >45,000 pharmacists. He said that analysis of 2957 pharmacist-provided patient compliance consultations showed marked improvement in medication adherence, and 88% of plan members said they had better understanding of their prescription medications after completing the consultation.

The session continued with a presentation by Winston Wong, PharmD, associate vice president, pharmacy management, CareFirst, BlueCross BlueShield, titled “MTM: Expanding from Medicare Part D to Commercial.” MTM and Part D utilize targeting criteria including multiple chronic diseases, multiple Part D drugs, and an annual drug spend of at least $3000. Dr. Wong pointed out that members who are on the verge of becoming “bad” (those who do not meet criteria today but with 1 major health event can meet criteria tomorrow) and those with cost-savings opportunities but few comorbidities are missed using a targeted reactive approach. The benefits of using a proactive approach by offering MTM to members who fail to meet target criteria create drug product cost-savings, distribution of costs across the entire population, and eliminate disparity in benefits. Hispanic and African American beneficiaries may have a lower likelihood of meeting eligibility criteria when compared with whites, Dr. Wong added, citing research released in August 2010.

CareFirst MTM-covered services mirror those presented by Dr. Newland, including CMR, prescriber/patient consultations, and patient education and monitoring. Dr. Wong also emphasized the importance of a dual approach to services, either pharmacist-initiated or plan-initiated.

The remainder of Dr. Wong’s comments focused on CareFirst MTM results from 2006 to 2010. He said that approximately 7500 patients were served, >700 of Outcomes’ MTM providers participated, and return on investment increased 237%. He concluded by emphasizing that extending MTM beyond Medicare Part D provides proactive services, cost-savings, and greater consistency in benefits.

The final speaker, Gayle Dichter, RPh, MBA, director of pharmacy, Senior Whole Health, presented “MTM and the PCMH.” Senior Whole Health provides a PCMH model that includes a care-management team, individual care planning, and flexibility. Ms. Dichter cited numerous benefits to patients, physicians, hospitals, skilled nursing facilities, Medicare, and Medicaid, including cost benefits, reduction of administrative burden, coordinated integrated care, reduction in preventable admission, coordination across care-team members, and assistance with medication management.

Ms. Dichter continued with a discussion of the advantages of centralized documentation, and she presented a sample case management overview consisting of detailed notes, a CMR, TIP, and medication review. Additional offerings by Senior Whole Health include quality improvement plans, and Star Ratings/healthcare effectiveness data and information set and medication synchronization.

She concluded the session by providing evidence of the success of MTM and the PCMH model. Acute care admissions showed a 43.2% decline in days/000 over a 3-year period. Over the same period, there was an 18% increase in complex care. A Massachusetts study revealed that enrollees were 40% less likely to be admitted to nursing homes for long-term care compared with fee-for-service Medicaid enrollees; in addition, nursing home episodes decreased in duration by 1 to 2 months.