Saturday, February 26, 2011

The Problem With MTMs

Judging from what we're told at school, MTMs are the second coming of Jesus. It is "an example of the future of the profession" or "identifies the new role of the pharmacist in the health care community."

That is entirely true... to an extent. The problem though is that everyone, and by everyone I mean those in power, realize what MTMs can do for the profession... yet choose to ignore the relevant problems of adopting it to our current business model.

We all know the benefits of a service such as MTMs. Physicians are even conceding to the benefits of MTMs, a fact which is more groundbreaking than most realize.

The problem is the consumer does not know the benefits of MTMs. Hell, they don't even know what MTMs are for the most part.

I covered this fact earlier last year and it is something I have been pushing APhA to look into for the last few months.

Essentially we are telling the various insurance providers that we can offer this service which will, ultimately, save them money but will do so in a novel approach. Herein lies the bigger problem... there's no demand for these services.

Really, there's not. Name one time a patient came up to you asking for something similar to what MTMs do? I bet you cannot name one specific instance can you?

That all comes back to the fact that the public is blissfully unaware of what a pharmacist can do. We have to create the demand if we want to take this next step. Some pharmacists, namely Eric, RPh, are already taking the brave first step into this new world.

If we're so intent on moving in this direction, we have to tackle the business aspects that we have so far been ignoring. Pharmacists, in general, have been the passive members of the health care community and in many ways this has become an ingrained trait. It is time to step out side of this self-induced funk and reassert ourselves.

And if not for ourselves, for the future of our profession.

Would it really be so difficult to devise a system for billing for time spent monitoring a patient? We already have ICD-9 codes and DURs to classify what it is we're doing, would it be so difficult to add one more field classifying some time scale? This wouldn't require a complete rewrite of how we do our every day business, merely a small adjustment.

Honestly, I think that is the biggest hurdle places like WAGs, CVS and the likes have with pushing for these services, successful implementation of billing. Sure there would be some trust involved, but it's there are ways to self, and externally, audit times.

And for the business minded folks, the sheer dollar amount that is available out there is astounding. It's almost as if we're sitting on top a giant field of oil, yet we're too scared to drill some test wells.

Ironically enough, the exact same could be said in terms of benefits for patients.

Really, what on Earth are we waiting for?


Anonymous said...

You raise some good points, I enjoyed the post.

My perspective comes from the Insurance/managed care side of pharmacy. Our company has evaluated the literature, done pilot studies and we currently perform MTM for patients. Currently we are focusing on uncontrolled/non-adherent diabetics patients. We are looking to expand across other chronic disease states.

Our MTM services are all phone based currently. That may change in the future if we decide to contract with individual pharmacies.

Personally I see the future of MTM operating in this fashion. We will keep our MTM services in house by our own nurses and pharmacists. More efficient for quality measure tracking, documentation review, and data analysis by our analytics team.

I also see a future for pharmacy MTM services based out of medical clinics in the future Accountable Care Organization (ACO). I have seen pharmacy services and the clinic level work extremely efficiently at the VA and Kaiser as well as some larger physician clinics. The pharmacist is available on-site and reviews medication profiles, meets with patients, and runs collaborative practice agreements to adjust drug class agents to the most appropriate per each patient's formulary.

In school I interned at a primary care clinic where physicians had the option to refer complicated patients for pharmacy consult visit. The referred patient would meet with pharmacist for full MTM/collaborative practice visit. This is the best and most-effective MTM I have ever seen practiced. Hands down more thorough than anything I have seen in the community. If we really want what is best for the patient than this is the model to push for first.

I honestly do not see a strong future for community pharmacy based MTM. The business model is not there and community pharmacists lack access to the patient's full medical record, making the MTM less valuable overall. The pharmacist at the clinic level or PBM level has greater access to information and has the time dedicated to retrieve the information. Part of their job is dedicated to offering these services and the clinic or PBM sees financial incentive in offering these services. The clinic may get higher Third party reimbursements under the ACO model if they offer MTM services on-site and the PBM will see decreased per patient expenditures. The management in retail just wants you to count and fill scripts as fast as physically possible, with no time for bathroom breaks let alone counseling or MTM! Where is the financial incentive for retail....? It just isn't there and I don't see it coming anytime soon. I hope I wrong but I strongly believe I am right.

The Redheaded Pharmacist said...

The problem with the big chains becoming involved in MTMs is that they will devalue them just like they've devalued every other aspect of our profession. Can you imagine what Walmart would price an MTM consult just to undercut everyone and drive the market into the gutter like they do for every other business they jump into? As much as having the big chains involved more with MTMs and developing those services would be great I think in the end if we rely on a bunch of know nothing business majors to be the ones to advance our profession we will end up with more of the same old terrible results we already are seeing in the community setting. If the big chains are the only way for widespread MTM services to exist in the community setting than I would rather not have that option available to me than to see the likes of CVS or Walmart destroy yet another aspect of our great profession!

Anonymous said...

The problem with MTM is that we cannot provide the service as the program is currently structured to all patients. When a patient sees a doctor, he does his evaluation and bills for ALL services to ALL patients. We are basically told what SELECT services to provide to SELECT pts the insurance company deems worthy. An example; we had a pt a few months ago woth med d and medicaid on avapro. They were compliant and had no copay, but the MTM came down asking us to switch to a generic. Who did this benefit other than the insurance? It should be worked out that whenever we make a therpeutic interchange, provide counseling, vaccinate, or whatever, we can document and submit for payment but we are not at that point yet. Time will tell I guess.

Anonymous said...

I work for a retail chain & all pharmacists in my corporation are expected to do MTM, with the exception of floaters. We are contracted with insurers to provide this service.

To effectively provide MTM, you need continuity either with the patient (which I have) or with the prescriber. I have 2 very large prescriber bases, one which is an academic institution. Although it would be helpful to access the medical record - that is not always the complete answer.

I've had many situations in which the patient's PCP will be at one of these large clinics, but the specialist will be free-standing or vice-versa. I am often the one who will pull it together, particularly when there is an interaction, non-formulary, or frequency of use problems.

I disagree with the first responder with regard to the VA & Kaiser. I've experienced both as a pharmacist & the record is often filled with irrelevant or just wrong information - primarly due to the inability of the patient to see the same physician over & over, seeing only a PA or NP or resident or just being rushed thru their appointments.

I honestly feel MTM is a huge, huge waste of time & money. Its a sad response to pressures of money & lack of time at the physician appointment level. Additionally, the reporting systems need to be streamlined and standardized if they are to every be implemented in a widespread fashion. They are cumberson and seem to be written by a PGY2 who has had to do a project.

Really - when you get an insurance rejection, the patient gets dismayed by a copay or the dosing is questionable - you are doing MTM. We've all been doing this for decades! This IS part of what we do & have been doing - not its just checking off boxes for a silly $10 fee.

My corporation doesn't really care that much. The patient has already be counseled by the pharmacist & had all his/her questions answered.

Why should the insurers be driving this? What of the uninsured or cash patients? Wouldn't you provide that very same service? Its called pharmacist counseling!

Anonymous said...

I do agree that it is something we have and should be doing anyway, but dont we always complain that we give our knowledge away for free? we get paid exactly the same amount for a easy prescription as we do for a really complicated one. Can you name one thing that the doctors do for free, or anyone else. Think about getting your car service, you pay for labour, so if they spend more time on an issue they get more money.

I think the big risk is the large multiples turning this into a dirty money grabbing scheme by forcing their pharmacists to do MTM on every single patient regardless of benefit. (SEE UK EXPERIENCE OF MEDICINE USE REVIEWS). You just feel dirty when you go in to review the use of a single item that a patient has been using for years, just because your big company want that money.

Student Pharmacist Desk said...

I love your blog-really good points. It is an exciting time for us being entering the profession right now