Nontraditional or noncentralized models of diabetes care: Medication therapy management services

,

Article

Nontraditional or noncentralized models of diabetes care: Medication therapy management services

November 2011 · Vol. 60, No. 11 Suppl: S12-S18

References

1. Biola H, Green LA, Phillips RL, et al. The U.S. primary care physician workforce: minimal growth 1980–1999. Am Fam Physician. 2003;68(8):1483.-

2. Council on Credentialing in Pharmacy. Scope of contemporary pharmacy practice: roles, responsibilities, and functions of pharmacists and pharmacy technicians. J Am Pharm Assoc (2003). 2010;50(2):e35-e69.

3. Drab S. Translating clinical guidelines into clinical practice. Role of the pharmacist in type 2 diabetes management. J Am Pharm Assoc (2003). 2009;49(6):e152-e162.

4. Posey LM, Tanzi MG. Diabetes care: Model for the future of primary care. J Am Pharm Assoc (2003). 2010;50(5):623-626.

5. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47(3):533-543.

6. Malloy MJ, DeBellis R. Collaborative drug therapy management, medication treatment management, and Medicare Part D: What do they have in common? Harvard Health Policy Review. 2006;7(1):186-188.

7. McGivney MS, Meyer SM, Duncan-Hewitt W, Hall DL, Goode JV, Smith RB. Medication therapy management: its relationship to patient counseling, disease management, and pharmaceutical care. J Am Pharm Assoc (2003). 2007;47(5):620-628.

8. Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care. 2011;34(suppl 1):S89-S96.

9. Daly A, Kulkarni K, Boucher J. The new credential: advanced diabetes management. J Am Diet Assoc. 2001;101(8):940-943.

10. Alliance for Pharmaceutical Care. Collaborative Drug Therapy Management: A Coordinated Approach to Patient Care. http://www.ashp.org/s_ashp/docs/files/about/CDTM.doc. Accessed February 3, 2011.

11. Roberts S, Gainsbrugh R. Medication therapy management and collaborative drug therapy management [letter]. J Managed Care Pharm. 2010;16(1):67-68.

12. Martin CM, McSpadden CS. Dispelling the myths about medication therapy management services. Consult Pharm. 2008;23(11):866-872, 875.

13. American Pharmacists Association. Delivering Medication Therapy Management Services in the Community. http://www.pharmacist.com/ctp/mtm. Published March 1, 2009. Accessed February 1, 2011.

14. American Society of Consultant Pharmacists. Delivering Medication Therapy Management Services in The Community—Updated for 2010. https://www.ascp.com/articles/professional-development/delivering-medication-therapy-management-services-community-update. Accessed February 1, 2011.

15. Pellegrino AN, Martin MT, Tilton JJ, Touchette DR. Medication therapy management services: definitions and outcomes. Drugs. 2009;69(4):393-406.

16. Bluml BM. Definition of medication therapy management: development of professionwide consensus. J Am Pharm Assoc (2003). 2005;45(5):566-572.

17. Centers for Medicare and Medicaid Services. 2010 Medicare Part D Medication Therapy Management Programs. https://www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet_2010_06_2010_final.pdf. Published June 8, 2010. Accessed February 1, 2011.

18. American Pharmacists Association; National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc (2003). 2008;48(3):341-353.

19. American Pharmacists Association. Medication Therapy Management Digest. Perspectives on 2009: A Year of Changing Opportunities. http://www.pharmacist.com/AM/Template.cfm?Section=Home2&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=22674. Published March 2010. Accessed February 1, 2011.

20. Abt Associates. Exploratory Research on Medication Therapy Management. Final report. http://www.cms.hhs.gov/Reports/downloads/blackwell.pdf. Published July 8, 2008. Accessed February 1, 2011.

21. Buffington DE. Future of medication therapy management services in delivering patient-centered care. Am J Health Syst Pharm. 2007;64(15 suppl 10):S10-S12; quiz S21–S23.

22. Law AV, Okamoto MP, Brock K. Ready, willing, and able to provide MTM services?: A survey of community pharmacists in the USA. Res Social Adm Pharm. 2009;5(4):376-381.

23. Lounsbery JL, Green CG, Bennett MS, Pedersen CA. Evaluation of pharmacists’ barriers to the implementation of medication therapy management services. J Am Pharm Assoc (2003). 2009;49(1):51-58.

24. Freeman JS. Insulin analog therapy: improving the match with physiologic insulin secretion. J Am Osteopath Assoc. 2009;109(1):26-36.

25. Davies MJ, Derezinski T, Pedersen CB, Clauson P. Reduced weight gain with insulin detemir compared to NPH insulin is not explained by a reduction in hypoglycemia. Diabetes Technol Ther. 2008;10(4):273-277.

26. Fajardo Montanana C, Hernandez Herrero C, Rivas Fernandez M. Less weight gain and hypoglycaemia with once-daily insulin detemir than NPH insulin in intensification of insulin therapy in overweight Type 2 diabetes patients: the PREDICTIVE BMI clinical trial. Diabet Med. 2008;25(8):916-923.

27. Mandosi E, Fallarino M, Rossetti M, Gatti A, Morano S. Waist circumference reduction after insulin detemir therapy in type 2 diabetes patients previously treated with NPH. Diabetes Res Clin Pract. 2009;84(2):e18-e20.

28. Korytkowski M, Bell D, Jacobsen C, Suwannasari R. A multicenter, randomized, open-label, comparative, two-period crossover trial of preference, efficacy, and safety profiles of a prefilled, disposable pen and conventional vial/syringe for insulin injection in patients with type 1 or 2 diabetes mellitus. Clin Ther. 2003;25(11):2836-2848.

29. Molife C, Lee LJ, Shi L, Sawhney M, Lenox SM. Assessment of patient-reported outcomes of insulin pen devices versus conventional vial and syringe. Diabetes Technol Ther. 2009;11(8):529-538.

30. Jankovec Z, Cechurova D, Krcma M, Lacigova S, Zourek M, Rusavy Z. The influence of insulin pump treatment on metabolic syndrome parameters in type 2 diabetes mellitus. Wien Klin Wochenschr. 2009;121(13-14):459-463.

31. Machado M, Bajcar J, Guzzo GC, Einarson TR. Sensitivity of patient outcomes to pharmacist interventions. Part I: systematic review and meta analysis in diabetes management. Ann Pharmacother. 2007;41(10):1569-1582.

32. Wubben DP, Vivian EM. Effects of pharmacist outpatient interventions on adults with diabetes mellitus: a systematic review. Pharmacotherapy. 2008;28(4):421-436.

33. Rochester CD, Leon N, Dombrowski R, Haines ST. Collaborative drug therapy management for initiating and adjusting insulin therapy in patients with type 2 diabetes mellitus. Am J Health Syst Pharm. 2010;67(1):42-48.

34. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003;43(2):173-184.

35. Fera T, Bluml BM, Ellis WM. Diabetes Ten City Challenge: Final economic and clinical results. J Am Pharm Assoc (2003). 2009;49(3):383-391.

TABLE 1

Patient eligibility criteria for MTM programs¹⁷

Multiple chronic diseases
Programs must offer MTM services to patients who have at least 2 or 3 chronic diseases (at the plan’s discretion) and must target at least 4 of the following: Diabetes Hypertension Heart failure Dyslipidemia Respiratory diseases (such as asthma or COPD) Bone disease/arthritis Mental disorders (such as depression, schizophrenia, bipolar disorder).
Multiple covered drugs
Plans vary in the number of drugs patients must be prescribed to qualify, with thresholds ranging from 2 to 8.
Cost threshold
Patients must be expected to incur at least $3000 in annual Part D drug costs.
COPD, chronic obstructive pulmonary disease; MTM, medication therapy management.

FIGURE

The top 10 diseases targeted by MTM programs in 2010 and the percentage of MTM programs that targeted these diseases¹⁷

COPD, chronic obstructive pulmonary disease; MTM, medication therapy management.

Reproduced with permission from Centers for Medicare and Medicaid Services. 2010 Medicare Part D Medication Therapy Management (MTM) Programs. https://www.cms.gov/PrescriptionDrugCovContra/ Downloads/MTMFactSheet_2010_06-2010_final.pdf. Published June 8, 2010. Accessed February 1, 2011.TABLE 2

Core elements of an MTM service model¹⁸

Medication therapy review
Systematic review of the patient’s medications to assess and prioritize problems and create a plan to resolve them.
Personal medical record
Comprehensive record of the patient’s prescription and nonprescription medications, herbal agents, and nutritional supplements. The record is kept and updated by the patient, brought to appointments in different settings, and used by the patient in medication self-management.
Medication-related action plan
List of actions for the patient to use in self-management. The plan is developed collaboratively by the patient and pharmacist and used to track progress toward achieving specific goals.
Intervention and/or referral
The pharmacist intervenes or refers the patient to another health professional to address medication-related problems.
Documentation and follow-up
The pharmacist documents all MTM services and interventions— ideally, electronically. Follow-up or a referral to a different care setting is scheduled based on the patient’s needs.
MTM, medication therapy management.

MTM services in pharmacy practice

MTM services are becoming well established in pharmacy practice. According to an annual survey conducted by the American Pharmacists Association, 72% of pharmacist respondents were offering MTM services in 2009, and about one-third of the rest planned to offer the services soon.¹⁹ About 84% of payer respondents (mostly health maintenance organizations, managed care insurers, and prescription benefit management plans) were offering MTM services. Contracted pharmacists provided about two-thirds of MTM care, with in-house pharmacists and contracted MTM organizations providing substantial amounts of services, and nurses and physicians providing a small proportion.^19-20 MTM services are not restricted to Medicare patients, but are increasingly being offered by managed care organizations and fee-for-service plans.^12,21 Some payers support pharmacist-provided MTM services as part of a broader multidisciplinary disease management program.²⁰

Community pharmacists wishing to offer MTM services have several potential business models. Although they can contract directly with Medicare Part D insurers, it can be difficult and time-consuming to develop these individual contracts. Many insurers are not yet equipped to deal efficiently with pharmacists wishing to initiate this type of arrangement, and insurers are only slowly making the shift toward regarding pharmacists as providers.

A second option is to contract with an MTM intermediary company that links payers with pharmacists. These companies can be approached via their Web sites.¹² Their services make it unnecessary for pharmacists to contract with different payers, find patients, or establish new billing systems. The American Society of Consultant Pharmacists offers a program through its Web site (http://www.ascp.org). Known as the MTM Provider Partners Program, it is a pathway for its members to enter the MTM world.

A third option is for pharmacists to provide patients with MTM services and then bill payers—so-called blind billing. Bills for patients covered by Medicare can be submitted using the CMS-1500 form available from the Web site of the Centers for Medicare and Medicaid Services, http://www.cms.gov. Assistance with billing codes is available from the Pharmacist Services Technical Advisory Coalition, http://www.pstac.org. It should be noted that although submission of these claims to various payers is becoming more standardized, there is no guarantee of payment with blind billing. Pharmacists may be reluctant to provide complex, time-consuming MTM services in the absence of such a guarantee. Providing MTM directly to patients in a fee-for-service manner is another option being explored in a few pharmacies.

Inconsistent documentation requirements and reimbursement policies among payers are barriers to community pharmacists’ adoption of MTMs.²⁰ Other barriers to adoption of MTMs, or to their most effective use, include a lack of pharmacists’ time, staffing issues, difficulty forming collaborative relationships with physicians, poor patient mobility and low health literacy, a lack of medical information, and difficulty motivating patients to engage in the programs.^15,20-23 It can be challenging to persuade patients of the value of a commitment to time-consuming MTM care, but once they have tried it, many become enthusiastic participants. As the following case study illustrates, use of the various components of the MTM model can help give patients with diabetes and multiple other illnesses a sense of ownership and control.