LT Scott Raisor, PharmDIndian Health Service, Phoenix Area,Colorado River Service Unit

1962: Shift from distribution to clinical services

1969: Pharmacists provide direct patient care as primary care providers

1996: RADM Michael Trujillo codifies Pharmacists as Primary Care Providers (PCPs) with prescriptive authority

1997: National Clinical Pharmacy Specialist (NCPS) certification established

2011: PHS Pharmacy Report to the Surgeon General and the Surgeon General’s Support Letter

1.5 billion preventable medication related problems occur each year

The United States health care system spends over $177 billion dollars annually on medication related problems

“Advance beyond discussion of the value of expanded roles of pharmacists and move towards health system support and implementation of these roles.”

• Medication Therapy Management services are patient centered assessment and evaluation of the patient’s full medication regimen and not only individual medications

• Goals:• Optimize medication use• Improve collaboration• Enhance communication• Empower patients

MTM is separate and distinct from pharmacist managed disease state clinics

Pharmacist managed clinics require and provide a higher level of care

Medicare Part D sponsors are required to provide MTM services to their patients

42 CFR 423.153 (d)

(d)Medication therapy management program (MTMP)— (1) General rule. A Part D sponsor must have established a MTMP that—

(i) Is designed to ensure that covered Part D drugs prescribed to targeted beneficiaries described in paragraph (d)(2) of this section are appropriately used to optimize therapeutic outcomes through improved medication use; (ii) Is designed to reduce the risk of adverse events, including adverse drug interactions, for targeted beneficiaries described in paragraph (d)(2) of this section; (iii) May be furnished by a pharmacist or other qualified provider; and (iv) May distinguish between services in ambulatory and institutional settings. (v) Must enroll targeted beneficiaries using an opt-out method of enrollment only. (vi) Must target beneficiaries for enrollment in the MTMP at least quarterly during each plan year. (vii) Must offer a minimum level of medication therapy management services for each beneficiary enrolled in the MTMP that includes all of the following:

(A) Interventions for both beneficiaries and prescribers. (B) Annual comprehensive medication review with written summaries. The comprehensive medication review must include an interactive, person-to-person, or telehealth consultation performed by a pharmacist or other qualified provider unless the beneficiary is in a long-term care setting and may result in a recommended medication action plan. (C) Quarterly targeted medication reviews with follow-up interventions when necessary. (D) Standardized action plans and summaries that comply with requirements as specified by CMS for the standardized format.

Medicare criteria1. Multiple chronic

disease states2. Multiple

medications3. High drug costs

Medicaid Florida, Iowa,

Maryland, Minnesota, Missouri, Mississippi, Ohio, Virginia

Private plans Employers Self-pay

Chronic disease states CMS requires 3 or

less

Sponsors must include the 7 core chronic diseases

Diabetes Hypertension Dyslipidemia Heart failure Respiratory disease Bone disease Mental health disorder

2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at https://www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet2011063011Final.pdf.

Accessed on May 16th, 2012

Multiple medications CMS requires 8 or

less

High drug costs $3,000 or higher in

annual medication costs

Average $250 per month

2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at https://www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet2011063011Final.pdf.

Accessed on May 16th, 2012

APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

CMS regulations established a general framework that allows for best practices

10 pharmacy organizations collaborated to develop the core elements of an MTM visit

Medication Therapy Review (MTR)

“is a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them”

Personal Medication Record (PMR)

“is a comprehensive record of the patient’s medications”

Medication-Related Action Plan (MAP)

“is a patient-centric document containing a list of actions for the patient to use in tracking progress for self-management”

Interventions or Referrals “The pharmacist provides

consultative services and intervenes to address medication-related problems; when necessary, the pharmacist refers the patient to a physician or other healthcare professional”

Documentation and Follow Up “MTM services are

documented in a consistent manner, and a follow-up MTM visit is scheduled based on the patient’s medication-related needs, or the patient is transitioned from one care setting to another”

APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

Medicare sponsors must provide a minimum level of MTM services1. Comprehensive Medication Review (CMR)

Annually

2. Targeted Medication Review (TMR) Quarterly

Comprehensive annual review of all medications

Interactive person to person Phone call Pharmacy visit

Affordable Care Act standardizes the content and format of the CMR starting January 1, 2013 Components

Cover Letter Medication Action Plan Personal Medication List

TMR must be provided at least quarterly

TMR is meant to address specific or potential medication-related problems

Does not have to be face-to-face

Pharmacists Only provider

specifically mentioned

Registered Nurses Physicians Non-physician

providers

2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at https://www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet2011063011Final.pdf. Accessed on May 16th, 2012

Electronic Health Record (EHR) Allows for comprehensive reviews

Physician notes, lab work, and medication lists IHS mode of counseling

New Three prime questions

Refill Show and tell

Open dialogue about disease not just medicine

1. After your appointment, the doctor enters your prescription into the computer

2. The pharmacy receives the order signed by the doctor

3. The pharmacist checks the prescription for errors

4. The pharmacist looks at your lab results

5. The pharmacist reviews your chart for drug interactions and allergies

6. The pharmacist may call your doctor for questions

7. The medications are counted and packaged

8. The pharmacist does a final check for safety and accuracy

9. The pharmacist counsels you on your medications

10. You receive your medications and can ask any questions you have

Five Key Elements to an MTM visit:1.Medication Therapy Review (MTR)2.Personal Medication Record (PMR)

Document

Document

Document

3. Medication-related Action Plan (MAP)4. Intervention or referral5. Documentation and Follow Up

MTRReview EHR

PMRMedication

List

MAP Intervention

APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

IHS Prescription Processing Chart

Meds ordered in EHR

Meds dispensed and patient counsel

ed

Our legacy of innovation has allowed PHS pharmacists to lead the profession Providing clinical services since 1962 We are already providing MTM for our

patients

Potential reimbursement opportunities?

Medicare Part D Plans

Nu

mb

er

of

Pre

scri

pti

on

s

The largest Part D provider does not allow for reimbursement to community pharmacists for MTM services

The second largest provider only has four patients who qualify for MTM reimbursable services

Part D sponsors determine payments for MTM services Considered

administrative costs 80% allow external

personnel 31% use vendors 25% use community

pharmacists Plans require

contracts with pharmacies Separate from

medication dispensing

There is not much published on reimbursement  Limited to vendor’s

published numbers

MirixaPro®®

Mirixa.com No cost for

participation

MirixaEdge®®

Pay Provides

documentation to submit to non-contracted part D plans or for out of pocket billing

Outcomes®®

Getoutcomes.com No cost for

participation

Others: PharmMD®®

Pharmmd.com Employ pharmacists Can make

$2,000/month

MirixaPro®®

Comprehensive medication review $60 Welcome review $40 Medication adherence

15 minute initial $30 10 minute follow up (2) $20

Cardiovascular risk 45 minute initial $90 Follow up $30

www.mirixa.com

Outcomes®®

+Comprehensive Medication Review $50 to $75

+Prescriber Consultation× Cost Efficacy Management $20× Drug Therapy Problem $20

+Patient Compliance Consultation $20+Patient Education/Monitoring $10+Prescriber Refusal $2+Patient Refusal $2

www.getoutcomes.com

Providing MTM services improves outcomes

Reimbursement for pharmacist-delivered patient care is a step forward, BUT: Part D pays the pharmacy not the pharmacist Pharmacists are not the only providers Right now, MTM does not look to prevention

Eligible patients are already a burden on health system

“Pharmacist-delivered patient care services fit most definitions of “primary care” services (with the exception of diagnosis) as defined by major medical and health organizations”

“Compensation … should reflect the level of care provided”

Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S.

Public Health Service. Dec 2011.

Potential reimbursement for actions that PHS pharmacists engage in currently Create time to make appointments, proper

documentation, and provide opportunities for reimbursement and reporting

Work with Tribes Provide presentations on correct medication habits

MTM should not prevent PHS pharmacists from continually leading with new and innovative patient care practices

APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

Lee MP, Giberson S. Implementation of the Indian Health Service National Clinical Pharmacy Specialists (NCPS) Program. Available at www.usphs.gov/corpslinks/pharmacy/clinpharm/doc/ncps.ppt. Accesses May 16th, 2012.

2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at https://www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet2011063011Final.pdf. Accessed on May 16th, 2012.

Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.

Schupbach R. Insights from the bizarre perspective and mind of Ryan Schupbach. Presented at the Oklahoma Area IHS Pharmacy Chief’s Meeting, February 17th, 2012.

LT Scott Raisorthomas.raisor@ihs.govColorado River Service Unit12033 Agency Road Parker, AZ 85344928.669.3330