Development of a Pharmacy Business (MTM)

Chelsea ShipmanSouhanda SefinWesley Singleton

What Is Medication Therapy Management?

• MTM services, or programs, are patient care services that were established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

• Creating and maintaining a successful MTM practice necessitates a culture change where staff training, workflows, and processes revolve around delivery of a service as opposed to delivery of a product such as prescription medications.

Core Elements of an MTM Service Model in Pharmacy

Practice The MTM service model in pharmacy practice includes the following five core elements: • Medication therapy review (MTR) • Personal medication record (PMR)• Medication-related action plan (MAP)• Intervention and/or referral• Documentation and follow-up

Medication Therapy Review• The 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• The personal medication record (PMR) is a comprehensive record of the

patient’s medications (prescription and nonprescription medications, herbal products, and other dietary supplements).

Medication-Related Action Plan• The 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.

Intervention and/or Referral• 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-upMTM 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.

Current Atmosphere of MTM Services

Quality Measures• Though current pharmacy practice models do involve provision of some patient care

services, the majority are tied to the product. • Counseling on a medication the patient is picking up is a prime example of this, as

the patient may view receiving the product as the primary goal of visiting the pharmacy and counseling as an adjunctive service.

• Product centered workflows and behaviors create a discrepancy between where the profession wants to go (i.e. service centered) and where pharmacy practice remains rooted.

Legislation in MTM Services• The Medicare Drug Benefit is commonly known as Medicare Part D. The Centers for Medicare and

Medicaid Services (CMS) require plan sponsors, such as prescription drug benefit managers or Medicare Advantage organizations, to develop and administer MTM programs.

• Requirements for Medication Therapy Management Programs (MTMP): Under 423.153(d), a Part D sponsor must have established a MTM program that:• Ensures optimum therapeutic outcomes for targeted beneficiaries through improved medication use• Reduces the risk of adverse events• Is developed in cooperation with licensed and practicing pharmacists and physicians• Describes the resources and time required to implement the program if using outside personnel and

establishes the fees for pharmacists or others• May be furnished by pharmacists or other qualified providers• May distinguish between services in ambulatory and institutional settings• Is coordinated with any care management plan established for a targeted individual under a chronic care

improvement program (CCIP)

PayersMedicare Part D payers are required to cover MTM services for eligible patients. After identifying and contracting with Medicare Part D plans, a consultation with each payer should be done to determine how MTM services should be billed. The most common scenarios for provision of Medicare Part D MTM services are the following: • The payer (Medicare Part D plan) uses its own employee pharmacists to

provide MTM and does not contract for the services.• The payer contracts with pharmacies or individual pharmacists to provide the

services.

https://www.youtube.com/watch?v=NevLYzsG2Y8

MTM Skills• Strong verbal and written

communication skills• Listening skills • Ability to work on a team• Ability to question patients• Empathy

• Independent thinker• Dependable• Evaluating medication regimens• Identifying medication-related problems• “Making recommendations to patients, caregivers,

and healthcare professionals”

"Delivering Medication Therapy Management Services." American Pharmacists Association. American Pharmacists Association, 17 Mar. 2012. Web. 17 Apr. 2016.

Pharmacist: Medication Therapy Management Communication and Care Center. University of Florida Human Resource Services, 17 Apr. 2016. PDF.

Becoming a MTM provider • Planning is a multistep process

• Create an Business Plan• Executive Summary • Business Profile• Services• Marketing Analysis and Plan• Operations and Management• Financials Assessment• Conclusion

Needs Assessment• The first and most important step to planning • For the needs assessment, there are three basic questions to ask:

• What is the patient need or problem to be addressed? • How large is this problem, and what are the trends? • How well are the patient needs currently being addressed?

What is the patient need or problem to be addressed?

• Primary Information• interview • Survey• Observations• Patient records

• Secondary Information• Literature articles• Continuing education programs• Research databases

How large is this problem, and what are the trends?

• Primary Research• Secondary Research

• Patient trends • Incidences• Medical outcomes• Disease prevalence or complications

How well are the patient needs currently being

addressed?• Physicians• Nurses• Pharmacists• Pharmacy benefit management

companies• Need assessment grids

SWOT AnalysisA critical evaluation of the internal and external factors that may

affect the success of a pharmacy service is needed• Strength• Weakness • Opportunities• Threats

Service Planning• Mission and vision statements• Goals of the services

• Manage Diabetes Patients• Reduce Patient Hypertension• Educate HIV and AIDS patients

Organizational Structure• Organizational Hierarchy Outline

• Staffing• Rules and Guidelines of Operation• Policies and Procedures• Documentation

• “SOAP” method

Financial Justification• Cost avoidance (ex. Hospitalizations, surgery)• Increase Revenue

• Financial analysis• Cash flow and startup costs• Break-even analysis• Sensitivity analysis• Back of the envelope (BOE) analysis

Payment• Gross margin from dispensing prescriptions• Medicare Part B

• Immunization• Durable medical equipment • Outpatient diabetes management training• Laboratory tests via Clinical Laboratory Improvement Amendments (CLIA)

waiver • Collaborative practice agreement

• Medicare Part D

Billing Models• Direct Billing

• Pharmacist viewed as provider • Indirect Billing

• “Incident to physician billing” or “backdoor”

• Collaborative practice agreement• New Billing Methods

• Patient Centered Medical Home (PCMH)

• Accountable Care Organization (ACOs)

• First or Third Party Payer• Medicare B• Medicare D• Private Insurance• Patient

• Common Average Billing Payments• $26.58 ($1/min)• $53.16 ($2/min)• $79.72 ($3/min)

Program Evaluation• Economic Outcomes• Clinical Outcomes• Humanistic Outcomes

FLORIDA & HIV/AIDs

FLORIDA DEPARTMENT OF HEALTH DIVISION OF DISEASE CONTROL AND HEALTH PROTECTION HIV/AIDS Surveillance Program 2016

HIV/AIDS One Stop Shop.

HIV/AIDS One Stop Shop.

Executive summary• HIV/AIDS are one of the most common diseases being treated today.

However besides treatment, patients also need counseling.• Only 25% of HIV patients are virally suppressed HOSS is a facility where

HIV/AIDs infected patients can go and receive total care • The mission HOSS is to create a company where HIV/AIDS will be

acknowledged and discussed in every asset and the patient can go and receive complete care without fear of embarrassment.

Objective & Mission • HOSS is a facility where HIV/AIDs infected patients can go

and receive total care • The mission HOSS is to create a company where HIV/AIDS

will be acknowledged and discussed in every asset and the patient can go and receive complete care without fear of embarrassment.

Key to success• Making sure each patient is taking his or her medication on

time and as directed. Compliance• Providing coping mechanism and counseling outlets• Patient education on the disease and all its phases.

Services • Patient counseling,• Medication therapy review (MTR)• Prescription pick up

• Fast • On the go service • Convenient• Knowledge • Counseling

Marketing Analysis • Strengths:

• Three experienced pharmacist students• Weaknesses:

• New company• Small staff

• Opportunities: • Decrease rates of secondary infection• Improve patient adherence

• Threats: • Walgreens, HIV MTM service• Big Bend Cares

Quiz Time…

1. Core elements of MTM include all of the following except.A. Medication therapy review (MTR) B. Personal medication review(PMR)C. Medication-related action plan (MAP)D. Intervention and/or referralE. Documentation and follow-up

2. What is Medicare Drug benefit commonly known as?A. Medicare Part DB. Medicare Part BC. Medicare Part CD. Medicare

3. What are MTM skills?A. Strong verbal and written communication skillsB. Listening skills C. Ability to work on a teamD. Ability to question patientsE. All of the Above

4. What Does SWOT stand for?A. Services, weakness, opinions, threats B. Strength, weakness, opportunities, threats C. Strength, welfare, opinions, threatsD. Services, welfare, opportunities, threats

5. Which of the following is considered First or Third Party Payer?

A. Medicare AB. PharmacyC. Private InsuranceD. Doctor

References• American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in

community pharmacy practice: core elements of an MTM service (version 1.0). J Am Pharm Assoc. 2005;45:573-9. • Peterson, Sara Lynn, PharmD. "Transitioning Community Pharmacies to a Service Centered Model: A Key Factor for MTM

Success." Pharmacy Practice (n.d.): n. pag. Web. 17 Apr. 2016.• "Medication Therapy Management." - Centers for Medicare & Medicaid Services. Federal Government, 3 Feb. 2016. Web. 17

Apr. 2016.• Analysis of pharmacist charges for medication therapy management services in an outpatient setting. Michelle M. Zingone,

Karen E. Malcolm, Stephanie W. McCormick, Kristir R. Bledsoe. Am J Health Syst Pharm. 2007 September 1; 64(17): 1827–1831. doi: 10.2146/ajhp060438

• "Delivering Medication Therapy Management Services." American Pharmacists Association. American Pharmacists Association, 17 Mar. 2012. Web. 17 Apr. 2016.

• Pharmacist: Medication Therapy Management Communication and Care Center. University of Florida Human Resource Services, 17 Apr. 2016. PDF.

• Monthly Surveillance Report: Hepatitis, HIV/AIDS, STD and TB. Florida Department of Health Division of Disease Control and Health Protection HIV/AIDS Surveillance Program. Florida Health, 10 Mar. 2016.