Making MTM work in Wisconsin

August 15, 2010

Numerous studies show that patients benefit from medication therapy management (MTM) services provided by pharmacists. The drawback to many programs is that it is financially difficult to offer them. In Wisconsin, however, clinical and retail pharmacists participating in the Pharmacy Society of Wisconsin's (PSW) MTM pilot project are reimbursed for the time they spend reviewing patients' formulary or explaining how patients should use drugs.

Numerous studies show that patients benefit from medication therapy management (MTM) services provided by pharmacists. The drawback to many programs is that it is financially difficult to offer them.

In Wisconsin, however, clinical and retail pharmacists participating in the Pharmacy Society of Wisconsin’s (PSW) MTM pilot project are reimbursed for the time they spend reviewing patients’ formulary or explaining how patients should use drugs. The program, which was started in 2008, is made available by PSW’s board and regional insurance providers Unity Health Insurance and Group Health Cooperative of South Central Wisconsin.

Now, 2 major health programs are taking the state’s MTM pilot project to the next level. UnitedHealthcare, the state’s largest insurer, has come on board with approximately 720,000 patients, and Wisconsin’s Medicaid program is expected to begin participation later this year.

“With the implementation of UnitedHealthcare and Medicaid, the number of patients eligible will increase from 150,000 to 2 million,” said Chris Decker, RPh, executive vice president, PSW in Madison.

As a result, the number of participating pharmacists is also expected to rise. The current 53 pharmacists in the system come from every setting for pharmacy care: independent, ambulatory, clinical, regional chain pharmacies, and national chain pharmacies. “We will be working to have a build-out plan for additional pharmacists to participate…in order to provide the services for the large number of patients,” Decker said.

Not only has the program improved patient care, it has allowed pharmacists to be reimbursed for spending extra time with patients. “Overall, the feedback has been positive. It is a business service, a niche service,” Decker said. In addition, PSW found that for every dollar that Unity Health and Group Health have paid in reimbursements, they have saved $2.50 in drug costs, according to Decker. PSW’s board has provided at least $100,000 a year to help support the program.

“We really wanted to make this a viable business model. All of us are community pharmacies, and we know it is important to add this to our services,” said Susan Sutter, co-owner of Marshland Pharmacies in Horicon, Wis. Sutter was president of PSW when it began looking at the pilot project. Marshland’s three pharmacies participate in the program.

Insurance providers reimburse between $30 and $100 per service, based on the type of service. At the lower end of the reimbursement scale, pharmacists are providing simple intervention-based services. At the $100 level, pharmacists typically spend 30 to 45 minutes with patients, conduct an assessment of their medication needs, and set up ongoing visits with them, if needed.

“The pharmacist can identify a gap in therapy, such as a diabetic patient not taking a drug or a patient who is on duplicate therapies. They can provide formulary management services, advise on the most effective therapy management options, and tell the patient the most cost-effective therapies,” Decker said.

Sutter added, “Colleagues have used the appointments for diabetics; so many things can be reviewed and discussed. We have an asthma module as well that the program can be used for.”

In addition, the state’s Medicaid program will provide patients who are likely to have increased MTM needs. “A number of people who are on antidepressants and antipsychotic therapies end up with pretty long lists of medications. We also look forward to serving seniors,” Sutter said.

The pilot project has been successful, Decker believes, thanks to the “collaborative spirit” of all parties involved. “If there is one secret to success, it is the collaboration between insurers and pharmacy providers. It takes not just one health insurer and one pharmacy group, but multiple health plans and multiple pharmacy providers, which agree to work together,” Decker said.