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Commercial medication therapy management programs are gaining in strength and popularity for medical, financial, and practical reasons. In Minnesota, a pilot program for state employees was so successful that two years later it expanded into a program for all fully insured members. Another program is in use by Minnesota Medicaid and General Mills. And in North Carolina, the Asheville Project is still going strong.
Brian Bertha, senior vice president of marketing for McKesson U.S. Pharmaceutical, headquartered in San Francisco, is confident that, compared to three years ago, medication therapy management (MTM) programs have picked up speed.
He bases his opinion on three primary factors. The first is recognition that MTM need not be defined only by Part D guidelines developed by the Centers for Medicare & Medicaid Services (CMS). For example, Bertha refers to "focused MTM consultations," in which a plan using MTM leverages the expertise of a pharmacist to close a gap in care, as opposed to delivering comprehensive medication reviews. "Generally, the commercial plan populations do not have the same level of complexities as the Part D population, but do have a wide spectrum of simpler issues whose need for resolution is just as necessary; hence, the focused consultations," he said.
Second, commercial plans do not have the same formal MTM requirements as are found under Part D and thus are more flexible. And, finally, market pressures demand that health plans continue to innovate continually to keep avoidable medical costs at bay.
In fact, Tom Halterman, CEO of Outcomes Pharmaceutical Health Care in Des Moines, Iowa, a provider of MTM services, believes that MTM programs in the commercial sector may be held to a higher standard than those under Part D. "Since commercial-sector plans have the option of not driving MTMPs at all, they must be able to prove quality improvement and cost control stemming from the pharmacist interventions," he said. "This means pharmacists must successfully consult with prescribers to resolve drug complications and influence patients to adhere appropriately to medication regimens."
The commercial sector, which includes pharmacies, insurance plans, and employers, is showing off its MTM programs - not only how they work, but eligibility requirements, reimbursement, what services are offered, and, in some cases, program results.
From pilot to program
What started in 2006 as a Part D MTM program sponsored by HealthPartners in Minneapolis, Minn., expanded into a pilot program with the State of Minnesota the following year and then into a program for all fully insured commercial members in 2008. This year, the health insurer is offering an MTM program to its employees.
In the pilot version, all state employees with diabetes were eligible to have their prescription copayments waived if they participated in a pharmacy counseling program and chose a HealthPartners' clinic for treatment. Members in the fully insured program had to be taking five or more unique medications and incurring more than $1,000 in pharmacy costs within a three-month period.
Initial consultations with clinical pharmacists were hour-long drug reviews, with subsequent 30-minute meetings to discuss potential cost savings, monitor conditions affected by medications, and help prevent side effects and adverse drug events. Meetings could take place in person or by phone. As many as 84 percent of visits were face-to-face, with 16 percent by phone. Studies show that through counseling, pharmacists have been able to identify an average of two drug-related problems for each patient.
According to Vyvy Vo, PharmD, clinical pharmacy program manager for HealthPartners, the keys to an effective MTM program are face-to-face interaction, use of an incentive, buy-in from members' physicians, and a collaborative practice agreement between pharmacists and prescribing physicians to change and modify therapies.
HealthPartners also designed eligibility requirements for clinical pharmacists. They must have graduated from a college of pharmacy after 1996, be licensed in the state, and offer a private place for consultations. Community pharmacists in the program bill fee-for-service; the rate is currently under renegotiation.
After the first year of the pilot, compared to nonparticipants the 300 patients in the program had 39 percent fewer emergency-room visits and 24 percent fewer hospital admissions, as well as a 137 percent improvement in meeting optimal blood pressure, cholesterol, and blood sugar levels, taking daily aspirins, and remaining tobacco-free. Cost savings revealed by a six-week study of some of the pilot participants revealed reduced expenses of $376 per patient through drug error intervention.