11-439 Mtm Module 2-Final

Becoming an MTM Practitioner:

A Plan for Success

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M o d u l e ❷Becoming an mTm PracTiTioner: a Plan for SucceSS

delivering Medication Therapy Management Services American Pharmacists Association 16

The MTM Business Plan:Your Road Map for Success

Many pharmacists contemplate starting a medication therapy management (MTM) practice and are eager to provide services, but are not sure how to begin. Developing a business plan is an important step for creating a fi nancially viable MTM service. The plan should serve as a guide for service implementation, act as a tool for marketing the MTM service to internal and external stakeholders, and help gauge the success of the MTM service.

A business plan is a document that provides information for making decisions about a proposed business. It is designed to achieve a specifi c set of goals—in this case,

the fi nancial and professional success of the MTM service. To formulate a business plan, it is necessary to assess the feasibility of the proposed business, create projections of its success, and plan its implementation. Pharmacists who intend to seek loans or other start-up funding to initiate their MTM services may need to develop a formal business plan. Numerous resources are available to guide the development of such a plan (see For AdvAnced Study). However, even if a formal business plan is not needed, it is essential to carefully consider how you will manage various aspects of your MTM service.

A thoughtful plan will defi ne the proposed MTM service and provide a strategy for implementation and evaluation. It should be simple, realistic, specifi c, and complete. Moreover, the plan should investigate possible obstacles and routes around them before implementation. The plan should outline a sound strategy for implementing the services, including preparing the pharmacy and the employees, marketing the service, and monitoring its success, both clinically and fi nancially. A business planning worksheet for MTM services is available at: www.pharmacists.com/mtm.

Creating Your Vision for the MTM Service

When beginning a business plan for an MTM service, research is fundamental. Investigating the proposed service may uncover fi nancial, clinical, and demographic data to guide the development of the service. Searching the pharmacy literature, discussing the business idea with those knowledgeable about MTM, and speaking with other MTM providers are all useful strategies.

When beginning a business plan for an MTM service, research is fundamental.

Many resources are available online to assist your research for the MTM business plan. MTM Connections was developed jointly by the American Pharmacists Association (APhA) and the Academy of Managed Care Pharmacy to create a searchable repository of MTM services that are provided and a library of articles that have been published about MTM. This resource is available at http://www.mtmconnections.org/fi nal/2215100.asp.

Researching the types of services that have been successful and the sources of payment for those services may help you identify business models that may have success for your region. APhA maintains a website that lists MTM providers by state at http://www.pharmacist.com/mtm/statemap. Pharmacists can use this website to

Learning ObjectivesAfter completing this module of the self-study activity, pharmacists will be able to:

1. Describe the components of a business plan.

2. Evaluate the strengths and weaknesses of current pharmacy operations and list potential services and barriers using a SWOT analysis and needs assessment.

3. Formulate goals for providing medication therapy management (MTM) services.

4. Describe appropriate activities for pharmacy technicians, student pharmacists, and pharmacy practice residents involved with MTM services.

5. Discuss reimbursement strategies to incorporate in the MTM business model.

6. Outline the process and key considerations of making MTM services operational and integrated with existing services.

7. Identify measures to track the economic, clinical, and humanistic outcomes of an MTM service.

8. Project revenues and expenses to establish fees for MTM services.

9. Describe elements of a marketing plan for attracting patients, providers, employers, and payers to MTM services.



research other services provided in their state and review state-specific resources. Pharmacists who provide MTM services are encouraged to list themselves so they can be located by payers, patients, and other stakeholders in search of services. In addition, the site features links to articles in Pharmacy Today that provide detailed profiles of MTM providers and their practices.

To assess your potential patient population, demographic data can be obtained from public health and government websites. For example, data on the prevalence of a certain disease within a specific state, county, or city might help gauge the size of the market for the proposed business. Selected websites are listed in For AdvAnced Study. It should be noted that not all information on the Internet is peer-reviewed or necessarily accurate, and differentiating good sources from bad ones is important.

Finally, it may be helpful to identify a mentor or business coach who can guide you and offer suggestions throughout the development of your business plan. Ideally, a mentor or business coach will have experience with the successful implementation and delivery of MTM services. Other sources of advice include online discussion boards. For example, the APhA MTM Services/Medicare e-Community, which is available free to APhA members, is focused on discussions and information related to the implementation of MTM services in pharmacy practice. More general business development advice can be obtained from the U.S. Small Business Administration at http://www.sba.gov.

Where Are You Now?—The SWOT AnalysisA useful assessment technique to evaluate your current

market is the SWOT analysis, which defines the internal Strengths and Weaknesses of the business in the context of the Opportunities and Threats presented by the external environment in which it operates.1,2 The ideal MTM service capitalizes on the strengths of the organization, minimizes weaknesses, takes advantage of market opportunities, and prepares for major threats.

Strengths and Weaknesses— Assessing the Internal Environment

Strengths and weaknesses are internal characteristics of the pharmacy or service relative to its competitors. Initial information can be gathered through an informal assessment of the practice site. Examples of strengths may be the staff’s advanced level of training, a prime store location, stable patient base, or intangible factors, such as good reputation or strong relationships with physicians or regional health plans. Weaknesses include any barriers that hinder the ability to deliver high-quality service, such as low employee morale, poor pharmacy design, limited patient access, or workflow problems. When identifying strengths

and weaknesses, consider the following issues:• Pharmacy services. What types of services are currently

offered? Assess patients’ perceptions of and satisfaction with these services. If problems are identified, the pharmacist should address them before beginning a new service.

• Pharmacy operations. Pharmacists frequently mention lack of time as a barrier to providing MTM services. Assess workflow in the practice site to determine what modifications may be needed to free pharmacists’ time for patient care and counseling. (Strategies for improving efficiency are provided in the MAnAging PhArMAcy WorkFloW section of this module.)

• Human resources. Assess the training, motivation, and professionalism of pharmacy staff. Are they excited about the prospect of providing new services and willing to learn new ways of doing business? Are residents, student pharmacists, pharmacy technicians, and clerks available to assist with basic patient relations and allow more efficient use of the pharmacist’s time?APhA has developed an MTM self-assessment survey

(reSource D) to help pharmacists gauge their organization’s readiness to provide MTM services. Although this tool is not intended to be a comprehensive assessment instrument, it can help pharmacists determine areas where physical changes to practice sites are required and identify the education and training needed for themselves and staff.

Opportunities and Threats— Assessing the External Environment

Pharmacists who take advantage of opportunities and prepare for threats within the marketplace will have a better chance of running a successful MTM service. When assessing opportunities, think broadly about the market. MTM services can be offered to any patient who could benefit from the service and is willing to pay (or has other coverage) for it.

Pharmacists who take advantage of opportunities and prepare for threats within the marketplace will have a better chance of running a successful MTM service.

The market for MTM services is not limited to patients. Rather, it refers to all individuals and organizations that are actual or potential purchasers of the MTM service.



The market includes physicians, adult children of patients, health plans, retirement centers, and self-insured employer groups in the area. (A more detailed discussion of the potential market can be found later in the MArketing PlAn section.) Examples of physician purchasers include those who are developing integrated practice models (e.g., medical homes, accountable care organizations [ACOs]) and want to contract with pharmacists. Examples of potential self-paying patients include Medicare benefi ciaries who are not considered “targeted benefi ciaries” by Part D plans or younger people with chronic diseases, such as asthma, diabetes, or hyperlipidemia.

An analysis of the competition is needed to identify potential threats. Competitors include any individual or organization offering the same or similar service as the proposed service, including other pharmacists, physicians, nurses, and physician assistants. Some of these providers may be employed by managed care organizations; others will be in the community.

The business plan must articulate how the pharmacist’s MTM service differs from likely competitors and how these differences benefi t the consumer. A good place to start is by examining the organization’s strengths and weaknesses identifi ed in the SWOT analysis and comparing them with those of competitors. For example, in a comparison of the pharmacy’s MTM service to a nurse-run call center MTM service, the pharmacy’s MTM service is distinguished by the medication expertise of the pharmacist.

Some pharmacists will consider other community pharmacies as a threat. However, successful provision of MTM services may require a new way of thinking about competition. Creating a suffi cient regional supply of pharmacist-provided MTM services could transform this threat into an opportunity. Each participating pharmacy may be more attractive to payers because health plans want to ensure their members have convenient access to services. For example, to increase leverage with drug plan sponsors, a group of community pharmacies in Florida have formed a coalition in their geographic area. This allows the pharmacies to offer a network that provides MTM

Learning Reinforcement Exercise 2.1a. Strengths and weaknesses are internal characteristics of the

pharmacy or service relative to its competitors. List three examples of strengths and weaknesses within your organization.Strengths1. _______________________________________________________2. _______________________________________________________3. _______________________________________________________Weaknesses1. _______________________________________________________2. _______________________________________________________3. _______________________________________________________

b. When assessing the external environment that affects the proposed business, pharmacists need to think broadly about the market. Other than eligible Medicare Part D patients, list three types of people or organizations that should be considered when evaluating market opportunities.1. _______________________________________________________2. _______________________________________________________3. _______________________________________________________

Answers on page 41.

Learning Reinforcement Exercise 2.2Describe your proposed MTM service by answering questions about what you plan to do and for whom. Think about how your service will fulfi ll the unmet health needs of patients in your community and which features will distinguish your practice from competing services.

Description of the MTM ServiceWho will be your primary patients? _________________________________________________________________________________________ ___________________________________________________________ What other stakeholders, if any, will have a role in the service? __________________________________________________________________ ___________________________________________________________ What MTM services will you offer? _________________________________________________________________________________________ ___________________________________________________________ What are your primary goals for the MTM service? ____________________________________________________________________________ ___________________________________________________________ Answers on page 41.



services to health plans serving the area.3 Furthermore, research shows that as patients become more familiar with MTM services, they become more likely to understand the value and desire the service. As more pharmacists in the community offer at least a core set of MTM services, the public may come to expect and demand these services as part of their desired care.

Collaboration with other health care providers is another possibility worthy of investigation. For example, a regional drug plan might decide to use a nurse-run call center to provide less intensive forms of MTM services, but refer higher risk patients to community pharmacies for face-to-face consultations and follow-up care. reSource E provides ideas for collaboration with selected alternative settings and organizations.

Figure 2-1 shows an example of a completed SWOT analysis for an MTM service. A blank SWOT analysis worksheet can be found in reSource F.

Choosing a Service Delivery Model

Armed with information from the SWOT analysis, you can determine the types of services that best match your strengths and opportunities. Do you plan to provide core MTM services such as comprehensive medication therapy review (MTR) and/or targeted reviews in a community pharmacy? Or do you plan to seek to provide MTM in the form of medication reconciliation for patients undergoing transitions of care? Or do you seek to form partnerships with medical homes and ACOs? Or do you plan to use a mix of these and other options? If you are already offering some services, are you planning to build your MTM practice around them? Do you envision developing collaborative practice agreements with prescribers that will allow you to modify prescription drug regimens under protocol during the MTM visit?

Some pharmacists work as independent practitioners, providing MTM services directly to the patient or through a contract with a pharmacy. They may provide comprehensive MTM to all patients or offer specialized services to suit specifi c populations or patient needs (e.g., geriatrics,

Figure 2-1. Example of a Completed SWOT Analysis for an MTM Service

Internal Factors

Strengths Weaknesses

• Strong clinical expertise and training in patient care

• Counseling area already installed• Friendly and professional employees• Several patient care services already

in place • Staff enthusiastic about

implementing new MTM services• Positive relationships with many

physicians in the community

• Workfl ow problems need to be resolved

• Shortage of technician help• Number of patients who might

want service is unknown• Management’s perception

that MTM services provided by pharmacists provided by pharmacists have a low or negative return-on-investment

• Staff concerns about lack of time to provide patient care services

External Factors

Opportunities Threats

• Growing suburban community with several “55-plus” developments

• Affl uent base of patients who are likely to be actively involved in their health care

• A number of local employers who self-insure for health care

• Positive relationships with many physicians in the community

• Medicare Advantage Prescription Drug plans, managed care organizations, and self-insured companies that may fi nd MTM to be fi nancially advantageous

• It may be challenging to educate self-insured employers about the value assfociated with MTM

• Most patients are unfamiliar with the MTM services and have expressed little demand for it

• Some health care professionals are concerned about turf issues

MTM = medication therapy management; SWOT = strengths, weaknesses, opportunities, threats.

pediatrics, pain management, oncology care).You may need to tailor your services to the specifi c

needs of various payers based on the opportunities that are available to you. Nevertheless, it is useful to have a clear vision of your ideal service to compare with opportunities and to use for marketing purposes.

Consider the following elements when working to defi ne your service3:• Intended consumers. Which groups of patients are likely

to use MTM services? Will they be patients who attend an ambulatory care clinic, eligible benefi ciaries of a Medicare Part D plan or state Medicaid plan, and/or self-pay patients? Are there other stakeholders who may benefi t from or have an interest in this service, such as



local physicians, medical homes, ACOs, or self-insured employers?

• Services and products. What kinds of MTM services will the pharmacist offer? Comprehensive medication reviews, targeted medication reviews, and/or medication reconciliation? Will these services be accompanied by other services such as disease state management or collaborative drug therapy management?

• Location of services. Will services be provided face-to-face or telephonically? Will you work in a community pharmacy, ambulatory care clinic, and/or physician’s offi ce? Or, will you deliver services as an independent MTM provider who travels throughout a region to deliver services at various locations (e.g., community pharmacies, clinics, work sites) under multiple contracts? (For more information on such an approach, see reSource g).

Setting GoalsWhat are your goals for the MTM service and how will

you know if you have achieved them? It is helpful to divide this list into short-term goals, such as those for the pilot or initial MTM service, and long-term goals that refl ect the ultimate vision for the practice. For each goal, the pharmacist will list the activities needed to carry it out, along with a timeline. Activities should be quantifi able

whenever possible. For example, if the primary goal is to serve Medicare Part D benefi ciaries, state the number of people the service can reasonably expect to reach within a specifi ed number of months. A useful acronym when developing goals is SMART—aiming for goals that are Specifi c, Measurable, Achievable, Realistic, and Time-limited.

Determining the MTM Service’s Operations

Once you have defi ned the MTM service, the next step is to determine how the business will function. To get a complete picture of pharmacy operations, the business should be analyzed from different perspectives. One of the fi rst things the pharmacist will want to do is assess the pharmacy’s structure and the processes within the pharmacy. This assessment includes the layout and design of the pharmacy, workfl ow, and documentation.

Pharmacy Layout and DesignA private or semiprivate area for conducting MTM

sessions should be identifi ed. The specifi c design of the area depends on the scope of services to be offered and the anticipated volume of patients. While a separate room may not be feasible, it is necessary to have an area where conversations with patients are private. The space should have good lighting, be quiet, and provide seating for both the patient and pharmacist. This creates an environment conducive for patient interviews, especially with elderly patients. Room for charts, forms, educational materials, and point-of-care supplies also should be taken into account when allocating space.

Pharmacy redesign need not be expensive, and many resources offer guidance on this issue. One helpful resource is the chapter titled “Re-engineering the Pharmacy Layout” in A Practical Guide to Pharmaceutical Care, 2nd edition.2 Keep in mind that the best design is one that meets the pharmacy’s needs and budget. The organization should strive to create an environment that allows pharmacists to talk privately with patients, improves workfl ow effi ciency, and conveys a professional health care image.

Consider what equipment and software you will need to run the service and where you will locate it. The documentation of MTM services will require at least one computer and printer to manage patient records and print personal medication records (PMRs) and medication-related action plans (MAPs). Also consider how you will communicate with outside entities. Will most of your communications be electronic, necessitating Internet access, or will you fax communications?

The storage of MTM service records is another consideration. Even if an electronic or web-based system

Setting Realistic GoalsGoals should be realistic. Keep in mind that it takes time to build a practice, and effi ciency will likely improve over time. While goals are necessary, having too many goals may be frustrating and overwhelming. Examples of short-term goals include: • Contracting with at least one third-party MTM vendor

within 2 months.• Receiving at least fi ve referrals per month from

physicians who send patients to the pharmacy for comprehensive MTRs.

• Getting at least fi ve appointments with area physicians willing to hear your MTM service marketing presentation.

• Providing at least three comprehensive MTRs within the fi rst 3 months of the service.

• Contracting to provide services with at least one pay-for-performance organization within 3 months.



is used for maintaining patient records, a tangible chart to store any paperwork associated with each patient (e.g., lab values, physician’s notes) is still needed. An individual MTM-specific chart should be created for each patient who receives MTM services at the pharmacy, and this chart must be filed securely. Patient records may be stored alphabetically under patients’ names, or for added security, a numerical system can be employed using a unique identifier number for each patient. Such records may be separate from or integrated with other patient records. A system for backing up records and ensuring secure storage in compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements is essential.

Managing Pharmacy WorkflowDuring the creation of the business plan, the pharmacist

should decide whether to provide MTM services on a scheduled or walk-in basis. Each approach has advantages and disadvantages. Seeing patients for an MTR by appointment allows pharmacists to work with the patient without interruption. Appointment times need to be convenient for patients, which might require staffing changes or new hires. A walk-in service is more convenient for patients, but delivering proper care on an as-needed basis in a busy pharmacy can be difficult, especially for a comprehensive MTR.

The vision for the MTM service will play an important role in staffing considerations. It may be wise to begin with only minor staffing modifications and then adjust schedules as demand for services grows. The MTM encounter usually is by appointment because the service requires that the pharmacist dedicate his or her time to the patient. Realistically consider how many patients will likely participate in the service as well as the length of time for each encounter, and aim to match your capacity to the demand. Working efficiently with technicians and other support personnel is one strategy for freeing the pharmacist’s time to provide MTM and other patient-focused activities. However, in general, additional pharmacist staffing is necessary to manage dispensing roles during MTM visits, particularly if the pharmacist plans to provide multiple comprehensive MTRs each day.

Scheduling appointments allows for pharmacists to ensure adequate staffing while services are provided. However, if too many patients do not keep appointments, it will threaten the service’s financial viability. Strategies to remind patients to keep their appointments may reduce no-shows. A day or two before the appointment, a technician or other personnel can make a reminder phone call that details the appointment date, time, and specific items that the patient must bring to the appointment, such as prescription and nonprescription medications, dietary supplements, insurance information, and laboratory reports.

Pharmacies may find that a mix of both scheduled and walk-in encounters may be the best approach, depending on the scope of services patients need. For example, a comprehensive MTR typically would be conducted as a scheduled visit. This ensures the pharmacist has adequate time to obtain necessary information prior to the interview and to complete the core elements of an MTM service during the appointment, including the patient interview, the medication review, and the documentation of patient data and interventions. The pharmacist may conduct briefer, more targeted MTRs on a walk-in basis, when the complexity of the current medication-related problem and the pharmacist’s current workload allow for it.

Pharmacies may find that a mix of both scheduled and walk-in encounters may be the best approach, depending on the scope of services patients need.

Managing Appointments Efficiently

An MTM service is more likely to be successful if it is run efficiently. Some payers will compensate for only a fixed amount of time. Therefore, it is important that appointments are managed in the best possible manner. With experience, most pharmacists become quicker and more adept at providing MTM services. If services will be provided initially by less experienced pharmacists, they may need additional time to conduct patient interviews and complete their documentation as they learn their new duties and gain confidence. Documentation software that manages scheduling of appointments, collection of data, printing of reports, and patient billing can improve the pharmacist’s efficiency.

While the pharmacist wants to conduct a thorough MTR, clear guidelines for the duration of MTM visits should be set. The service will not be sustainable if pharmacists routinely spend an hour with patients scheduled for half-hour visits if they are compensated on a fee-for-service basis.

Appointments can be managed more efficiently if patients are aware of approximately how long the appointment will last prior to the visit. Informing patients of the time limit for the appointment when it is scheduled can help set expectations. For example, “Mrs. Wilson, you are scheduled to meet with the pharmacist from 2:00 PM to 2:30 PM on Tuesday the 14th.”

Pharmacists should become familiar with tactful ways to keep the patient visit moving forward or bring it to a close when needed. When a talkative patient’s conversation veers



away from MTM issues, the pharmacist might say: “That’s helpful information, Mrs. Wilson. Now let’s talk about….” If the pharmacist is not able to resolve all of the patient’s medication-related problems in this period, a follow-up visit can be scheduled. “Mrs. Wilson, it looks like we are out of time for today. Let’s work on resolving three of the issues we identifi ed and once we get them under control we can take a closer look at some of the other problems we identifi ed today.” (More information about prioritizing medication-related problems is provided in Module 4.)

Finally, pharmacists can work more effi ciently by delegating tasks that do not require clinical judgment to technicians or ancillary staff.

Pharmacists should become familiar with tactful ways to keep the patient visit moving forward or bring it to a close when needed.

Expanding the Role of the Technician

Technicians can be instrumental in the success of the MTM service by reducing the amount of time pharmacists must dedicate to prescription dispensing. In some pharmacies, well-trained technicians handle all aspects of prescription dispensing, except the fi nal check and patient counseling, which must be done by the pharmacist. This workfl ow pattern gives the pharmacist more time to counsel patients, determine their medication-related needs, or promote MTM services. Before assigning tasks to technicians, it is necessary to evaluate the current pharmacy workfl ow, staffi ng and responsibilities, and technician training and skills. After assessing these aspects of the pharmacy operations, pharmacists can determine which tasks can be delegated to the technicians.

In addition to dispensing-related tasks, technicians can perform any function that does not require professional judgment, in accordance with the state’s practice act. With education and training, technicians can assume a variety of responsibilities that support the effi cient delivery of MTM services (tAble 2-1). Using properly trained technicians in these areas can help improve the effi ciency of the service, giving the pharmacist more time to conduct patient interviews and assessments.

Other Strategies to Free the Pharmacist’s Time

Expanding technician responsibilities is only the beginning of improved effi ciency of the pharmacy. Adding student pharmacists and pharmacy practice residents

into the process of delivering MTM services brings new ideas, enthusiasm, and a fresh perspective to patient care. With appropriate training and oversight, both students and residents can assist with providing existing patient care programs or implementing new MTM services.

Other support personnel, such as clerks, can help maximize effective use of the pharmacist’s time. For example, support staff who answer phones, manage schedules and paperwork, and greet patients can save the pharmacist signifi cant time and convey a professional image for the pharmacy.

In conjunction with staffi ng modifi cations, pharmacists may want to explore technological measures to improve effi ciency. Automation of dispensing could reduce prescription preparation time. More information on using automation to improve effi ciency can be found in the APhA books Managing the Patient-Centered Pharmacy and A Practical Guide to Pharmaceutical Care, 2nd edition.1,2 Other strategies to free the pharmacist and staff from repetitive tasks include technologies that allow patients to enter


Table 2-1. Tasks for Technicians Assisting With MTM Services• Help identify patients in need of MTM services

through conversations with patients or screening pharmacy records.

• Explain the pharmacy’s MTM services to prospective patients.

• Promote MTM services by stuffi ng prescription bags with fl yers or assisting with other marketing efforts.

• Provide support for administrative tasks, such as maintaining the fi ling system, scheduling appointments, making reminder calls, and supporting documentation, billing processes, and third-party claims.

• Assist in preparing for a patient visit by: printing a current medication list from the pharmacy system; obtaining laboratory values and other health professional documentation from the patient; measuring vital signs and performing point-of-care testing, when appropriate; and ensuring the consultation area is neat, organized, and stocked with appropriate supplies.

• Assist patients in fi lling out forms to ensure completeness and accuracy.

• Gather data and input into software application, if relevant; data may include patient demographic information, vital signs, and current medications, including over-the-counter medications, and herbal products.

MTM = medication therapy management.



their own refi lls (e.g., telephone interactive voice response systems, refi lls using the Internet, self-service kiosks where patients enter their refi ll information using a touch screen), e-prescribing, and automatic prescriber fax authorization.

Ambulatory Care Practice Models

A number of models may be used by pharmacists who provide MTM in ambulatory care settings such as medical homes. In such practices, pharmacists may schedule MTM visits with patients. Another innovative approach is the shared appointment, in which the pharmacist sees the patient either before, during, or after the patient’s visit with the physician or other provider. This patient-centered approach increases access and convenience for the patient, who can see all relevant providers in the clinic in a short period of time. It also allows for effi cient resolution of medication-related problems that are identifi ed during the visit. (Note that this model is different from group appointments, in which the provider sees more than one patient at the same time, although the terms are sometimes used interchangeably.)

Documenting MTM ServicesDocumenting care is a core element of the model

framework for MTM services. It is essential to document patient care activities to create a record of the care provided. Documentation is required for billing, transmitting claims to third-party payers, and monitoring patient outcomes. In addition, documentation serves these vital purposes:• Creates a permanent record of the pharmacist’s thought

process and the care provided to patients.• Facilitates communication between the pharmacist

and the patient’s other health care providers regarding recommendations intended to resolve or monitor actual or potential medication-related problems.

• Improves patient care and outcomes. • Enhances the continuity of patient care among providers

and care settings.

• Provides important information for follow-up care by the pharmacist.

• Ensures compliance with laws and regulations for the maintenance of patient records.

• Protects against professional liability. • Captures services provided for justifi cation of billing or

reimbursement (e.g., payer audits). • Provides data for measuring the value of pharmacist-

provided MTM services. • Demonstrates clinical, economic, and humanistic

outcomes. For many pharmacists, documentation of patient care

activities is a big adjustment. Pharmacists have always maintained pharmacy prescription records, but most do not have the experience or a process for documenting patient care.

Pharmacists who provide the core MTM elements (as discussed in Module 1) need to generate three types of

Liability and DocumentationThe issue of liability is not new to pharmacists; they have always assumed the responsibility of preparing their patients’ prescriptions accurately and according to professional standards. When pharmacists manage their patients’ medications, they are extending that responsibility to the patient outcomes of any interventions they may recommend. These interventions are documented in the pharmacy’s patient record, providing an account of the recommendations that were made and why they were advised. While the purpose of the pharmacist’s documentation is to benefi t the patient by providing a record of care, it also serves as a risk prevention tool. Therefore, the pharmacist’s documentation must be clear, concise, and accurate.

According to David Brushwood, BSPharm, JD, pharmacists who document everything in an attempt to prevent liability may actually be increasing their risk. Extensive documentation provides more material for attorneys to scrutinize when building a case.4 The patient chart is a legal document, and any documentation that appears in the patient’s pharmacy record may become the pharmacist’s testimony at a later date. Brushwood advises pharmacists to record only information that is correct and necessary to promote positive patient outcomes and to be consistent.

Learning Reinforcement Exercise 2.3List three activities related to the provision of MTM services that could be performed by a pharmacy technician.• ___________________________________________• ___________________________________________• ___________________________________________Answers on page 41.



documentation from their patient encounters: 1. Records for their patients, which generally include the

PMR and the MAP.2. Records for themselves. One widely used format is

the SOAP note, which stands for Subjective, Objective, Assessment, and Plan. The SOAP format is discussed in greater detail in Module 4 of this self-study program.

3. Communication with the rest of the patient’s health care team and other outside parties such as payers. This could include copies of the SOAP note, updates in electronic medical records, or other forms of communication.

Documentation Systems

Early practitioners of pharmaceutical care thought “it was impossible to imagine providing care without the aid of a computerized software program.”5 However, a survey published in 2006 found that over half of pharmacists providing patient-centered services used a paper-based system.6 While paper systems may be less expensive, electronic and web-based systems have several advantages, including easier patient data retrieval, outcomes monitoring, and report generation. Electronic systems also reduce time spent documenting interventions.6 For example, a system that can generate a PMR from the pharmacy’s dispensing records will provide greater effi ciency.

Several software systems are currently available for documentation of pharmacy-based patient care services. Pharmacists can choose systems for their desktop or handheld computer, or a web-based system. Most of these systems include electronic tools that document and bill patient encounters. Others contain special features, such as the recording of progress or SOAP notes, tracking of vital signs and laboratory values, documentation of interventions and outcomes, and scheduling and managing of patients. Some systems use clinical rules to identify potential medication-related problems based on prescription claims databases and then refer the patient to the pharmacist for a targeted MTR to address the issue.

In general, pharmacists who contract with certain third-party MTM vendors are required to use the vendor’s proprietary MTM software for documenting services. Thus, pharmacists who contract with more than one such vendor may be required to use multiple documentation systems.


Table 2-2. Examples of Commercially Available Electronic Documentation Systemsa

System (Developer/Marketers) WebsitesAssurance (Medication Management Systems Inc.)

http://www.medsmanagement.com

Community CCRx http://www.communityccrx.comGuardianRx (CarePoint Inc.) http://www.carepoint.comHealthMapRx (APhA Foundation) http://www.healthmaprx.comJASRx (JASCORP) http://www.jascorp.comMedKeeper http://www.medkeeper.comMirixaPro (Mirixa Corporation) http://www.mirixa.comMTMPath (Clinical Support Software LLC) http://www.medicationpathfi nder.comOutcomes Pharmaceutical Health Care http://www.getoutcomes.comPatient Tracker (Advanced Technical Medical Data System, LLC)

http://www.patienttracker.com

Pharmacist’s Companion (Apothacare) http://www.apothacare.comPharmMD (PharmMD Solutions LLC) http://www.pharmmd.comPillHelp Works (PillHelp LLC) http://www.pillhelpworks.comRxPertise (Managed Health Care Associates Inc.)

http://www.rxpertise.com

aListing of the documentation systems in this table does not imply endorsement by the American Pharmacists Association.

Source: Adapted from Reference 6.

Learning Reinforcement Exercise 2.4List three reasons why pharmacists should monitor and evaluate the patient care process.1. _________________________________________2. _________________________________________3. _________________________________________Answers on page 41.

tAble 2-2 provides examples of MTM third-party vendors and other organizations that produce software for documenting MTM.6 The list is not comprehensive and other useful products may be available or in development stages. It is advisable to explore several electronic documentation options before selecting the system(s) to best suit the organization. Currently, most third-party payers have an established documentation system that is required for billing their claims.

Ideally, electronic systems used for documenting MTM encounters can be linked to a patient’s overall electronic health record (EHR). Currently, pharmacists who practice in some ambulatory care practices or integrated health systems are able to use systems that provide access to patient electronic medical records, including all



laboratory data, clinic notes, problem lists, and hospital and emergency department records. Such arrangements provide a more complete picture of the patient’s history and status, but are not yet standard.

Many efforts are currently underway to develop EHR and the underlying health information technology infrastructure. Many of these initiatives stem from the American Recovery and Reinvestment Act of 2009, which calls for “meaningful use” of EHR for all Americans by 2014.7 The Pharmacy e-Health Information Technology Collaborative was launched in 2010 to support the development of EHRs that support safe, effective, and effi cient medication use, continuity of care, and access to the patient care services for pharmacists including MTM. In such a system, pharmacists would be able to access patient data and laboratory values and have the capacity to exchange patient information with other members of the health care team.8

Legal and Regulatory RequirementsPharmacists need to examine all local, state, and federal

regulations that affect the delivery of MTM services, such as HIPAA and, if the MTM service includes point-of-care testing, the Clinical Laboratory Improvement Amendment (CLIA) and Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Regulations. Quality standards or regulations by professional or accreditation organizations may be more voluntary in nature, but are equally important. When planning the MTM service, the organization must address how these requirements will be met and how ongoing compliance will be monitored.

Protecting Patient Privacy

The proper handling of confi dential health information, such as information collected during the patient interview, is a necessary part of any pharmacy practice. Keeping patients’ health information private is a professional duty—it is also the law. One of the provisions of HIPAA was to create national standards for privacy. The law requires that health care providers implement safeguards to protect the security and confi dentiality of patient information. All medical records and other individually identifi able health information used or disclosed by a health plan or health care provider are covered by this privacy rule. Health care providers,

Pharmacists planning to provide point-of-care testing services must obtain a CLIA waiver. Information about obtaining such a waiver is provided by CMS at http://www.cms.hhs.gov/CLIA/downloads/

including primary care physicians, pharmacists, dentists, mental health providers, and physical therapists, must comply with these rules.

The proper handling of confi dential health information, such as information collected during the patient interview, is a necessary part of any pharmacy practice.

A detailed discussion about compliance with the HIPAA privacy regulations, as they relate to MTM, is beyond the scope of this self-study module. Pharmacists need to be aware that failure to comply with HIPAA regulations can have devastating consequences. The pharmacy and implicated employee(s) may receive expensive fi nes and possible jail time. Furthermore, disclosure of a patient’s private information can result in insurance problems, social embarrassment, or loss of employment for the patient. Therefore, creating a culture of privacy and security within the pharmacy is crucial.9 Pharmacists may want to consult with an individual or fi rm with expertise in HIPAA procedures to determine the best ways to comply with the regulation.

Implementing reasonable safeguards to protect patient privacy—including both verbal communication with the patient about personal health information and documentation that contains this protected health information (PHI)—is essential. For example, if a patient asks for advice on a sensitive topic within earshot of others, the pharmacist can invite the person to step over to a more private setting, such as the counseling area. The pharmacist also must be sensitive to his or her surroundings when using the phone to discuss patient information with others, such as a pharmacy technician or physician. Patient documentation must be managed according to HIPAA regulations. Patients should be provided with the Notice of Privacy Practices and asked to sign their names to acknowledge its receipt before rendering MTM services. In addition, HIPAA regulations specify that security requirements for PHI and electronic communications must be encrypted.

Although it is not required, some organizations may request pharmacists or other providers to obtain their patients’ consent for uses of PHI that involve treatment, payment, or health care. For example, physicians usually can share treatment-related health information with the pharmacist without a patient’s consent. However, a signed



patient authorization may be required for uses of PHI beyond these activities. Privacy regulations may be more stringent in some states; therefore, pharmacists are encouraged to become familiar with federal, state, and local privacy regulations.

The HIPAA security regulation is another major component of the same federal legislation that mandated the HIPAA privacy regulations. The Security Standards for Protected Health Information were created to safeguard PHI in electronic form, including claims for MTM services. More information about this regulation is available from APhA at http://www.pharmacist.com/AM/TemplateRedirect.cfm?template=/CM/ContentDisplay.cfm&ContentID=12079.

Planning for SustainabilityNo matter how sound your clinical skills are, your MTM

service will not be sustainable if it is not profitable over the long term. To be financially viable, an MTM service must receive payment for the service that covers the costs of providing it. Pharmacists need to look critically and creatively at all potential sources of income and the costs associated with their MTM services.

Estimating Projected Revenues and Expenses To determine if the MTM service is financially viable, the

organization will need to identify and quantify anticipated revenues and expenses associated with patient care services. Initially, it may be reasonable to expect an operating loss; however, the business of delivering MTM services must be self-sustaining over the long term. Worksheets to help estimate projected expenses and revenues can be found in reSource H.

The costs of implementing an MTM service will vary relative to its scope and according to the staff, equipment, and facilities needed to provide the service. Pharmacists should estimate anticipated expenses in three general categories: start-up costs (e.g., training expenses, purchases of new equipment); variable costs (i.e., costs determined by the volume of service, such as supplies related to the delivery of the service); and fixed costs (i.e., costs not dependent on volume of service, such as rent and utilities).

Projections of revenue depend on the expected number of patients using MTM services and the associated fees for those services. Additionally, an estimate of sales of related prescription and over-the-counter (OTC) products resulting from improved adherence or self-care may be considered.

Once revenues and expenses are identified, profit and loss estimates can be calculated under different scenarios: best case, worst case, and most likely. For MTM services, these scenarios will depend heavily on the number of patients who participate. Specific and concrete goals can be used to measure progress and determine the break-even

point for the service (i.e., the point in time when revenues will meet, then begin to exceed, expenses). Because financial forecasting is based on a number of uncertainties, the plan should be flexible enough for the organization to incorporate alternative strategies.

A number of factors need to be considered when setting fees for an MTM service, including the cost of pharmacists’ time, overhead expenses, and the amount and types of compensation insurers and other consumers of the service are willing to pay.

Determining Fees

A number of factors need to be considered when setting fees for an MTM service, including the cost of pharmacists’ time, overhead expenses, and the amount and types of compensation insurers and other consumers of the service are willing to pay. Keep in mind that your fee for the providing the service must cover time gathering records to prepare for the visit, documentation, and communication with other health care providers, as well as the time you actually spend with the patient. It is essential to determine the level of compensation necessary for your services to generate a fair profit before you begin contracting with payers. Treating more patients will help you amortize (i.e., spread out) your start-up and overhead costs. Therefore, if you provide services to only a few patients each month, it may be difficult to be profitable. The investment in service development should be tailored to the anticipated number of patients.

Although Medicare Part D prescription drug plans set the fees for MTM services for targeted beneficiaries, pharmacists may be able to negotiate fees with other payers. Information about pharmacists’ fees for MTM services can be found in the Lewin Group report, commissioned by APhA, which summarizes results of extensive interviews with a nationwide sample of pharmacists (see For AdvAnced Study).10

Investigating opportunities to tie your compensation to the outcomes associated with your services is an option to consider. Such a model may be a possibility for organizations that have pay-for-performance models (e.g., medical homes, ACOs). These organizations also may be willing to hire you on a salaried basis and/or provide bonuses for



achievement of outcomes. Self-insured employers may be willing to explore creative compensation options, such as linking your compensation to reductions in hospitalization rates among employees who participate in the service.

Not all patients who could benefi t from MTM have third-party coverage for the service. However, patients (or their family members or caregivers) may be willing to pay out-of-pocket for pharmacy-based services when they recognize the value.11,12 Pharmacy-based programs geared toward cash-paying patients potentially are a substantial source of revenue, and some pharmacists have been very successful delivering MTM services to this group.

For patients who pay out-of-pocket for the service, the price should be set at a reasonable level that both adequately refl ects the value provided by the service and is manageable for patients. Pharmacists may choose to explain to patients that they are providing a professional service similar to a lawyer or accountant. Flexible and convenient payment plans, such as installment plans that spread payments over several months, may encourage more patients to use these services.

If you contract with Part D prescription drug plans to provide services to Medicare benefi ciaries, keep in mind that it is considered fraud to charge Medicare benefi ciaries for a service while providing it free to others. Also, be aware that if you contract with Medicare and/or Medicaid, you are prohibited from charging others a lower rate.

ContractingSome payers, such as Medicare Part D prescription

drug plans, third-party MTM vendors, and state Medicaid

programs, offer a standard contract. Covered services and payment rates offered through such programs may vary and are generally not negotiable. Some contracts are based on the amount of time spent with the patient, while others offer a fl at fee per encounter. You may need to start providing MTM services to get a good sense of the amount of time required to assess the profi tability of a fee-per-encounter payment system. Keep in mind that service delivery is likely to become more effi cient as you gain experience. However, do not be afraid to turn down contracts that will not allow you to generate a fair profi t.

Contracting with small to midsized employers generally allows more room for negotiation. Be prepared to offer your own draft contract for services that can be adapted to meet company needs. A generic MTM contract template is provided in reSource i. Know beforehand which aspects of your contract you are willing to negotiate. For example, will you charge based on the amount of time spent with patients, by the visit, or by the number of patients with a certain disease state who enroll in the program? When will payment for services be received? What types of documentation must accompany the invoice? The contract also should specify how patients will be identifi ed for the program and whether patients will be offered incentives to participate. It may be prudent to ask the company to provide credit references and call those references to assess the company’s payment history.

Carefully review all contracts to familiarize yourself with the terms of the agreement. For example, some contracts include language describing the types of insurance coverage you must carry. Clauses about indemnifi cation, which specify legal responsibilities, are common and should be fully understood or clarifi ed as needed. Ensure you know both your rights and responsibilities under any contract, and have it reviewed by a lawyer, before signing anything.

Billing for MTM ServicesDepending on their business model, pharmacists

may need to bill a variety of payers for MTM services. Payers might be the patients or their surrogates, Medicare prescription drug plans and/or their third-party vendors, a state-based Medicaid program, or insurers (both commercial and self-insured). Tips that may assist pharmacists with billing are shown in tAble 2-3.

Different payers require different billing processes. Therefore, pharmacists should contact third-party payers to determine whether they will recognize your claims for services, and clarify their procedures, ensure that their system is confi gured to process MTM codes, specify codes that will be recognized, and clarify any other requirements (e.g., prior authorization, specifi c submission instructions).13 (Pharmacists can submit bills even if they do not anticipate

Tips for Self-Paying Patients Marketing to potential cash-paying patients must be clear and up-front about pricing policies. Misunderstandings can arise when patients suppose that their health insurers will reimburse services, while the pharmacist expects the patients to pay in cash. Let patients know before providing the service whether they will be directly responsible for payment. If the possibility exists that their insurance company may reimburse for the service, offer to assist patients in clarifying the terms of their coverage. In all cases, provide a receipt for the services provided, so patients can attempt to seek reimbursement from insurers on their own, or apply the costs to a fl exible health spending account or health savings account.



being paid. These invoices, submitted with clinical documentation, can be used as a marketing tool.) Depending on contractual agreements, payment may be sent directly to the pharmacist, a pharmacy, or a provider organization.

A variety of coding mechanisms are used for health care billing. The Pharmacist Services Technical Advisory Coalition (http://www.pstac.org) works to improve the coding infrastructure necessary to support billing for pharmacists’ professional services and provides information about these coding mechanisms. Several different mechanisms exist for pharmacists to receive compensation for their services.

The Form CMS-1500 (Figure 2-2) and its companion coding systems for diagnoses (International Classifi cation of Diseases, Ninth Revision, Clinical Modifi cation [ICD-9-CM], which will change to the tenth revision [ICD-10] on October 1, 2013) and procedures (Current Procedural Terminology [CPT]) are widely used by health care providers.14,15 Electronic versions of Form CMS-1500 are commonly used and made available as part of billing software packages. However,

the form is not universal; pharmacists will need to verify with third-party payers whether this form is accepted. Additionally, providing the completed Forms CMS-1500 to patients who pay out-of-pocket may assist them in obtaining reimbursement from their insurers.

Payers may require the use of ICD codes in conjunction with CPT codes. ICD codes are often provided as part of patient referrals. If the patient was not referred, it is necessary to contact the primary care provider to determine which ICD code to use. Alternatively, if EHRs are available and accessible, the ICD code can often be obtained from those records.

CPT Codes

CPT codes, which are developed by the American Medical Association and updated yearly, are a listing of descriptive terms and identifying codes for reporting services and procedures. The current HIPAA guidelines require all professional health care services, including those provided by pharmacists, to be billed using CPT codes.13

The Pharmacist Services Technical Advisory Coalition has helped to establish permanent CPT codes specifi cally for pharmacists’ MTM services (tAble 2-4).16 These codes can be used in all pharmacy practice settings and for all payer types for the delivery of face-to-face MTM services. The CPT codes are time-based but do not have any established payment schedules. (Payment schedules, known as relative value units [RVUs], are assigned for most CPT codes.) Although these codes can be used to bill MTM services, their use does not guarantee payment. Pharmacists will need to contact payers to discuss billing mechanisms.

Pharmacists can bill in 15-minute increments at a rate determined by the prescription drug plans or other third-party payers or as negotiated by the pharmacist and payer. For example, if the pharmacist sees a new patient for 40 minutes, the visit would be billed using CPT code 99605 once for the fi rst 15 minutes and CPT code 99607 twice for the remaining 25 minutes.

Although these CPT codes were specifi cally designed for billing MTM services, they are not the only ones that can be used. Physicians may bill for non-physician services through the use of “incident to” evaluation and management (E&M) codes, and pharmacists who provide MTM and other patient care services at physicians’ offi ces can have their services billed using these codes (e.g., 99211). (E&M codes are used by physicians for patient visits that do not involve procedures.) To avoid perception of fraud, these codes should not be used for the same patient on the same date of service as the MTM codes.13 There are specifi c criteria for using “incident to” codes and pharmacists should check with CMS for the most

delivering Medication Therapy Management Services American Pharmacists Association

Table 2-3. Billing Tips for Pharmacists

• Billing a third-party payer often requires pharmacists to go through a pharmacy or recognized provider’s offi ce, such as a physician’s offi ce. Check with the payer to determine how to bill for pharmacists’ services.

• If a third-party payer requires the use of a specifi c billing system, work with the payer to ensure that you and your staff receive adequate training.

• An NPI number is required to bill for MTM services covered under Medicare Part D; to acquire an NPI, go to https://nppes.cms.hhs.gov/NPPES/Welcome.do.

• Determine whether the payer requires any training, credentialing, or the use of special documentation systems to provide and bill for MTM services.

• Identify each payer’s criteria for patient eligibility.• Contact health insurance companies directly for

patients who have health insurance coverage other than Medicare Part D to determine whether MTM services are covered, what billing codes to use, and where to submit the claim.

• If unable to determine a patient’s eligibility for MTM services, explain to the patient that a receipt will be provided, which he or she can use to submit a claim to the insurance carrier. If the service is not covered, the patient will be responsible for payment in full.

• For self-paying patients, clearly communicate fees prior to delivering the service.

MTM = medication therapy management; NPI = National Provider Identifi er.


delivering Medication Therapy Managment Services American Pharmacists Association 29

up-to-date requirements.13 The CMS Medicare web page for pharmacists is available at http://www.cms.gov/center/pharmacist.asp.

National Provider Identifi er

Any pharmacist who plans to electronically submit billing forms, such as Form CMS-1500, will need to obtain a National Provider Identifi er (NPI). HIPAA requires all health care providers—individual or organization—to obtain this unique 10-digit identifi er to complete electronic transactions. Both pharmacists and pharmacies must have NPI numbers to bill for clinical services or products. However, having an NPI number does not guarantee payment from the payer. It is important to note that the NPI is not the same as provider status under Medicare Part B. There is no charge to obtain the NPI; pharmacists can apply online at the National Plan and Provider Enumeration System (https://nppes.cms.hhs.gov/NPPES). More information about the NPIs is available at http://www.cms.gov/NationalProvIdentStand/.

Both pharmacists and pharmacies must have NPI numbers to bill for clinical services or products.

1a. INSURED’S I.D. NUMBER (For Program in Item 1)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH

b. EMPLOYER’S NAME OR SCHOOL NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described below.

SEX

F

HEALTH INSURANCE CLAIM FORM

OTHER1. MEDICARE MEDICAID TRICARE CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.

SIGNED DATE

ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)

MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

FromMM DD YY

ToMM DD YY

1

2

3

4

5

625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

(For govt. claims, see back)

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY

CODE ORIGINAL REF. NO.

$ CHARGES

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

PICA PICA

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

5. PATIENT’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH

c. EMPLOYER’S NAME OR SCHOOL NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

( )

If yes, return to and complete item 9 a-d.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB? $ CHARGES

22. MEDICAID RESUBMISSION

23. PRIOR AUTHORIZATION NUMBER

MM DD YY

CA

RR

IER

PA

TIE

NT

AN

D IN

SU

RE

D IN

FO

RM

AT

ION

PH

YS

ICIA

N O

R S

UP

PL

IER

INF

OR

MA

TIO

N

M F

YES NO

YES NO

1. 3.

2. 4.

DATE(S) OF SERVICEPLACE OFSERVICE

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

DIAGNOSISPOINTER

FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG

Single Married Other

3. PATIENT’S BIRTH DATE

6. PATIENT RELATIONSHIP TO INSURED

8. PATIENT STATUS

10. IS PATIENT’S CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

10d. RESERVED FOR LOCAL USE

Employed Student Student

Self Spouse Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN) (ID)

( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. D. E.

PROVIDER ID. #

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

EMGRENDERING

32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

c. INSURANCE PLAN NAME OR PROGRAM NAME

Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

G.EPSDTFamilyPlan

ID.QUAL.

NPI NPI

CHAMPUS

( )

1500

APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)

Code 99605 MTM service(s) provided by a pharmacist to an individual patient during a face-to-face encounter that involves an assessment and intervention if provided; use to code the fi rst 15 minutes of an initial encounter with a new MTM patient.

Code 99606 Initial 15 minutes with an established patient.

Code 99607 Each additional 15 minutes of an initial or subsequent MTM encounter; list separately in addition to code for primary service and in conjunction with 99605 or 99606.

This is the fi rst page of a two-sided form. Source: Reference 14.

Figure 2-2. Form CMS-1500

Table 2-4. Pharmacist-Specifi c CPT Codes for MTM Consultations

CPT = Current Procedural Terminology; MTM = medication therapy management. Source: Reference 16.


delivering Medication Therapy Managment Services American Pharmacists Association 30

Superbills

In addition to billing interactions with third-party payers, which are generally performed electronically, many pharmacists provide their patients with superbills at the conclusion of services. Superbills also are used to communicate the services performed to individuals who are responsible for billing on behalf of the pharmacist.

A superbill (Figure 2-3) is a paper summary of all the services the pharmacy offers and includes CPT codes and the patient’s diagnosis or reason for service.17 Pharmacy superbills are modeled on those used by physicians, dentists, and other health care providers. The pharmacists can check off the appropriate services provided and hand the superbill to the patient. Including the dollar amount of the service, even if the patient has no out-of-pocket charges, reinforces the perception of value for the MTM service. The patient brings the superbill to the technician or pharmacy clerk to check out, similar to what is done in a physician’s offi ce. This method allows the pharmacist to be more effi cient and reinforces a professional image in the patient’s mind.

The Marketing PlanThe term MTM is still relatively new to many

stakeholders who are not familiar with the role of pharmacists in direct patient care. However, once stakeholders understand the intent and scope of MTM, they generally recognize its value. Therefore, an effective marketing campaign to educate patients, caregivers, other health care providers, and payers is often the key to a successful MTM service. Your marketing plan should be shaped by your planned service. For instance, if your goal is to work in a patient-centered medical home, you will need to focus your efforts on physicians. On the other hand, if you will deliver MTM services in a community pharmacy, direct patient marketing efforts are essential to the success of the service.

Pharmacists often play important roles in conducting marketing efforts, and may seek support from corporate offi ces and/or management when such resources are available. In addition, pharmacy technicians and clerks can be trained to market services to pharmacy patrons. A clerk with good communication and interpersonal skills can welcome patrons,

Source: Reference 17.

Figure 2-3. Example of a Pharmacy Superbill

Learning Reinforcement Exercise 2.5Match the following acronyms with their descriptions:

1. _____ ICD

2. _____ CPT

3. _____ RVU

4. _____ NPI

5. _____ E&M

a. Codes used to identify the procedures that a patient receives.

b. A set of codes that physicians use when billing for patient visits that do not include procedures.

c. A set of codes that identify a patient’s diagnoses.

d. A unique 10-digit number required for submitting billing forms electronically.

e. Established payment schedules for most procedures.

Answers on page 41.



answer basic questions, and generate interest in the pharmacy’s MTM services. A number of excellent articles and books are available to help pharmacists plan and conduct an effective marketing campaign for their services. Selected marketing information is listed in For AdvAnced Study. This section provides an overview of marketing strategies.

Crafting Your MessageAs you develop your marketing materials, keep in mind

that an essential aspect of a strong marketing campaign is disseminating a clear message. Identify and emphasize the key features of your MTM practice that are most likely to appeal to your market (e.g., reduce emergency room visits, reduce medication costs, improve patient care, bolster patient empowerment) and ensure that the message is clear and consistent throughout your marketing materials. Plan to be persistent—MTM services remain a new concept for many, and you may need to continually reinforce your message to garner support and referrals.

In addition to being prepared to provide an in-depth review of the features and benefits of the MTM service, pharmacists should develop a brief (1 to 2 minute) synopsis that describes the service. Such a synopsis is often referred to as an “elevator speech”—intended to succinctly explain MTM services in the amount of time available in an elevator ride. Such a speech is designed to explain MTM to someone who is not familiar with the concept. You may find it helpful to include one or two case examples that demonstrate the value of MTM services in this speech. For example, you could describe a patient with polypharmacy issues whose health problems were resolved by a few tweaks to a medication regimen. Using specific examples may enhance others’ understanding of the value of MTM more than broad statements such as “we provide medication solutions.”

Of course, the elevator speech should not be reserved for the elevator. It can be used any time you have a brief opening to explain what you do. Once you have piqued the interest of stakeholders, they may be willing to give you more of their time to provide a comprehensive presentation.

While the features of the service remain the same, the benefits selected for discussion may vary from one stakeholder to the next. When meeting with physicians, the pharmacist may want to emphasize services that can improve the continuity of care, such as providing patients with an updated patient medication list that includes prescriptions from other physicians as well as all nonprescription, herbal, and other dietary supplements. Pharmacists may want to provide examples of cases in which an MTM intervention led to resolution of a medication-related problem to illustrate the benefits of the service.

A slightly different approach may be needed when

presenting the MTM service to self-insured employers. In this case, the pharmacist might shift the emphasis to benefits such as reduced health care costs and increased employee productivity. Highlighting a case in which therapeutic duplication was identified and prescription drug costs were reduced might be a more persuasive example.

Marketing Services to PatientsPatients requiring an MTR typically have multiple

chronic conditions and take numerous medications. They can be identified as appropriate candidates for MTM in a variety of ways. Prescription drug plans, health plans, other pharmacists, physicians, or other health care professionals may refer patients to a pharmacist. Alternatively, the pharmacist may recommend an MTM appointment to the patient if actual or potential medication-related problems are identified, if the patient is suspected to be at higher risk for medication-related problems, or during a transition of care. Finally, patients who learn about the service may request it on their own.

Many patients, including those who have third-party coverage for MTM services, may not be familiar with the service or the value it provides. A lack of patient demand for MTM services has been noted as a primary barrier to service provision.18 However, research has found that as patient awareness of MTM increases, so does their appreciation of and desire for the services.19-21 Therefore, efforts to increase patient awareness of MTM services are an essential component of a marketing campaign.

In-store or in-clinic marketing strategies are an effective way of gaining the attention of potential patients. Overhead announcements or phone “on-hold” messages can be used to briefly describe the MTM service with a prompt for individuals to inquire when visiting the pharmacy counter. Messages on register receipts also can be used to promote the service. tAble 2-5 provides additional promotional strategies for creating awareness and interest.

Employers who contract with pharmacists to provide MTM services to employees may offer incentives to their employees (e.g., waived co-pays) for participation in the service. Such incentives are often effective for enticing patients to enroll in services. Then, as patients begin to experience MTM, they see the value and can act as important referral sources.18

Responding to Objections

Participating in a pharmacy-based MTM service will be a new and unfamiliar experience, so expect some patients to express objections. A patient’s initial “no” response may simply mean that he or she needs more information before making a decision.24 For example, if a patient states that the service seems unnecessary, the pharmacist may respond



by explaining how the service can address the individual’s needs. Employing the following steps is useful when addressing objections25:• Step 1—Acknowledge the objection. This simple feedback

mechanism assures the patient that the pharmacist has heard and understood the objection. The acknowledgment need not be lengthy. Simply stating: “I understand how you might feel that way” may be sufficient.

• Step 2—Probe for more information. Politely asking for more information about the objection helps the pharmacist to gain a clear understanding of the objection and formulate an accurate response.

• Step 3—Respond to the objection. Think about the features and benefits of the service being offered as well as the patient’s unique situation. Explain how the benefits of the service can address the patient’s needs in a way that resolves the objection and his or her reluctance to use the service. These strategies can help build rapport and

understanding with patients or any individual or organization involved in the patient’s care. Figure 2-4 shows examples of objections that patients may have to participating in MTM services and effective ways to respond to them.24

Depending on the patients’ responses, the pharmacist or other staff member may decide to end the interaction by “asking for the sale”—that is, ask the patient to schedule an appointment. For example, “It sounds as though you do have some concerns about the medications that you are using. Let’s take a look at the schedule to see when we can get an appointment for you. What are the best times for you?”

Marketing Services to Other Health Care Providers

Patients are often more open to MTM services if they are referred by a physician or other prescriber. When possible, face-to-face conversations between pharmacists and prescribers, including physicians, nurse practitioners, and physician assistants, help develop relationships and build rapport. Establishing relationships with key support staff in the provider’s office, such as a receptionist or a nurse, can be helpful for making appointments. Inviting prescribers and other health care providers (e.g., diabetes educators, care managers) to the pharmacy to see the practice site is another excellent way of promoting MTM services.

Patients are often more open to MTM services if they are referred by a physician or other prescriber.

The pharmacist should prepare for the meeting by gathering background information on the prescriber’s practice and patient population as well as gathering information about the MTM service to share with the physician. The pharmacist can initiate the discussion about MTM by asking how he or she can help the prescriber improve patient outcomes. It is important to emphasize that the pharmacist’s services will focus on his or her field of expertise (i.e., medication use) and that patient encounters will be documented, patients will be monitored, and with patient consent, a full report will be sent to the primary care provider.

When speaking with prescribers, it may be beneficial to highlight the successes pharmacists have had in improving patients’ adherence to complicated medication regimens. Prescribers will probably welcome the pharmacist’s help in improving their patients’ medication adherence. Providing case examples or testimonials from patients can be an effective strategy. (If you have limited patient care experience, you may want to ask the individuals for whom you perform MTM as part of this training program for testimonials.) It may be useful to record or maintain a log of illustrative cases that demonstrate the benefits of your services so you can readily recall such examples.

When marketing to physicians and other prescribers, pharmacists should conclude the visit by asking for the sale, such as suggesting they select some of their more challenging patients to refer for the service. Questions that pharmacists might want to use to ask for referrals might include:• “Do you plan to refer any of your patients to me?”• “Can you think of any patients who might benefit from

this service?”• “Do you have any patients with poorly controlled chronic

conditions?”If prescribers indicate that they will refer patients to you, respond with enthusiasm and describe how you plan to follow up. If they decline, probe to find out why and then work to address the objections.

If you do not have experience with sales, it may be a bit uncomfortable to ask such direct questions. You may find it helpful to conduct a few practice sales calls with friends, family members, or colleagues. Figure 2-5 shows examples of ways to respond to prescribers’ objections about referring patients for MTM services.

Keep in mind that physicians often hear many sales presentations from pharmaceutical representatives and others. If you feel that the meeting is not going well, you could try an approach that acknowledges your perception such as, “I’m not sure if I’m doing a good job explaining this service to you. My training is in taking care of patients, not in sales. I’m sure you hear a lot of sales presentations and I would really appreciate it if you could tell me what I’m doing



Figure 2-4. Responding to Patient’s Objections About MTM Services

Objection #1 My doctor already takes care of this for me.Acknowledge You’re right to see your doctor for your condition(s).

Probe Does your doctor have time to educate you about your medications and lifestyle changes that can help improve your condition?

Respond Our MTM service can help you learn how to use all your medications more safely and effectively, including prescription drugs and OTC products. We also can help you make lifestyle changes that may help relieve your symptoms or improve your long-term health.

Objection #2 The last thing I need is another health care provider!Acknowledge We understand it can be diffi cult to see multiple doctors and other health care professionals.

Probe Is each of your doctors aware of all the medications you use? Do they also know which OTC products you may be taking?

Respond We will provide you with a personal medication record that provides information on all your medications and a medication-related action plan to help you use your medicines safely and effectively. Sharing this information with all your health care providers can help prevent drug interactions and other problems. We also may be able to reduce or eliminate some unnecessary medications, which could save you money.

Objection #3 I’m just too busy to spend the time on this.Acknowledge I understand you have a lot to do.

Probe What are your most critical time commitments?

Respond Taking steps to stay healthy and use your medicines more effectively can help save time in the long run, such as by avoiding emergency medical visits that can be very time consuming. Also, we have some fl exibility about when we could schedule you for the service.

MTM = medication therapy management; OTC = over-the-counter.Source: Reference 24.

Identifying Patients for MTM ServicesAccording to the core elements document discussed in MODULE 1, pharmacists may use a number of factors to identify patients who are likely to benefi t most from MTM services. General patient eligibility considerations were included in the MTM core elements model. These criteria include23:• Patient is referred for MTM services by a health care

provider.• Patient is receiving medications from more than one

prescriber.• Patient is on four or more chronic medications.• Patient has at least one chronic disease state (e.g.,

congestive heart failure, diabetes, hypertension, hyperlipidemia, asthma, osteoporosis, depression,

osteoarthritis, chronic obstructive pulmonary disease).

• Patient has laboratory values outside the normal range, which could be improved with medication therapy.

• Patient has demonstrated nonadherence with his or her medication regimen for more than 3 months.

• Patient has issues of limited health literacy and/or cultural differences, and intensive communication is needed to maximize care.

• Patient’s total monthly cost of medication exceeds $200.

• Patient has been discharged from the hospital or skilled nursing facility within 14 days and prescribed a new medication regimen.



wrong.” (Be aware that pretending to be an inexperienced salesperson is also a sales technique, and the physician may point this out to you.) In addition to possibly eliciting some useful feedback, asking the physician for guidance psychologically triggers a helpful response. This response may shift his or her mindset to be more likely to want to work with you.26

Other health care providers also may become important

sources of referrals. For example, geriatric care managers are professionals who specialize in assisting older people and their families to meet their long-term care needs. Pharmacists can collaborate with geriatric care managers by simplifying patients’ complex medication regimens and identifying individuals at risk for or currently experiencing medication-related problems. More information can be obtained from National Association of Professional


Table 2-5. Patient Marketing Strategies

Strategic Resource

Suggested Methods

Display a large sign or poster

Create a large poster with the pharmacist’s photograph, name, and title. Include text that briefl y describes MTM services.

Alternatively, establish workshops to educate patients about MTM services and post a sign that states, for example: “Medicare now pays for one-on-one consultations for certain patients such as those with diabetes, asthma, hypertension, hyperlipidemia, or congestive heart failure. Learn more on Tuesday from 6:00 PM to 7:00 PM, or speak with a member of the pharmacy staff.”

Distribute brochures explaining MTM

Mail brochures directly to patients and/or hand out brochures to patients receiving prescriptions and those who come to the pharmacy for other services such as immunizations. Brochures also can be distributed to other stakeholders, such as potential referral sources with a request that the brochures be given to patients who could benefi t from the service.

A patient brochure explaining MTM titled “Get Your Medication Check-Up” is available from APhA’s main MTM page, http://www.pharmacist.com/MTM. This brochure includes a blank area where your contact information can be listed.

Or, you could create your own brochure to explain the types of services offered by your pharmacy, describe the staff’s qualifi cations, and list the criteria for patients to be eligible for the service.

Host special events or presentations

Conduct periodic “MTM events” to present information about the types of services offered by the pharmacy and outcomes research demonstrating improved care when a pharmacist is involved. Presentations could be held in the pharmacy or at various locations in the community, such as senior centers, patient support groups, civic associations, community fairs, libraries, and houses of worship.

Engage the media Write opinion editorials and news releases about pharmacy-based MTM services for local newspapers or other media to help increase awareness about MTM. Pharmacists who enjoy public speaking may try to promote their expertise on local television or radio health shows.

Add a web page to the pharmacy’s site

Provide information about the MTM service and your contact information.

Use radio, television, or newspaper advertisements

Although use of mass media usually is the most expensive and least targeted method of promotion, it is another effective way to raise awareness. Advertising in (or providing editorial content for) niche publications, such as magazines aimed at senior citizens or retirees, can help reach the target audience.

MTM = medication therapy management. Source: Adapted from reference 22.



Geriatric Care Managers (http://www.caremanager.org). Additional referral sources might include diabetes educators, social workers, and hospital discharge planners.

Organizations and agencies that care for elderly adults also can be a source for both individual and organization purchasers of MTM services. Less traditional settings offering excellent opportunities for collaboration include home health care, hospice care, adult day services, assisted living facilities, home care, senior centers, and Area Agencies on Aging. reSource J provides more information for several of these services.

Marketing Services to Third-Party PayersAs discussed in Module 1, numerous third-party payers

currently compensate pharmacists for the provision of MTM services. Several national Medicare Part D plans, state Medicaid programs, and national MTM service administrators (e.g., Mirixa, Outcomes, PharmMD) actively sign up pharmacists meeting certain criteria to provide MTM services. Such criteria may include being a network provider, having a private or semi-private area to deliver services, having the ability to document and bill the encounter using a certain format, and/or having specifi ed training. Pharmacists who are network providers for such

Figure 2-5. Responding to Prescribers’ Objections About MTM Services

Objection #1 I don’t think my patients will want to pay for this.

Acknowledge Finances are certainly an important consideration when making a recommendation to your patients.

Probe Do any of your patients have the insurance types that provide MTM services as a benefi t?

Respond There is often little or no charge to patients for these services. Furthermore, our MTM services often can save patients money. We are often able to identify less expensive prescription alternatives that save patients money. In addition, when we work in partnership with prescribers to get patients’ chronic conditions under better control, those patients wind up saving substantially by avoiding costly hospitalizations. [Providing real-life examples of such events can be very helpful for demonstrating this point.]

Objection #2 I already manage all of my patients’ medications.

Acknowledge We understand that as the primary care provider it is your responsibility to oversee the patient’s entire plan of care.

Probe Do you have time during your patient visits to sit with your patients to ensure that they haven’t started taking any new medications or dietary supplements, and to explain the use of each medication and verify that patients are adherent to their medications?

Respond Often during our MTM visits, we identify medication-related problems that the prescribing physician was not aware of previously. This is particularly common when there are multiple prescribers. We are then able to coordinate with the prescriber to adjust the plan of care and produce improved clinical outcomes.

Objection #3 I don’t think you are qualifi ed to make recommendations about medication use to my patients.

Acknowledge I appreciate that you want to provide the best possible care for your patients.

Probe Are you familiar with the extent of the training that pharmacists receive to care for patients?

Respond Pharmacists are trained to be the medication experts on the health care team. In addition to extensive schooling, I have participated in an MTM certifi cate training program and have [insert any specifi c training here]. I regularly participate in continuing education programs and have extensive experience working with patients. Although I don’t have the same training as a physician, my expertise in medication use often results in improved outcomes for the patient.

MTM = medication therapy management.



third-party payers should approach the plans to explore opportunities to provide services.

In addition, pharmacists may look beyond Medicare Part D plan sponsors for other potential purchasers of services to build a strong and diversifi ed base for MTM services. Markets worthy of exploration include employers (especially those with self-insured health care plans), and other public or private organizations that assume risk for health care services.

Self-insured employers constitute a large and mostly untapped market for MTM services.25 Employers with self-insured plans pay for their participants’ health care claims directly out of the income or assets of the organization. With health care expenses rising, these employers have

a strong incentive to implement cost-effective wellness programs. This provides an opportunity for pharmacists to discuss ways in which MTM services can reduce health care costs, improve patient outcomes, and enhance workers’ productivity, morale, and quality of life.

Pharmacists who are interested in presenting their programs to employers should be prepared to discuss studies and programs that document how pharmacists’ interventions can both lower the cost and improve the quality of health care. The studies cited in Module 1, as well as many of those available on the MTM Connections website provide useful data if you do not have any outcomes analyses of your own to share.

Finally, some commercial insurance programs are beginning to recognize the value of MTM services and offer it as a possible benefi t to various employer groups. Pharmacists can contact commercial insurers in their area to explain the benefi ts of MTM and explore opportunities to begin MTM pilot programs or sign up to provide services.

Identifying the Decision Makers

Ideally, you want to present your services to the highest level person who will be involved in the decision about contracting with you for the provision of MTM services. Identifying this person and getting an appointment with him or her can be a challenge. Individuals who are the decision makers could be the president at a small self-insured company or the director of human resources at a larger one.27

You may need to approach various contacts at the company and provide multiple presentations to various audiences before you have an opportunity to meet with the key decision makers. Prior to the meeting, it is a good idea to seek clarifi cation about the person’s authority to make the decision to contract with you. If the person you are meeting with will not be making the fi nal decision, use the meeting as an opportunity to learn more about the company’s decision makers regarding your services. Ask the individuals you meet with whether they plan to recommend your services to their supervisors, and seek to learn who you should meet next and map out a follow-up plan.

When meeting with decision makers, close the presentation by asking for the sale and offering concrete next steps (e.g., offer to send a standard contract for their review). Always follow-up by sending a thoughtful note that thanks the participants for their time and asks for action on next steps.

Measuring Outcomes for MTM Services CMS has said, “In order to pay for quality, we have to

measure it and it has to be reported.”28 Monitoring and evaluating the care process and patient outcomes are necessary to assess the impact of the MTM service, which can be valuable for several reasons, as described in tAble 2-6.29,30

CMS has said, “In order to pay for quality, we have to measure it and it has to be reported.”

To gather meaningful patient outcomes data, thoughtful planning needs to occur before implementation of the MTM service. Planning data collection allows the pharmacist



to put in place the necessary documentation systems and procedures to retrieve the selected data in an effi cient and meaningful way.

Data demonstrating that a pharmacy’s MTM services improve patient outcomes and reduce costs can act as a powerful marketing tool when seeking contracts with payers or persuading physicians to refer patients. If the pharmacy already has a contract with a health plan or employer, such data may be required to decide upon future contracts or payment levels, particularly if the pharmacist enters into pay-for-performance contracts. Ensuring that there is a plan to capture relevant data at the beginning of program implementation will immensely aid the process for demonstrating outcomes later.

Developing a Process to Track OutcomesDetermining how you will collect data and monitor your

outcomes at the beginning of your practice is essential. If the organization plans to measure changes in patient outcomes over time, then obtaining a baseline measurement before service starts and at subsequent intervals will show patients’ progress. Another approach is to compare the outcomes of the MTM service with published benchmarks in the literature for similar patients. In a chain pharmacy setting, it may be possible to compare pilot sites that offer MTM services with other pharmacy sites that do not.

Forming partnerships with researchers to assist with monitoring the outcomes of the service can be helpful. For

example, an outside expert (or perhaps a knowledgeable colleague) may provide useful information on the best statistical tests to run, the number of patient encounters needed to analyze for meaningful results, and the most effi cient software programs for data entry and analyses.

Pharmacists may consider hiring a consultant, such as a researcher at a local college of pharmacy, to perform much or all of the pharmacy’s outcomes planning and analysis. In addition to the knowledge and experience an expert can bring, he or she may provide an objective perspective on the measured outcomes and enhance the credibility of the fi ndings in the eyes of health insurers and other stakeholders. Practice-based research networks (PBRNs) can provide additional opportunities for pharmacists and academic researchers to partner to conduct research about practice and publish their fi ndings. Information about developing PBRNs, as well as results of a PBRN investigating an MTM service, is available in the published literature.31-33

When tracking outcomes, there needs to be a plan in place to keep any data collected from patients or providers confi dential and private in accordance with HIPAA requirements. If involved in research intended for publication or external use, ensure that ethical approval for the study has been obtained through an institutional review board.

What Should Be Monitored and Evaluated?Pharmacists should identify which data elements they

will collect to show the impact of the MTM service. If the pharmacy provides core MTM services, basic data collection may include the number of patient visits, the number and types of drug therapy problems documented, the types of pharmacist interventions, and the results of those interventions. For MTM services that include some disease state management components, outcomes consistent with widely used evidence-based guidelines are appropriate.

Focus on the specifi c outcomes that will be most meaningful to the organization and key stakeholders. These outcomes may be those identifi ed by national quality measure organizations (e.g., PQA measures, Healthcare Effectiveness Data and Information Set ratings, CMS star ratings) as well as organization-specifi c measures (e.g., reduced total health care costs, reduced employee sick days). Such data can be particularly helpful when marketing the service.

Often, the same tools and software documentation systems used to identify medication-related problems during MTM visits can be used to track patient outcomes over time. Collecting the appropriate data electronically is more effi cient and may yield more accurate aggregate data. Monitoring and evaluation measures generally fall into two broad categories—process measures and patient outcomes.

Table 2-6. Why Track Outcomes?Clinical Purposes• Identifying new or unresolved medication-related

problems and wellness opportunities • Maintaining up-to-date medication use

information • Documenting changes in the patient’s health and

functional status • Revising the care plan as needed

Business Purposes• Reporting quality measures to pay-for-

performance payers and other stakeholders• Providing cost-savings or cost-benefi t

information to payers, including patients and third-party payers

• Establishing the pharmacist as a credible resource and member of the health care team

• Protecting the pharmacist’s professional liability • Identifying areas for improvement or service

expansion



Process Outcomes

Measures of process outcomes relate to the actual delivery of care—that is, how appropriately, how much, and how often. It measures aspects of the intervention or the service (not the health or functional status of the patient) such as the number of patients using the MTM service in a certain time frame, patient characteristics, the number and types of medication-related problems documented, the types of interventions made by the pharmacist, and the amount of time used to complete a comprehensive MTR.

Patient characteristics to record include age, sex, ethnicity, education, and income level. Data elements associated with medication-related problems should include the category of problem as well as medication(s) associated with the problem. Other elements to track include type of interventions and outcomes (both positive and negative).

The American Society of Consultant Pharmacists Foundation’s Fleetwood Project Phase III, which evaluated a new model of long-term care pharmacy practice, included a thorough evaluation of the process of care provided by the pharmacists.34 Selected process measures tracked in the Fleetwood Project are shown in tAble 2-7 and can be adapted for other practice settings and interventions. In addition, the National Council for Prescription Drug Programs has information on standard coding for pharmacy process measures (http://www.ncpdp.org).

Patient Outcomes

Patient outcomes are measures of change in patient status that result from the MTM service. Typically, patient outcomes are categorized as clinical, humanistic, or economic. Clinical outcomes are physiological or clinical variables that track changes in patients’ health status and disease management. Examples include rates of medication adherence, specifi c clinical measures of disease status (e.g., blood pressure, lipid levels, A1C), as well as physical or functional assessment (e.g., pain assessment, Geriatric Depression Scale, Mini Mental Status Exam). tAble 2-8 shows examples of quality indicators or outcome variables that may be measured to demonstrate improvement in various disease states. (Target outcomes may need modifi cation for various patient populations.)

Humanistic outcomes are those that capture the more subjective measures of symptoms and complaints, quality of life, and satisfaction that directly or indirectly relate to a health care product or service. Examples include patients’ ability to perform daily activities and behavioral changes, such as medication adherence, smoking status, or amount of exercise.

Table 2-7. Selected Process Measures

Type of Process Measure

Examples

Medication-related problem identifi ed

• Drug-drug interaction• Drug-disease interaction• Drug-age precaution• Drug allergy alert• Drug-food interaction• Drug-lab confl ict• Suboptimal dose or dosage

form• Poor adherence identifi ed• Therapeutic duplication• Additional drug therapy

needed• Adverse drug reaction• Patient complaint/symptom• New disease/diagnosis• Unnecessary drug• Prescriber consultation• Health care provider referral• Laboratory test needed• Payer/processor question• Patient care recommendation

Intervention or professional service

• Patient referral• Prescriber consulted• Patient medication history

taken• Laboratory test performed• Patient assessment and/or

monitoring• Coordination of care• Therapeutic product

interchange• Patient education/instruction

Outcome or result of service

• Recommendation accepted by prescriber

• Recommendation not accepted by prescriber

• Medication and/or regimen changed

• Drug therapy unchanged




Table 2-8. Examples of Disease-Specifi c Quality Indicators for Pharmacists’ Services

Condition Quality Indicator or Outcome

Diabetes • Adherence with healthful eating and physical activity• Adherence with drug therapy (e.g., insulin, oral antidiabetes medications)• Percentage of patients with A1C <7%a • Percentage of patients with blood pressure <130/80 mm Hg a • Percentage of patients who: Self-monitor blood glucose a Receive annual eye exam, lipid panel, fl u shot, and comprehensive foot exam

Obesity • Adherence with healthful eating and physical activity• Adherence with drug therapy, as indicated a• Percentage of patients who reach and maintain a reasonable weight loss goal (e.g., lose

5%–7% of initial body weight)• Percentage of patients with a waist circumference <40 inches (men) or <35 inches

(women)

Asthma • Patient-reported reduction in symptoms (e.g., wheezing, dyspnea, cough, chest tightness)

• Adherence with controller therapy (e.g., inhaled corticosteroids) in patients with persistent asthma

• Patients’ use of proper inhaler technique, as indicated• Percentage of patients with peak expiratory fl ow ≥80%• Percentage of patients with reduced:

Asthma exacerbations or emergency department visitsUse of short-term reliever medicationsNeed for oral corticosteroids

COPD • Percentage of smokers who have quit • Patient-reported reduction in symptoms (e.g., cough, sputum production, dyspnea on

exertion) • Adherence with drug therapy and patients’ use of proper inhaler technique, if indicated a • Percentage of patients who receive recommended fl u shots• Reduction in COPD exacerbations

Hypertension • Adherence with healthful eating and physical activity• Adherence with antihypertensive drug therapy• Percentage of patients who reach target blood pressure goals.a For example:

<140/90 mm Hg in those with hypertension<130/80 mm Hg in those with hypertension and diabetes or renal disease

Dyslipidemia • Adherence with healthful eating and physical activity• Adherence with statin medication or other pharmacotherapy• Percentage of patients who reach target lipid goalsa

aTarget goals vary for different patient populations depending on the presence and degree of certain risk factors and comorbidities, age, and cognitive ability. Different guidelines can vary slightly in their target goals for a given clinical parameter. Adherence goals and management strategies may need modifi cation for patients with cognitive impairment.

A1C = hemoglobin A1C; COPD = chronic obstructive pulmonary disease.



Humanistic outcomes are those that capture the more subjective measures of symptoms and complaints, quality of life, and satisfaction that directly or indirectly relate to a health care product or service.

Typically, humanistic outcomes are gathered through oral or written patient surveys to assess patient satisfaction or quality of life. Larson and colleagues have published a validated patient satisfaction survey for use in pharmacies.35 A version of this survey, adapted for MTM services, is available in reSource k. A variety of health-related quality-of-life instruments also are available, such as the Short Form 36 questionnaire to measure general quality of life.

Economic outcomes demonstrate that the services have produced a benefi t resulting in cost savings. Costs are tallied, but patient outcomes are not included in the analysis. Examples of economic outcomes include changes in costs associated with medication use, medical costs, emergency department visits and hospitalizations, and total health care costs. Productivity measures, such as missed work or school days, also fall in this category.

When measuring and evaluating costs, it is necessary to identify whose costs were measured (e.g., patient, payer, pharmacy) and the perspective of the analysis. Cost savings, revenues generated, and costs incurred from providing services are some elements that can be tracked.22

A measure called return-on-investment (ROI) is usually calculated as part of an economic outcomes analysis. ROI can be calculated in several ways and is reported as (return):(investment). For example, 4:1 would mean that the return (revenue or savings) is four times the investment. An ROI is often calculated for stakeholders, particularly payers. In this analysis, pharmacists compare the amount of money that the plan paid to the pharmacist with the amount of

money the plan saved as a result of the MTM interventions.Furthermore, pharmacists should calculate the ROI of

the service for themselves—the amount of money invested into developing an MTM service compared with the amount of revenue generated by the service. The fi nancial value of the service to the pharmacy should be closely monitored, with adjustments to the service made as necessary to ensure that the service is sustainable.

Moving Toward Quality Report Cards for MTMSeveral initiatives are underway to defi ne, assess, and

improve the quality of pharmacy services, including MTM. PQA has led several of these initiatives to develop and test pharmacy measures, and develop “report card” systems for communicating performance on quality measures. Several of these measures are currently being tested in pharmacy practice.

In 2009, PQA completed Phase I demonstration projects of pharmacy quality measures. Phase II projects are currently underway with initial results expected in 2011 and overall outcomes in 2012. These Phase II projects include36:• A unique point-of-dispensing adherence intervention

that could easily be implemented in any community pharmacy. The impact of improved adherence on health care spending will be assessed.

• An assessment of pharmacist-provided MTM on adherence to chronic medications and subsequent health care utilization. This project will utilize both telephonic and face-to-face MTM consultations.

• The effectiveness of telephonic MTM interventions, which will be triggered by clinical rules from a centrally located pharmacy claims database.

Learning Reinforcement Exercise 2.4List three reasons why pharmacists should monitor and evaluate the patient care process.1. _________________________________________2. _________________________________________3. _________________________________________Answers on page 41.

Learning Reinforcement Exercise 2.5Match the following acronyms with their descriptions:

1. _____ ICD

2. _____ CPT

3. _____ RVU

4. _____ NPI

5. _____ E&M

a. Codes used to identify the procedures that a patient receives.

b. A set of codes that physicians use when billing for patient visits that do not include procedures.

c. A set of codes that identify a patient’s diagnoses.

d. A unique 10-digit number required for submitting billing forms electronically.

e. Established payment schedules for most procedures.




Outcomes from these demonstration projects will be used to guide development of report cards and generate outcomes data to help shape future models for MTM service delivery. PQA is also involved in projects to assess innovative strategies that expose patients to new services, including quick adherence interventions, developing best practice models, and surveying patients about the perceived quality of services.

Reviewing and Implementing the Business Plan

Once you have thought through all the elements of the business plan, it will be useful to spend some time reviewing the plan and possibly seeking insight and advice from others. These individuals might include business professionals, such as the pharmacy accountant, respected professional colleagues, friends, or even select patients. Asking individuals outside the organization to review the business plan helps identify areas of the plan that are unrealistic, ambiguous, or inaccurate. tAble 2-9 lists questions reviewers should ask when critiquing the business plan.

After examining the business plan for delivering MTM services from various perspectives, the pharmacist must now focus on the fi nal element—the implementation strategy. Depending on the services offered, the pharmacist can choose to implement the services all at once or in several phases.

For many pharmacies, a wise approach will be to start small and build on the success with MTM services over time. Starting with a pilot project in one store or with one service provides employees with experience and the opportunity to test existing systems for documentation and billing. Once a well-tuned service delivery system is in place, expanded services can be rolled out to a greater number of patients and/or to additional stores. A successful pilot site also is valuable for training employees from other stores as MTM services are expanded to additional locations.

Learning Reinforcement Exercise Answers 2.1a: Possible answers include: Strengths—well-trained staff; prime store location; established pharmacist-delivered

services; large, established patient base; exceptional reputation; strong relationships with local physicians. Weaknesses—low employee morale; poor pharmacy design; limited patient access; workfl ow problems.

2.1b: Possible answers include: Physicians; health plans; self-insured employers; adult children of patient; non-Medicare patients with multiple chronic conditions.

2.2: Specifi c to your practice setting.

2.3: Any of the following answers are acceptable: identifying patients in need of MTM services through conversations with patients or screening pharmacy records; explaining MTM services to patients; performing administrative tasks, such as maintaining the fi ling system and scheduling appointments; measuring vital signs; assisting patients in fi lling out forms; any function that does not require professional judgment.

2.4: Any of the following answers are acceptable: documents achievement of patient goals; demonstrates the impact of MTM on the quality of patient care; shows whether the service is meeting performance targets; required by the payer; useful for promoting the MTM service; identifi es areas for service expansion; reveals areas for improvement.

2.5: 1 c, 2 a, 3 e, 4 d, 5 b.

Table 2-9. Questions to Ask When Reviewing the Business Plan • Does the business plan meet local patient needs? • Is the plan based on realistic assumptions, factual

information, and logical reasoning? • Is the plan’s design fl exible enough to respond to

unpredictable developments? • Do affected staff members have the necessary

knowledge, skills, and abilities for successful implementation of the plan? Are they committed to making it happen?

• Is the marketing plan on target? Will it bring in new patrons or payers?

• Are the fi nancial projections based on reasonable assumptions? Does the pharmacy have enough reserves to implement the plan?

• If the service fails to meet expectations, how will the plan be modifi ed?



ConclusionPharmacists who construct a well-developed business

plan will be better able to identify and resolve potential challenges to preempt problems regarding the viability of the MTM service. This strategy will result in producing an individualized document that guides the way for service implementation, including preparing the pharmacy and the employees, marketing the service, and monitoring its success, both clinically and financially. Following this structured approach and committing the results to paper will advance the success of the MTM service.

Pharmacists who construct a well-developed business plan will be better able to identify and resolve potential challenges to preempt problems regarding the viability of the MTM service.

References1. Hagel H, Rovers J, eds. Managing the Patient-Centered Pharmacy. 2nd

ed. Washington, DC: American Pharmacists Association; 2002.2. Rovers JP, Currie JE, Hagel HP (eds). A Practical Guide to

Pharmaceutical Care. 2nd ed. Washington, DC: American Pharmacists Association; 2003.

3. American Pharmacists Association; National Association of Chain Drug Stores Foundation. Medication Therapy Management Services in Community Pharmacy: Planning for Successful Implementation. Washington, DC: American Pharmacists Association; 2005.

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11-439 Mtm Module 2-Final

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