What's an MTM service?It's up to the drug plan

To fulfill its requirement to offer medication therapy management (MTM) under the new Medicare prescription benefit, Humana will use an approach stratified according to patient risk, a company official said. The plan will have, as its base, a system of educational mailings to patients. But it will move up to call centers through which patients can consult with nurses and pharmacists. And the call centers will also be used to schedule appointments with pharmacists.

Under the competitive model of the Medicare benefit, the companies offering the drug insurance plans have a lot of leeway in what coverage they offer. And the same holds true for the MTM they must offer.

Representatives from Humana and CareFirst (Blue Cross/Blue Shield) gave a few glimpses of what their programs will look like at a recent meeting of the American Health Quality Association (AHQA) in Arlington, Va.

Rob McMahan, Pharm.D., of Humana, said that beneficiaries speaking to that company's call center will have access to the pharmacy tools that the company has built up to identify problems and make recommendations on medications. And part of the call center's role will be speaking to people who have gotten letters indicating they are eligible for a higher-level intervention, trying to get these people face to face with a pharmacist. Those beneficiaries will be able to call in and have the call center direct them to a pharmacy, giving them choices in which pharmacy they use.

But if they don't call in, Humana has pledged to the Centers for Medicare & Medicaid Services (CMS) that it will make "outbound calls to those beneficiaries to explain the program to them, so that they understand what they are opting into or not electing to opt into," McMahan said.

Questioned on whether Humana's planned educational mailings can even be considered medication therapy management, McMahan acknowledged the concern but noted that that type of effort does fall within the CMS definition. The mailings, he said, are a way the company can get targeted materials to people with particular medication profiles, while the company is ramping up the other efforts. He added that many plans are doing only educational mailings

Winston Wong, Pharm.D., of CareFirst, an approved drug plan provider in Region Five, said his company has decided to make all the members who are covered by the drug plan eligible for MTM, although Medicare is paying only for those with particular profiles, including a likelihood of incurring $4,000 for covered drugs. He explained that CareFirst did not want the up-front burden of identifying which beneficiaries would be eligible under Medicare's rules, including generating identification cards to be shown to the pharmacists. But more important, he indicated, the firm was also motivated by the potential of cutting down on "medication waste" for all patients. He includes in medication waste circumstances higher-cost drugs than necessary, noncompliance or side effects that will require additional drugs down the road, or medication that is not having its intended benefit. "Medication waste does occur in all patients. It is not like once you hit a $3,000 threshold, you start wasting," Wong said. CareFirst has outsourced its MTM operation to Outcomes Pharmaceuticals Health Care, a company with over six years' experience providing MTM services with local pharmacists.

Are plans going to do anything to educate physicians about what is going on with pharmacists doing therapy management? Wong indicated that CareFirst may develop an educational piece for physicians, but the company feels pharmacists should be having this kind of interaction with physicians in any case.

Humana's McMahan said his firm will be doing physician education on MTM using all the tools with which it normally communicates with physicians. And if a pharmacist makes a recommendation on a prescription that must go back to the physician, there will be direct communication with the physician about what is happening.

Could physicians, given their limited time with patients, make referrals to pharmacists for MTM? McMahan said that's not a part of Humana's initial plan, but the company may look at it in the future: "We know very well that this is an evolving plan."

So what will pharmacists be paid for these services? McMahan said antitrust regulations prevent him from specifying amounts, but the rates will be based on the new CPT (current procedural terminology) codes for MTM and that they will be in the contracts offered to pharmacies. A representative from another drug plan noted that in cases where a pharmacist completes a comprehensive medication review and finds a number of problems requiring consultation, the fees would accumulate and could add up to over $100 per session.

Wong noted that, at this juncture, CareFirst does not have limitations on the number of submissions a pharmacist could make for one patient, although that policy may be revisited if the company begins getting excessive submissions.

THE AUTHOR is a writer based in Maryland.