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Medication Therapy Management: Pharmaceutical Safety and Savings
Updated: July 2010
Medications save or improve lives, but taken incorrectly or in excess they can make patients worse. With thousands of prescription drugs on the market, increasingly powerful and popular over-the-counter products and an array of less-regulated herbs and supplements, frequently no one prescriber or manufacturer knows the total picture for each patient.
Most often the local pharmacy is the like place to spot a probem and identify a solution. The patient submits a prescription order (handwritten, computer printed or totally electronic) across a counter and picks up a bag at the other end. A pharmacy technician checks for product accuracy, insurance copayment pricing and completes the sale. Ideally the patient, voluntarily and accurately, mentions all other conditions and medications and any dangerous or unintended medical results are avoided.
Yet, the Institute of Medicine's 2004 report on health literacy says 90 million people have difficulty understanding, using, and acting on health information.i The problem is compounded by the fact that most patients hide their confusion from their doctors because they are too ashamed and intimidated to ask for help.
To catch and resolve the more at-risk patients, pharmacists have designed a formal but consumer-friendly program called Medication Therapy Management (MTM) or Review. Usually MTM is used when a patient is taking many (eight plus) separate drugs. It is typically delivered as a face-to-face visit between the pharmacist and patient. The MTM consultation can be defined in statute or in a Medicaid, state or private contract, and is added as a reimbursed professional service.
The Core Elements of MTM
An alliance of 10 organizations representing the pharmacy and pharmacist professions designed a uniform definition of acceptable practice:
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Review all current medications including nonprescription and herbal agents,
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Assess medication-related problems
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Provide a personal medication record (PMR) - a comprehensive, reconciled list of all of the patient's medications to the patient and other clinicians for self-management, care coordination and continuity.
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Compile a medication-related action plan (MAP) for tracking progress in self-management.
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Identify cases needing intervention including collaborating with other clinicians
STATE M .T. M. PROGRAMS AND LAWS
The following are examples of MTM programs in 18 states; other states may have similar projects or payments.
State
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Type
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Description and Notes
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| California |
Medicaid |
HIV/AIDS MTM program for Medi-Cal.
Study Results: report online. This program is reported to have been cut in 2010. |
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Colorado
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Medicaid
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The MTM program was expanded statewide in 2008.
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Florida
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Medicaid
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An MTM program is operational.
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| Georgia |
Institutional
patients |
HB 361 of 2010: Enacts the Safe Medications Practice Act; provides for collaboration between hospital pharmacists and members of the medical staff on drug management therapy for a patient in an institutional setting. (Signed into law by governor as Act 392, 5/20/10) |
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Iowa
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Medicaid
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Iowa Medicaid reported that 31% of 3,037 eligible patients met with pharmacists; reporting 2.6 medication-related problems per patient, 52% recommended new medication and 31% recommended discontinuing a medication. Medicaid pays $75 for initial assessments, $40 for follow up problems and $25 for preventive follow-up.
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Minnesota
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Medicaid
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Minnesota implemented MTM services for low-income patients with complex medical and drug-related needs. Pharmacists received an average of $92.50 per patient visit, based on the complexity of care for the given patient. They resolved an average of 3.1 drug therapy problems per patient, usually issues of inadequate therapy. Patients averaged six medical conditions and 14 drugs each. Bills to create MTM were introduced over 12 years and finally enacted in 2005 [1]
2009 rates: a first-time, face-to-face encounter up to 15 minutes is $52, repeat visit is $34. Additional 15 minutes are billed at $24.
Study Results: MTM services resulted in a 31% reduction in total health expenditures per patient, from $11,965 to $8,197, and a 14% increase in meeting patient’s goals. The savings exceeded the cost of MTM services by more than 12 to 1. i
Signed into law as Minn. Stat. §256B.0625, subd. 13h in 2005.
[i] Source: Isetts BJ, Schondelmeyer SW. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. J Am Pharm Assoc. 2008;48:203-11
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Mississippi
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Medicaid
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Mississippi was first to offer MTM, in 2003; Medicaid pays $20 for initial visits, with a 12-visit annual cap.
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Missouri
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Medicaid
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Started January 2008, focusing on diabetes and asthma education. Subsequent phases will integrate chronic obstructive pulmonary disease, cardio-vascular disease, depression, gastro-intestinal disease, migraine, osteoporosis, and various other conditions. Reimbursement:
> Initial 15 min., new patient = $50
> Initial 15 min., established patient = $10
> Additional 15 minutes, all patients = $5
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Montana
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Medicaid
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An MTM program is reported operational.**
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New Mexico
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Medicaid
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An MTM program is operational.
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New York
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Medicaid
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New York’s 2008-2009 Budget authorized implementation of a pilot Medicaid MTM program to improve therapeutic outcomes. The program pays $35 for an initial new patient and $25 for a follow-up consultation, limited to six per year.
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North Carolina
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Medicaid;
State employee plan
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Medicaid has named the MTM program Focused Risk Management Program (FORM); it requires a limit of eight Rx per patient per month unless the patient enrolls in FORM.
North Carolina's ChecKmeds program is available to all 650,000 Medicare Part D patients, paid for by a state operated trust fund.
Study: NC State Employee MTM link
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Ohio
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Medicaid
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An MTM program is operational. |
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Oregon
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Medication Therapy Management (MTM) Pharmacists must enroll with DMAP as a professional provider to bill for MTM services. Services must be provided based on referral from a physician, licensed provider, or a Prepaid Health Plan (PHP).
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Description
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DMAP rate
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Code
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Initial 15 minutes, new patient
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$28.22
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99605
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Initial 15 minutes, established patient
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$26.34
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99606
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Each additional 15 minutes.
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$13.17
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99607
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For Oregon documentation requirements, refer to Guideline Note 64 of the Prioritized List of Health Services. http://www.dhs.state.or.us/policy/healthplan/guides/pharmacy/rxsupp1009.pdf
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Utah
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Medicaid
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| Vermont |
Medicaid |
An MTM program is reported operational.**
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Virginia
|
Medicaid
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An MTM program is reported operational.**
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Washington
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State, public employees
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Washington State Health Care Authority now administers an MTM program for eligible public employee enrollees of the Uniform Medical Plan (UMP) and the Aetna Public Employees Plan of Washington.
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Wisconsin
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Medicaid
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Medicaid pays $40.11 per encounter.
Public employee pilot.
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Wyoming
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Medicaid
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An MTM program is reported operational.
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** MTM program reported by NACDS, 1/09
Other State Actions
Idaho's legislature in 2008 considered, but did not pass, a resolution (HCR 40) "encouraging the Department of Health and Welfare to proceed with the development of a Medicaid Medication Therapy Management Program." It was not reconsidered in 2009.
Wisconsin's Pharmacy Society plans to pilot an MTM initiative with about 50 pharmacies during 2007 and evaluate the impact of the program before expanding it to third-party payers (health plans, employers, and state agencies, including public employees in ETF and DHFS). ETF is working with its PBM, Navitus, to determine areas of duplication, aswell as efficiency and quality enhancement opportunities.
Medicare Part D and MTM Requirements
Under federal statutes 423.153(d), each Medicare Part D sponsor must have established a MTM program that:
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Ensures optimum therapeutic outcomes for targeted beneficiaries through improved medication use.
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Targets beneficiaries who have multiple chronic diseases and cannot require more than 3 chronic diseases as the minimum number of multiple chronic diseases and must target at least four of the following seven core chronic conditions:
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Hypertension
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Heart Failure;
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Diabetes;
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Dyslipidemia;
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Respiratory Disease (such as Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung disorders);
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Bone Disease-Arthritis (such as Osteoporosis, Osteoarthritis, or Rheumatoid Arthritis);
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Mental Health (such as Depression, Schizophrenia, Bipolar Disorder, or Chronic and disabling disorders).
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Reduces the risk of adverse events
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Is developed in cooperation with licensed and practicing pharmacists and physicians
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Describes the resources and time required to implement the program if using outside personnel and establishes the fees for pharmacists or others
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May be furnished by pharmacists or other qualified providers
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May distinguish between services in ambulatory and institutional settings
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Is coordinated with any care management plan established for a targeted individual under a chronic care improvement program (CCIP)
Each Part D Sponsor is required to incorporate a Medication Therapy Management Program (MTMP) into their plans' benefit structure. A CMS-approved MTMP is one of several required elements in the development of Sponsor' bids for the upcoming contract year. CMS requirements online. [Updated 12/09]
Review of 2009 Medicare MTM Programs
There are 736 active Part D contracts with an approved MTMP in CY 2009 including 640 Medicare Advantage prescription drug plans (MA-PDs) and 96 prescription drug plans (PDPs). Employer MTM programs have been included in the statistics for PDPs. This analysis includes characteristics of 2009 MTMP applications approved during the Annual Review and changes approved during the March and June update windows as of July 21, 2009.
Additional Resources
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Patient Care Database– a fully searchable resource dedicated to raising the public’s awareness of important topics, such as medication adherence and other patient services provided by community pharmacy; published by the National Association of Chain Drug Stores (NACDS) Foundation. February 2010.
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Analysis of pharmacist-provided Medication Therapy Management (MTM) services in community pharmacies over 7 years. Barnett MJ, Frank J, Wehring H et al. J Manag Care Pharm 2009;15(1):18-31.
- Preventing Medication Errors. Washington, D.C.: Institute of Medicine, 2006; www.iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx.
According to one estimate, in any given week four out of every five U.S. adults will use prescription medicines, over-the-counter (OTC) drugs, or dietary supplements of some sort, and nearly one-third of adults will take five or more different medications. Most of the time these medications are beneficial, or at least they cause no harm, but on occasion they do injure the person taking them. Some of these "adverse drug events [ADEs]" as injuries due to medication are generally called, are inevitable--the more powerful a drug is, the more likely it is to have harmful side effects, for instance--but sometimes the harm is caused by an error in prescribing or taking the medication, and these damages are not inevitable. These errors can be prevented.
- Health literacy: A prescription to end confusion. Institute of Medicine. (2004, April 8). Accessed December 5, 2009, at www.iom.edu/report.asp?id=19723
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Evaluation of a pilot medication therapy management project within the North Carolina State Health Plan. Christensen DB, Roth M, Trygstad T, Byrd J. J Am Pharm Assoc (2003 ) 2007;47(4):471-483.
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"Patients Lack Knowledge of Their Hospital Medications" - Study by University of Colorado Hospital, December 10, 2009.
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CA: Evaluation of the first year of a pilot program in community pharmacy: HIV/AIDS medication therapy management for Medi-Cal beneficiaries. Hirsch JD, Rosenquist A, Best BM, Miller TA, Gilmer TP. J Manag Care Pharm 2009;15(1):32-41. . 2009
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Recent MTM Articles of Interest
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Florida: Clinical Pharmacist Improves Diabetes Patients' HbA1c Levels and Lowers Blood Pressure, Hospitalizations, ER Visits, Study Finds
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A clinical pharmacist counseling type 2 diabetes patients improved patients' HbA1c levels, lowered patients' blood pressure, and reduced hospitalizations and emergency room visits, according to a case study published in the February 15, 2010.
The Polk County Pharmacist Intervention Model, over one year, led to a 9% relative improvement in patients' HbA1c levels, a 30% reduction in all-cause hospitalizations, and a 24% reduction in all-cause emergency room visits, the study found. The model, implemented in February 2005, provided medication and disease counseling by a clinical pharmacist to diabetes patients in Polk County, Fla., who were employees, dependents, and retirees of the county government.
Program participants had six, 30-minute visits with the clinical pharmacist. Patients also received copayment waivers for disease-related medications, supplies, and nonprescription products. Patients were required to sign an agreement to comply with program rules and were terminated from the program if they did not. There were 564 patients enrolled in the program, with 477 patients who remained enrolled at the end of the program's first year.
The study is available at:
Iyer R, Coderre P, McKelvey T et al. An employer-based, pharmacist intervention model for patients with type 2 diabetes. Am J Health-Syst Pharm. 2010; 67:312-15.
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Pharmacists Reduce Hospitalizations, Length of Stay for Dialysis Patients, Study Finds
December 18, 2009 - American Society of Health-System Pharmacists
Patients with end-stage renal disease who received in-depth medication reviews by clinical pharmacists had 42% fewer hospitalizations and a 21% decline in length of hospital stay, according to a study in the December 2009 Pharmacotherapy.1 Pharmacists identified 530 drug-related problems among 57 patients while reviewing patients’ medications every three weeks during the two-year pilot study at a dialysis clinic in New Mexico. The pharmacists also joined weekly patient rounds and monthly patient reviews with the patients’ health care team. One of the pharmacists was a nephrology-trained clinical pharmacist, while the other two were completing nephrology pharmacotherapy postdoctoral training. The 47 patients in the control group received “periodic drug profile updates by dialysis nursing staff,” which is standard care. “This demonstrates that consistent care by a nephrology-trained clinical pharmacist can translate into cost avoidance for third-party payers (e.g., Medicare) and improved financial profiles for ambulatory hemodialysis centers that avoid lost revenue secondary to missed treatments while the patient is hospitalized,” the study’s authors stated. As a result of these findings, the study’s authors suggest health care policy makers consider adding pharmacists to a multidisciplinary care team for hemodialysis patients. An abstract of the article is available at http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.29.12.1433
Source: 1. Pai A B, Boyd A, Depczynski J et al. Reduced drug use and hospitalization rates in patients undergoing hemodialysis who received pharmaceutical care: a 2-year, randomized, controlled study. Pharmacotherapy. 2009; 1433-40.
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Pharmacists Improve Care of Diabetics While Cutting Costs
Source: University at Buffalo, December 28, 2009 - http://www.buffalo.edu/news/10781
The role of pharmacists hasn't received much attention in the debate on the cost of healthcare. But national and regional studies show that when pharmacists directly participate in patient care, they significantly reduce treatment costs and improve outcomes. A study on diabetic patients by the University at Buffalo (UB) School of Pharmacy and Pharmaceutical Sciences identified cost savings with improvements in a key indicator of glucose control in diabetes patients, the hemoglobin A1C measurement. The A1C provides a three-month average of the amount of excess glucose in the blood. Higher A1Cs indicate that a patient is at higher risk for developing long-term complications associated with diabetes, such as kidney disease or vision problems.
The study found that:
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In just six months, clinical pharmacists, in collaboration with primary care providers, were able to significantly reduce patients' A1C levels.
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Patients' A1C levels were reduced by an average of 1.1 percent, from an average of 8.5 percent to 7.4 percent, one year after being enrolled in the program, while also improving the overall metabolic profile.
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Enhancing the patient's access to care through collaborative physician-pharmacist relationships can yield lower blood glucose levels, improve the overall metabolic profile and reduce costs to the payor. These clinical improvements occurred while monthly costs per patient went down by approximately $212, around $2,500 per year, even though there were nominal increases in the cost of medications prescribed.
The key to success is that patients had unlimited access to pharmacists throughout the year, says Erin Slazak, PharmD, UB clinical assistant professor of pharmacy practice and board certified pharmacotherapy specialist. The UB pharmacists spent an initial one-hour appointment with each patient, where they worked up detailed health records covering dietary information and all medications and disease conditions, and then reviewed them with each patient. After that, patients could call or make appointments with pharmacists at will. For patients in the initial stages of administering insulin, Slazak says it was common to be contacted once every few days. The pharmacists then made suggestions to physicians about changes in medications, dosages or lifestyle that might be beneficial to their patients. That kind of individualized attention is far from the norm for diabetic patients. "Nationwide, the standard of care is that the primary care provider manages diabetes alone," says Slazak. "Pharmacists typically do not have direct involvement." That is partly because some states, including New York, have not yet approved collaborative practice agreements between physicians and pharmacists.
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As Medication Therapy Management Programs Become More Robust, Plans Need to Compare Cost to Health Status
Reprinted from MEDICARE PART D NEWS
The health reform law has codified CMS medication therapy management program (MTMP) requirements, aiming to make the program more robust and providing incentives for some plans to provide programs that go beyond CMS requirement. Some industry insiders would like to see plans do more with their MTMPs but acknowledge a conflict between cost and beneficiary health status. Read Full Story- may require user password |
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Missouri Foundation for Health. (October 2008) "Medication Marketplace: Getting the Best Price on Medications." http://www.healthcare4kc.org/uploadedFiles/Publications/Medication%20Marketplace%20Getting%20the%20Best%20Price%20on%20Prescription%20Drugs%20for%20Missourians%20101308.doc
J Am Pharm Assoc. 2009;49:e163–e170. Impact on drug cost and use of Medicare Part D of medication therapy management services delivered in 2007.
Isetts BJ, Schondelmeyer SW. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. J Am Pharm Assoc. 2008;48:203-11
Thompson, Cheryl A. AJHP News (March 15, 2008) State-Paid Medication Therapy Management Services Succeed.
Notes:
[i] Institute of Medicine. (2004, April 8). Health literacy: A prescription to end confusion. Accessed December 5, 2009, at www.iom.edu/report.asp?id=19723
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