College of pharmacy–based medication therapy management program for a university system

Experience

College of pharmacy– based medication therapy management program for a university system Timothy P. Stratton, Tim Cernohous, Keri Hager, Melissa Bumgardner, Andrew Traynor, Marcia M. Worley, Brian J. Isetts, Tom Larson, and Randall Seifert Received April 16, 2010, and in revised form May 11, 2011. Accepted for publication June 7, 2011.

Abstract Objective: To document and evaluate the design and operation of a medication therapy management (MTM) benefit and associated MTM clinic developed by the University of Minnesota College of Pharmacy as a covered health plan benefit for University of Minnesota, Duluth (UMD) employees, early retirees, and their dependents. Setting: Office-based, nondispensing pharmacy at UMD. Practice description: College of Pharmacy, Duluth faculty developed and provided MTM services as a covered health benefit for UMD beneficiaries. Practice innovation: Partnership between a university campus and a college of pharmacy to design and implement an MTM benefit as part of the university health plan covering current employees, early retirees, and dependents. Main outcome measures: MTM benefit design, MTM clinic implementation, patient complexity comparisons, and drug therapy problems identified and addressed. Results: Of 1,000 eligible beneficiaries, 68 (~7%) took advantage of the MTM benefit, consistent with national participation rates but lower than the 25% goal for participation. Beneficiaries receiving MTM services were three times more complex in terms of health resource use than the “typical” UMD beneficiary and were experiencing 7.22 drug therapy problems per patient. Conclusion: The UMD MTM clinic was successful in providing UMD beneficiaries access to MTM services. The MTM benefit was subsequently offered throughout the entire University of Minnesota system (Crookston, Duluth, Minneapolis–St. Paul, and Morris). Keywords: Medication therapy management, managed care, pharmaceutical care, health care costs, pharmacy benefits management. J Am Pharm Assoc. 2012;52:653–660. doi: 10.1331/JAPhA.2012.10050

Timothy P. Stratton, PhD, BCPS, FAPhA, is Professor of Pharmacy Practice, College of Pharmacy, University of Minnesota, Duluth. Tim Cernohous, PharmD, is Ambulatory Pharmacy Operations Manager, Essentia Health, Duluth, MN, and a PhD candidate in social and administrative pharmacy, College of Pharmacy, University of Minnesota, Duluth. Keri Hager, PharmD, BCPS, is Assistant Professor of Pharmacy Practice, College of Pharmacy, University of Minnesota, Duluth. Melissa Bumgardner, PharmD, BCPS, was Assistant Professor of Pharmacy Practice, College of Pharmacy, University of Minnesota, Duluth, at the time this study was conducted; she is currently owner, Abts Health Mart Pharmacy, Julesburg, CO. Andrew Traynor, PharmD, BCPS, was Assistant Professor of Pharmacy Practice , College of Pharmacy, University of Minnesota, Duluth, at the time this study was conducted; he is currently Associate Professor-Director of Residency & Practice Development, School of Pharmacy, Concordia University Wisconsin, Mequon. Marcia M. Worley, PhD, BSPharm, was Associate Professor, College of Pharmacy, University of Minnesota, Duluth, at the time this study was conducted; she is currently Associate Professor, Raabe College of Pharmacy, Ohio Northern University, Ada. Brian J. Isetts, PhD, BCPS, is Professor of Pharmacy Practice; and Tom Larson, PharmD, is Professor of Pharmacy Practice, College of Pharmacy, University of Minnesota, Twin Cities, Minneapolis. Randall Seifert, PharmD, is Professor of Pharmacy Practice and Senior Associate Dean, College of Pharmacy, University of Minnesota, Duluth. Correspondence: Timothy P. Stratton, PhD, BCPS, FAPhA, College of Pharmacy, University of Minnesota, Duluth, 232 Life Science, 1110 Kirby Dr., Duluth, MN 55812. Fax: 218-726-6500. E-mail: [email protected] Disclosure: Drs. Cernohous, Bumgardner, and Traynor provided medication therapy management (MTM) services through the University of Minnesota, Duluth MTM clinic during the study period. The other authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgments: To Dr. Greg Fox, University of Minnesota, Duluth Vice Chancellor; and to Dr. Frank Cerra, Vice President, University of Minnesota Academic Health Center, and Dean, University of Minnesota School of Medicine. From the University of Minnesota, Twin Cities: Dr. Stephen Schondelmeyer, Director, University of Minnesota PRIME Institute (College of Pharmacy); Dr. Henry Mann (Faculty of Pharmacy, University of Toronto); Dr. Amanda Brummel (Fairview Pharmacy Services); Dann Chapman (Human Resources); Ted Butler (Employee Benefits); Karen Chapin (Human Resources); Gavin Wyatt (UPlan Benefits Advisory Committee). From the University of Minnesota, Duluth: Judith Karon (Human Resources); Lita Wallace (Human Resources).

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I

n March 2007, University of Minnesota College of Pharmacy faculty based at the University of Minnesota, Duluth (UMD) campus proposed to UMD administration that medication therapy management (MTM) services be offered as a covered health benefit to UMD health plan (UPlan) beneficiaries. The current article describes how MTM services were established as a covered benefit for UMD beneficiaries on November 1, 2007, and subsequently made available throughout the University of Minnesota system on March 15, 2009. MTM services, provided within the practice of pharmaceutical care, is a standardized process of care defined by the American Medical Association (AMA) through its Current Procedural Terminology (CPT) codes,1 during which the following are assessed for every patient2,3: (1) health status and indications for drug therapy, (2) effectiveness of current therapies and need for additional therapies, (3) safety of therapies, and (4) convenience of therapies. The MTM care process involves reviewing patients’ medication therapy by assessing their drug-related needs: assessing the effectiveness and safety of patients’ drug therapy, creating

At a Glance Synopsis: A medication therapy management (MTM) clinic developed by the University of Minnesota College of Pharmacy as a covered health plan benefit for University of Minnesota, Duluth (UMD) employees, early retirees, and their dependents was successful in attracting therapeutically complex patients and was subsequently expanded to the entire university system. Beneficiaries receiving MTM services were three times more complex in terms of health resource use than the “typical” UMD beneficiary and were experiencing 7.22 drug therapy problems per patient. Despite incentives such as reduced prescription copayments and convenient location, only a small number of UMD health plan members took advantage of the benefit. Analysis: The authors cited the opt-in benefit design of the MTM program as a potential barrier to greater patient uptake, and recent evidence has shown an opt-out design to be more effective. Further research is needed to determine the motivators and inhibitors affecting patient participation in a free-standing MTM clinic. Offering MTM services outside of an established health system may require the capability to enter patient medical conditions, prior medical history, and clinical laboratory information into the care documentation system de novo at the initial visit. Although data entry could be carried out by administrative support personnel, based on the experiences of the authors with the system described here, as many as 2 hours may be necessary to document patient care for every hour spent conducting a patient's initial MTM interview.

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a personalized medication record, developing an individualized care plan, communicating with other health care providers to optimize outcomes, conducting follow-up evaluations with patients, and documenting all of these steps.2,4–6 The impact of MTM services has been most extensively studied through the Asheville Project.7–9

Objective The current project was undertaken to document and evaluate the design and operation of an MTM benefit and associated MTM clinic developed by the University of Minnesota College of Pharmacy as a covered health plan benefit for UMD employees, early retirees, and their dependents.

Methods

Design of MTM benefit The steps involved in designing and implementing the MTM benefit are outlined in Appendix 1 (electronic version of this article, available online at www.japha.org). To be eligible for the MTM program, UPlan beneficiaries had to (1) be active or disabled employees, early retirees (<65 years of age), or dependents of UMD employees; (2) be using four or more prescription medications covered by UPlan; (3) have two or more chronic conditions; or (4) be referred to the program by their primary health care provider. UPlan beneficiaries not otherwise qualifying for the MTM benefit could be seen once by the MTM pharmacist; however, subsequent participation required these patients to obtain a referral from their primary care provider. Because the MTM benefit was designed as an opt-in program, participants voluntarily enrolled in the program, provided informed consent to receive care, and authorized program pharmacists to communicate with the patient's other health care providers. Three incentives were offered to beneficiaries to encourage them to enroll in the MTM program: (1) participants were not assessed any copayment for MTM visits, (2) UMD employees could attend MTM appointments during work hours without having to take unpaid personal time off or paid illness leave, and (3) participants were offered copayment reductions on their UPlan formulary prescription medications (brand name and generic). MTM benefit business plan Pilot on-site clinic. A pilot MTM clinic was developed at UMD to determine the value of the MTM service and resolve as many operational issues as possible before implementing the MTM benefit across the entire university system. The Duluth campus was selected because of its smaller size vis-à-vis the University of Minnesota, Twin Cities campus and because college of pharmacy clinical faculty were readily available on the Duluth campus. An early challenge was to determine where to locate the MTM clinic. Space on the UMD campus was limited. The Student Health Services clinic was considered but ruled out, as the privacy of faculty and staff could be jeopardized if these pa-

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tients were seen and recognized by their students. Ultimately, the MTM clinic was located in a central area of campus already housing other private, non–student-related offices. The MTM clinic was set up in an office suite shared with two other health benefit programs: UMD's QuickCare clinic and the UMD Wellness Center's health coach. The UMD MTM clinic occupies 310 square feet of secure space divided into a reception area and a private consultation room. The 15 × 15-foot consultation room includes a scale, table, and chairs and a small storage space that contains a sink (www.d.umn.edu/ mtm/mtmclinic.swf). The MTM clinic itself was not registered with the Minnesota Board of Pharmacy because the state has no classification for an MTM practice unaffiliated with a dispensing pharmacy. Operating partner. Lacking a National Provider Identifier (NPI) or National Council for Prescription Drug Programs provider ID, as well as lacking the capability to transmit invoices and receive payments electronically, the University of Minnesota College of Pharmacy was unable to bill health insurance programs for faculty-provided clinical services. Therefore, the University of Minnesota Academic Health Center and College of Pharmacy sought an operating partner possessing these characteristics and capabilities. Three entities were approached and declined participation because of revenue or liability concerns. A contractual agreement was finally achieved between the University of Minnesota Academic Health Center and Fairview Pharmacy Services LLC (Fairview) to provide specific administrative support services for the UMD MTM clinic: licensing with the board of pharmacy, credentialing providers, billing, and quality assessment. Fairview also procured the software license for electronic documentation of MTM services (Assurance; Medication Management Systems [www.medsmanagement.com/index.html]). Business infrastructure. The contract between Fairview and the college of pharmacy defined the UMD on-campus MTM clinic to be a Fairview MTM clinic subject to Fairview's existing policies, procedures, and standards of care. MTM providers were faculty or staff who met minimum certification requirements defined by the health insurance plans contracted with Fairview and would be credentialed as Fairview providers. Each MTM pharmacist provider would be fully funded by the college of pharmacy (i.e., salary not dependent on patient care revenue), and all revenue generated from the UMD MTM clinic would be deposited in the college practice revenue account. The Assurance electronic documentation software provided under a separate contract between Fairview and Medication Management Systems allowed for the recording of information required by UPlan, relevant quality assurance information, and the CPT codes for the care provided by the MTM pharmacists.3 Data were transferred electronically to Fairview, which then submitted each claim via Assurance (in CMS-1500 [Centers for Medicare & Medicaid Services] format) to either Medica or Health Partners (UPlan's two medical insurance carriers). UMD faculty MTM practitioners maintained electronic records documenting the patient care provided and the claims submitted. Claims were reconciled with Fairview monthly and Journal of the American Pharmacists Association

payment made by Fairview to the college, less Fairview's perclaim fixed costs (office personnel and use of Assurance). Provider credentialing and liability. UMD MTM providers are licensed to practice pharmacy in Minnesota. Each MTM provider obtained an individual NPI number and was credentialed as an MTM provider by Fairview and as an approved provider by UPlan administrators Health Partners and Medica. Credentialing criteria were the same as required by the Minnesota Department of Human Services to provide MTM services to Medicaid patients.10 Professional liability coverage for MTM pharmacists was provided under the University of Minnesota Academic Health Center's blanket professional liability policy. General liability coverage was provided by UMD. Pharmacist staffing requirements. From reviewing administrative records obtained from UMD's pharmacy benefits manager, it was determined that 1,000 UMD beneficiaries qualified for the MTM benefit. Approximately 25% of these beneficiaries were anticipated to avail themselves of the MTM service. Based on the experiences of college of pharmacy faculty already providing MTM services in the Twin Cities, serving this number of patients was estimated to require 250 hours for initial visits (250 visits at 1 hour each) and 500 additional hours for follow-up visits (four visits for each of the 250 patients, allowing for 30 minutes per visit). These 750 clinic hours per year for MTM appointments translated into approximately 16 hours of direct patient care time per week. During the project period, five different faculty members provided care at the UMD MTM clinic. Clinic hours were shared between two or three faculty members at any one time. Patients tended to see the same faculty practitioner each visit, although this was not required. The MTM clinic also served as one of the first MTM advanced pharmacy practice experience sites (or clinical rotation sites) for PharmD students. When faculty MTM providers were not seeing patients or engaged in other activities directly related to the MTM service, they were involved in their other university duties, including classroom teaching, research activities, and committee work. Administrative support. Administrative functions performed before patient visits to the UMD MTM clinic were minimal and were carried out by UMD College of Pharmacy administrative support staff in addition to their other departmental duties. Administrative staff were educated about MTM and what patients could expect during their MTM visit. Because these support staff also coordinate visits of “teaching patients” who participate in the college's Pharmaceutical Care Teaching Laboratory, they had already completed the Health Insurance Portability and Accountability Act of 1996 training required of all University of Minnesota personnel who work directly with patients. Staff were briefed regarding the computer-based template used for making MTM appointments for patients and on ancillary procedures such as campus parking and asking patients to bring their current medication records to MTM appointments. A dedicated phone number for the MTM clinic appointment line, a second dedicated phone line for prescriber

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calls to the clinic, and a dedicated pager for the MTM pharmacists were also procured. Delivery of care. UPlan beneficiaries scheduled appointments to meet with an MTM pharmacist at the UMD Health and Wellness Center. Pharmacists documented care in Assurance, and the system generated an invoice that was electronically transmitted to patients’ insurance carrier. Assurance cannot be linked to patients’ electronic health records at their physician's office; therefore, UMD MTM pharmacists had to enter all patient information (e.g., demographic data, medical conditions, allergies, past and current drug therapy) de novo as part of a patient's first visit. In addition, MTM care plans had to be faxed to each patient's physician because Assurance could not communicate with the physician electronically. Program approvals. The conception, program design, and implementation of the MTM benefit was undertaken by a number of committees from UMD administration, the University of Minnesota Academic Health Center, UPlan (UMD's health plan administrator), RxAmerica (now CVS Caremark, which administered UPlan's Pharmacy Benefit), Health Partners and Medica (UPlan administrators), and Fairview Pharmacy Services (operating partner). The University of Minnesota Institutional Review Board reviewed and approved procedures to obtain patient consent and authorized use of patients’ medical records in the project. The MTM pharmacist consented for each patient to receive MTM services, to share patients’ MTM records with their primary care provider (and specialists as appropriate), and to use their deidentified data to evaluate the project. Marketing the MTM benefit to patients. The market for the UMD MTM clinic included 1,000 UMD UPlan members meeting the eligibility criteria described previously. The MTM program was marketed to eligible individuals using direct mail, e-mail, information on the UMD employee wellness website (www.d.umn.edu/umdhr/wellness), notices in the UMD Employee Health and Wellness Newsletter, posters around campus, brochures at the annual UMD Benefits Fair, narrated slideshow presentations, and a telephone marketing campaign. Promotional materials highlighted participant eligibility criteria, enrollment procedures, participant testimonials, the no-out-of-pocket-cost nature of the program, and the potential economic and health benefits to participants. Physician marketing and communication. One concern when launching new, unknown pharmacy services is the medical community's reception to those services.11,12 Because the UMD MTM clinic is a stand-alone operation, the planning team did not want local physicians receiving MTM assessments and patient care plans before being introduced to the MTM benefit. Two of the authors (R.S. and M.B.) addressed MTM pharmacist–physician communication issues with five different primary care or internal medicine physician groups that provided most of the care to UMD UPlan beneficiaries. Although the briefings were well received, physicians expressed concerns regarding additional phone calls from the MTM pharmacist; the majority preferred that facsimile communication be used in most cases. 656 • JAPhA • 5 2 : 5 • S e p / O c t 2012

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Drug therapy problem analysis MTM pharmacists are tasked with identifying, resolving, and preventing drug therapy problems (Table 1). The number and nature of drug therapy problems identified and addressed during MTM sessions for UPlan beneficiaries were analyzed. Drug therapy problems were classified using the drug therapy problem taxonomy of Cipolle et al.2: indication (unnecessary drug therapy, needs additional drug therapy), effectiveness (ineffective drug, dosage too low), safety (adverse drug reaction, dosage too high), and adherence (nonadherence). Payment considerations based on patient complexity Payments for MTM services were based on the five levels of patient complexity on the pharmaceutical care resource-based relative value scale (RBRVS).2,10 An initial MTM encounter warranted a higher payment amount than a subsequent follow-up visit with an established patient. MTM services were reported and billed for using the health reporting taxonomy from CPT.1 Pharmacy-specific CPT codes for MTM services are time based; therefore, they are cross referenced with the pharmaceutical care RBRVS system to determine payment level, similar to the Minnesota Medicaid MTM Care Program (Table 2).1,10 Although exact payment rates for UMD's UPlan MTM benefit are proprietary, the published compensation rates paid by the Minnesota Department of Human Services for MTM services are illustrative.10 Ambulatory care group analysis Ambulatory care groups (ACGs)13 are used to predict health risk and anticipate future health resource requirements among ambulatory care patients by specifying and comparing case mixes between different subpopulations of patients enrolled within the same health plan. Medica calculated and analyzed the ACG scores for a subsample of the 54 UMD UPlan/Medica patients continuously enrolled in the Medica health plan for more than 1 year and who participated in two or more MTM sessions during 2008. This convenience sample included all of the patients during the study period for whom an entire 12 months of medical, pharmacy, and MTM claims data were available. ACG scores for this subsample of UMD beneficiaries were compared with ACG scores generated for the remaining 3,600 UMD UPlan/Medica beneficiaries to compare the estimated complexity of UMD MTM clinic patients with the general population of UMD UPlan beneficiaries.

Table 1.   Drug therapy problem taxonomy Drug-related needs Indication Effectiveness Safety Adherence

Categories of drug therapy problems Unnecessary drug therapy, needs additional drug therapy Ineffective drug, dosage too low Adverse drug reaction, dosage too high Nonadherence

Source: Reference 2. Journal of the American Pharmacists Association

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Table 2.   MTM pharmacist workload intensity based on RBRVSa Level 1 2 3 4 5

Assessment of drugrelated needs Problem-focused: at least 1 medication Expanded problem: at least 2 medications Detailed: at least 3–5 medications Expanded detailed: at least 6–8 medications Comprehensive: ³9 medications

Identification of drug therapy problems Problem-focused: 0 drug therapy problems Expanded problem: at least 1 drug therapy problem Detailed: at least 2 drug therapy problems Expanded detailed: at least 3 drug therapy problems Comprehensive: at least ³4 drug therapy problems

Complexity-of-care plan- Approximate face-toning and evaluation face time (minutes) Straightforward: 1 medical condition 15 Straightforward: 1 medical condition 16–30 Low complexity at least 2 medical conditions 31–45 Moderate complexity: at least 3 medical conditions 46–60 High complexity: at least ≥4 medical conditions ≥61

CPT billing codes 99605 or 99606 99605 or 99606 and 99607 (×1) 99605 or 99606 and 99607 (×2) 99605 or 99606 and 99607 (×3) 99605 or 99606 and 99607 (×4)

Abbreviations used: CPT, Current Procedural Terminology; MTM, medication therapy management; RBRVS, resource-based relative value scale. a RBRVS levels based on a patient’s number of medical conditions, number of medications being taken, and number of drug therapy problems identified. Level 1 represents the least complex and level 5 the most complex patient.

Beneficiary feedback analysis Using a structured group interview, eight volunteer beneficiaries evaluated UPlan's UMD MTM benefit and the benefit's marketing program. Four members of the interview group had participated in the MTM benefit by attending at least one MTM visit; remaining members had received the marketing materials for the MTM benefit but had not personally used the benefit at the time of the interview. Unsolicited beneficiary comments submitted to the UPlan Health Benefits Office about the MTM benefit were also evaluated.

Results During the first 17 months that MTM services were offered, 68 UMD UPlan beneficiaries, including 37 female (54%) and 31 male (46%) patients, received MTM services (183 MTM visits total). All patients self-referred in response to the marketing materials they had received; no patients were referred by their physicians. The average age of the patients presenting to clinic was 56 years (range 6–85). The average age for all UMD employees at the time of this study (53.6% women and 46.4% men) was 47.8 years of age (G. Lee, personal communication, November 16, 2009). MTM patients were taking an average of 10 medications (range 3–23) to treat an average of eight medical conditions (range 1–16). The 11 most frequent indications for drug therapy among the 68 UMD MTM patients were dyslipidemia, hypertension, depression, allergic rhinitis, osteoporosis, gastroesophageal reflux disease, migraine, immunizations, generalized pain, anxiety, and asthma. These represent 52% of all indications for drug therapy among the 68 patients. Drug therapy problem analysis A total of 491 drug therapy problems were identified among the 68 patients presenting to the UMD MTM clinic between November 1, 2007, and March 14, 2009 (7.22/patient). All 68 patients had at least one drug therapy problem, 61 (91%) had three drug therapy problems, 50 (74%) had as many as five drug therapy problems, and 15 (22%) had 10 or more drug therapy problems. The most frequently cited drug therapy problem was Journal of the American Pharmacists Association

“needs additional drug therapy,” followed by “nonadherence” and “dosage too low.” Patient complexity analysis Figure 1 presents the distribution of pharmacist workload intensity across the pharmaceutical care RBRVS among patients seen at the UMD MTM clinic. The distribution of RBRVS determinations includes the unique RBRVS determination for each of the 183 visits made by the 68 patients during the 17-month study period. Of pharmacy claims submitted, 74% were for care delivered to patients with complexity levels of 3 to 5 on RBRVS. ACG analysis. The average ACG score for the 54 UMD Medica beneficiaries receiving MTM services was 2.6 compared with 0.8 for the remaining 3,600 UMD Medica beneficiaries. During 2008, these 54 MTM patients generated an average of $3,985 in prescription drug costs compared with $792 per patient in the general UPlan population. Structured interview results The eight interview participants recommended that the invitation letter and phone script place a stronger emphasis on the reduced copays for covered medications and that using the MTM benefit involved no out-of-pocket expenses. Interviewees also noted the importance of a beneficiary receiving a recruitment telephone call within 1 week of receiving the invitation letter. Interviewees also liked that promotional materials highlighted the convenience for UMD employees to use the MTM clinic: appointments conducted on campus, no need to take sick leave to attend an appointment during work hours, and appointment availability before and after normal work hours. Participants suggested changes to the telephone script used to recruit patients for the MTM service (Appendix 2 in the electronic version of this article, available online at www.japha.org). Beneficiary comments submitted to UPlan benefits office Four patients submitted unsolicited comments about the UPlan MTM program to the UPlan Health Benefits Office, all of which www. japh a. or g

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Patient encounters (%)

30%

26%

25% 20%

20%

27%

21%

15% 10%

6%

5% 0% Level 1

Level 2

Level 3

Level 4

Level 5

Patient complexity (n = 68 patients) Figure 1.  MTM pharmacist workload based on patient complexity: RBRVSa Abbreviations used: MTM, medication therapy management; RBRVS, resource-based relative value scale.aRBRVS levels based on a patient's number of medical conditions, number of medications being taken, and number of drug therapy problems identified. Level 1 represents the least complex and level 5 the most complex patient.

were favorable. Participants lauded the reductions in medication copays, the MTM pharmacist's excellent advice, better understanding of how their medications worked, regular communication between the MTM pharmacist and patients’ physicians, and helping patients make important decisions about their medications and health care.

Discussion University-conducted evaluations of MTM outcomes have been instrumental in convincing payers, employers, legislators, regulators, and AMA's CPT Editorial Panel that MTM services should become a standard health benefit.3,7 The lessons learned from the current effort to establish an MTM benefit for the University of Minnesota system are outlined below. Operational barriers encountered Need for an operating partner. Bringing the “business side” of MTM clinic operations completely in house would have obviated the need for an operating partner. Such an approach, however, would have required considerable infrastructure investment by UPlan and/or by the college. Therefore, behindthe-scenes administrative functions were outsourced to an operating partner that had the necessary operating structure already in place. Patient enrollment and marketing. Approximately 7% of 1,000 eligible individuals enrolled in the MTM clinic—a rate that is similar to patient recruitment experiences of other MTM programs.14,15 The marketing mix16 used in the current project (i.e., direct mail, informational brochures, presentations across campus) failed to yield the desired level of demand for 658 • JAPhA • 5 2 : 5 • S e p / O c t 2012

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MTM services (i.e., 25% of eligible beneficiaries). The optimum combination of incentives, messages, and targeting to successfully encourage enrollment in an MTM program remains to be determined.17 The UMD MTM benefit was designed intentionally as an opt-in benefit; however, this approach has recently been shown to be less effective than an opt-out design.18 Studies are currently being undertaken to explore both patient motivators and inhibitors to using a free-standing MTM clinic. Many of the patient suggestions received for improving promotion of the UMD MTM benefit were implemented as follows, in anticipation of expanding the MTM benefit throughout the University of Minnesota system: ■ Modified the MTM clinic logo printed on promotional coffee cups and water bottles ■ Altered the personal selling approach to university departments ■ Obtained supporting testimonials from physicians representing different health systems used by UPlan patients Electronic documentation system. In a fee-for-service payment system, an MTM documentation system must be efficient enough to allow pharmacists to see between 10 and 15 patients per day2 while completing documentation and billing for those patients in a reasonable amount of time. The UMD MTM clinic is a stand-alone MTM practice; not having the MTM patient care documentation system integrated with patients’ primary care electronic health records presented a challenge because patients’ past and current information needed to be entered de novo at the time of initial visit.

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A care documentation system providing the software functionality necessary for a viable MTM practice should do the following: be interoperable with other components of a patient's electronic medical record, generate treatment plans for patients and reports for physicians, collect data for performance evaluation and reporting, and bill for services.19 To the authors’ knowledge, no electronic health record platform or electronic MTM documentation/billing system currently provides all of these characteristics. Patient complexity The likelihood of drug therapy problems arising increases as the number of medications used by patients increases.2,20 UMD MTM clinic patients, who used four or more medications, had a mean of 7.22 drug therapy problems per patient, which was slightly greater than the five drug therapy problems per patient reported in an previous large study that did not limit patient participation.2 The UMD MTM benefit therefore appears to have successfully attracted patients for whom the benefit was primarily intended. ACG analysis revealed that UMD MTM patients in the UPlan/Medica subsample were approximately three times more complex than the average UPlan beneficiary in terms of predicted future health expenditures. This magnitude of difference in complexity was somewhat surprising because the UMD MTM benefit design used relatively broad eligibility criteria. In addition, 74% of the 183 MTM visits revealed drug-related needs at RBRVS levels 3 through 5. Despite the small percentage of eligible individuals who took advantage of the MTM benefit, patients with the most complex medical and drug-related needs appeared to be using the new benefit. The ACG analysis suggests that providing MTM to this high-risk group would offer the greatest opportunity for future cost savings. Systemwide roll out The University of Minnesota system consists of five campuses (Crookston, Duluth, Minneapolis, Morris, and St. Paul) and various extension offices and other service centers located around the state, resulting in approximately 36,000 lives covered by UPlan. The UMD MTM clinic was to pilot MTM services for 12 months; however, UPlan and university officials decided to roll out the MTM benefit systemwide before evaluation of the pilot clinic could be completed. Based on employment numbers for the University of Minnesota System,21 eligibility criteria, and percentage of eligibles estimated to participate in the MTM benefit, a systemwide MTM benefit would add an additional 5,325 patients seeking MTM services. Lessons learned What might pharmacists outside of academia learn from this project about establishing an MTM benefit? A stand-alone MTM practice outside of an established pharmacy or clinic might require pharmacists to first partner with an organization having an NPI number and the ability to electronically transmit claims and receive payments. Community pharmacies will already have this infrastructure in place. Offering MTM services outJournal of the American Pharmacists Association

side of an established health system may require the capability to enter patient medical conditions, prior medical history, and clinical laboratory information into the care documentation system de novo at the time of the first visit. Although data entry might be carried out by administrative support personnel, based on the experiences of the authors with the Assurance system, as many as 2 hours may be necessary to document patient care for every hour spent conducting a patient's initial MTM interview. Pharmacists practicing within a health system will have much of their patients’ personal and health information already populated in the electronic health record. The challenge for these pharmacists will be to determine how to document MTM patient care within their health system's electronic health record. This may require consulting with medical staff to determine the format in which prescribers would like to receive reports arising from MTM visits. If the pharmacist cannot document their MTM activities within the existing electronic health record, an additional MTM module may need to be purchased for the existing system, or MTM documentation software that is interoperable with the health system's electronic health record software may need to be obtained. Similar to earlier studies,13,15,18,20 marketing the MTM benefit in the current project proved challenging. Pharmacists will need to learn to segment their MTM market (patients/prescribers/administrators) and develop specific marketing plans for each segment. Within a health system, new patient referrals may be facilitated as a direct result of team-based care, patient-centered health homes, accountable care organizations, and pay-for-value reimbursement initiatives, but this remains to be seen.

Conclusion The UMD MTM benefit is now more than 3 years old. Launch of the UMD MTM benefit was accomplished within 6 months after proposal despite the complexity of designing the benefit and establishing the MTM clinic. Only a small number of UPlan members have taken advantage of the benefit. Incentives such as reduced prescription copayments and convenient location were apparently not sufficient to overcome an opt-in benefit design. The MTM benefit was successful in attracting therapeutically complex patients and was subsequently expanded to the entire University of Minnesota system. Work remains to increase the number of eligible beneficiaries participating in the MTM benefit to a level sufficient to allow the University of Minnesota system to realize the reduction in overall health care expenditures possible through MTM. References 1.  

American Medical Association. CPT 2011: Current Procedural Terminology. Chicago: American Medical Association; 2010.

2.  

Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: the clinician's guide. New York: McGraw-Hill; 2004.

3.  

Isetts BJ, Buffington DE. CPT code-change proposal: National data on pharmacists’ medication therapy management services. J Am Pharm Assoc. 2007;47:491–5.

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4.  

Bluml BM. Definition of medication therapy management: development of professionwide consensus. J Am Pharm Assoc. 2005;45:566–72.

13.   Weiner JP, Starfield BH, Steinwachs DM, et al. Development and application of a population-oriented measure of ambulatory care case-mix. Med Care. 1991;29:452–72.

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Isetts BJ. Evaluating effectiveness of the Minnesota Medicaid Medication Therapy Management Care Program. Accessed at www.dhs.state.mn.us/main/groups/business_partners/documents/pub/dhs16_140283.pdf, October 2, 2009.

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