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    MTM means more pharmacists deliver diabetes care


    The increasing number of medication therapy management (MTM) programs is creating new avenues for pharmacy reimbursement. Additionally, reimbursement by Medicare has prompted many states and private payers to re-examine their programs. In 2007, the American Diabetes Association added pharmacists to a short list of recognized providers for diabetes self-management education (DSME).

    Holly Divine, PharmD, CDE, Associate Professor of Pharmacy Practice, University of Kentucky College of Pharmacy
    "Pharmacists have become nationally recognized as providers in diabetes care," said Holly Divine, PharmD, CDE, associate professor of pharmacy practice at the University of Kentucky College of Pharmacy. "There are a lot of people who can do disease-state management, but pharmacists are in a special position to handle the medication piece of the diabetes puzzle."

    That piece is about to become even more important. Earlier this year, the Centers for Medicare and Medicaid Services (CMS) raised the bar for MTM, said Anne Burns, vice president of professional affairs for the American Pharmacists Association. Starting in 2010, CMS will require all covered patients to receive comprehensive MTM. CMS also plans to pay pharmacists for three MTM follow-up visits for every covered patient every year.

    "CMS is calling for the core of a serious MTM service," Burns said. "We are starting to move toward a standardized model, a consultative model where patients, payers and providers know what to expect from a pharmacist visit, just as they know what to expect from a medical or a dental visit."

    A standardized model is already emerging in diabetes. It starts with a pharmacist's assessment of the patient's current condition and treatment needs. The core is pharmacist-led education in diabetes self-management. The key component is long-term pharmacist follow-up, with specific care and management recommendations for the patient and primary care provider.

    Payer and patient incentives

    Divine is one of three pharmacists who run DiabetesCARE, a diabetes clinic sponsored by the University of Kentucky Health Plan. The fee-for-service MTM program is entirely supported by fees from UKHP and other third-party payers.

    "We are creating a new type of pharmacy practice," Divine said. "DiabetesCARE is about creating a workable business model. Payers support us because we have shown that we fill a niche with MTM. Patients with diabetes seldom have just diabetes. That's where our specific training comes in, dealing with those comorbidities."

    UK is self-insured, Divine said. That gives the university health plan an incentive to manage care for the best long-term outcome, not the lowest short-term drug expenditure. Pharmacists evaluate every medication patients take or should be taking.

    Patients have an incentive, too: a reduced copay on glucose test strips. Using the free diabetes clinic saves patients $15 to $30 per month on test strips.

    Newly diagnosed patients receive an hour-long pharmacist assessment that focuses on MTM. Results of the assessment and any immediate recommendations are forwarded to the primary care physician. Each patient then moves into a six-hour DSME program recognized by the American Diabetes Association. ADA recognition qualifies DiabetesCARE for reimbursement from a variety of third-party payers, Divine said.

    Most patients complete the three two-hour group sessions within a month. Then they begin maintenance visits with a pharmacist.

    Visits are scheduled every one to three months, depending on each patient's level of diabetes control and understanding of the condition, need for educational reinforcement, and continuing MTM issues.

    The pharmacist performs a physical assessment that includes blood pressure, foot exam, and weight. The pharmacist also reviews DSME goals, performs and evaluates any needed point-of-care tests such as HbA1C or blood lipid panels, downloads and evaluates the patient's self-monitoring blood glucose levels, and provides any needed MTM services. Results of each visit and any recommendations are sent to the patient's primary care provider.

    "We have a long history of pharmacists being part of the care team at UK," Divine said. "It has probably been a little smoother for us to establish DiabetesCARE because of that."


    Fred Gebhart, Contributing Editor
    Contributing Editor Fred Gebhart works all over the world as a freelance writer and editor, but his home base is in San Francisco.