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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."

    Starting with education

    Community pharmacy owner DeAnn Mullins, BSPharm, RPh, CDE, has created a similar diabetes care in the Florida Panhandle. But while Divine started with MTM, Mullins started with an ADA-recognized education program. When Mullins began providing diabetes care, the only reimbursement route open to pharmacists was through self-management education programs offered by durable medical equipment suppliers.

    Eight years later, Mullins is the sole provider of insulin pump training for Bay County, Fla. She also built a thriving DSME practice, WeCare Diabetes Education, that is independent of WeCare Mullins Pharmacy (based in Lynn Haven, Fla., and of which Mullins is president).

    "I routinely collaborate with primary care providers and patients to improve drug therapy — and I'm getting paid for it," Mullins said. "We are the first pharmacy in the state of Florida to be paid by Medicare for diabetes self-management and training. Our model of care is not widespread, but I'm hopeful that this will change."

    Mullins gets DSME referrals from local primary care providers. She does an initial patient assessment that includes a complete medication review, then moves patients into a 10-hour group education program that meets for 2 and a half hours a week for four weeks. Patients have regular follow-up pharmacy visits to monitor diabetes control and screen for any developing comorbidities. The referring primary care provider receives a four-page report and care plan as needed.

    The plan includes a detailed assessment of the patient's progress and condition as well as current lab values and recommendations for eye, foot, and renal exams, depression screening, activity or dietary changes, and medication changes.

    "I take on the role of care manager to ensure that the patient has the understanding, skill, and willingness to make an informed decision about their diabetes care," Mullins said. "I can't ensure that the patient actually gets the foot exam. My goal is to become progressively unnecessary, to give them wings so that they can self-manage this disease successfully for a lifetime."

    ADA-recognized programs

    Creating a diabetes self-management education (DSME) program that is recognized by the American Diabetes Association offers a direct route to reimbursement by Medicare and many third-party payers for medication therapy management and other diabetes-care services.

    Achieving recognition is not a difficult process, said Paulina Duker, MPH, APRN-BC, staff director for the ADA's Education Recognition Program. Pharmacists can use an existing curriculum template or create a customized program.

    ADA bases pharmacist-led DSME program recognition on 10 national standards published in 2007. The standards, which should be familiar to pharmacists, range from documenting organizational structure, mission statement, and goals (Standard 1) to measuring and demonstrating improvement in patient outcomes (Standard 10).

    "MTM happens all the time in DSME," said DeAnne Mulllins, BSPharm, RPh, CDE, president of WeCare Mullins Pharmacy in Lynn Haven, FL. "We help patients see why they need to start or change a drug, we help physicians see when to adjust and better manage therapy."

    Standard 5 requires that at least one instructor in any recognized DSME program be either a registered nurse, dietician, or pharmacist. That gives pharmacists an immediate advantage, Duker said, because most patients with diabetes already make regular pharmacy visits for medications, supplies, and advice. The ADA is making an effort to move DSME out of the traditional hospital setting and into the community.

    "DSME is all about patient access," Duker explained. "We are moving toward making education available in places where patients go. Medicare found that the self-education benefit was severely underutilized because patients just didn't want to go to a hospital for education. Most people associate hospitals with illness and disease, not with education and health. They are much more willing to go to a pharmacy."

    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.