Medication Management Systems, Inc.

The CMS Medicare Part D 2013 requirements allow beneficiaries to opt out of a comprehensive medication review (CMR) due to cognitive impairment. If a beneficiary demonstrates the inability to make decisions regarding his or her medical needs and an alternative individual is not able to complete the CMR on the beneficiary’s behalf, a CMR is not required as long as the cognitive impairment is appropriately documented. However, targeted medication reviews (TMRs) are still expected to be completed for these beneficiaries. 

Starting January 1, 2013, all providers of MTM services to Medicare Part D patients will need to have a process in place for determining cognitive impairment and attempting to contact an authorized individual, such as a caregiver or legal guardian, to take part in the CMR if needed. The Assurance System™ now incorporates; (1) a validated screening tool used for detecting cognitive impairment, (2) a workflow to identify an alternative individual, (3) documents the alternative individual’s contact information and mails the ‘Patient Medication Summary’ to them, and (4) sends alerts to pharmacists if beneficiaries have cognitive impairment.

If you haven’t thought about preparing a process to fulfill this specific CMS requirement and are interested in utilizing our program within the Assurance System™, please contact your account manager (952-746-8185; Abbie Frank ext. 227, Jenny Gordon ext. 223 and Stephanie Smith ext. 231). We have worked hard to ensure that the cognitive impairment program follows CMS recommendations and has been efficiently incorporated into the general workflow making it minimal extra work for practitioners. We look forward to receiving your feedback on the resources.

As MMS  clients know, in 2013 CMS will require a new standardized format for written summaries of annual comprehensive medication review (CMR) for the MTM Program in Part D of Medicare. We have received many questions and comments about these requirements over the past two months. During this time we have been working diligently to understand the new requirements and we now have completed initial development of the new standardized CMR format in the Assurance System™ and it is now functional and in the final testing phase. The new CMR format will be in production in the Assurance System™ and available for you to use and review by the end of August.

MMS staff is proud to announce that it has created a document that; 1) exceeds the Standardized Format requirements, 2) automatically populates the format without additional documentation on your part, and 3) allows for customization by the client. MMS Staff has also completed the translation work on the Spanish version of the document. We can make this requirement “easy work” for you.

During the development process our IT personnel identified many issues with the instructions and requirements initially provided by CMS. We made our concerns known to CMS and we are happy to report that many of the questions and inconsistencies we identified have now been addressed with three new publications recently made available by CMS:  1) MTM Program Standardized Format English and Spanish Instructions Samples July 2 2012, 2) MTM Program Standardized Format FAQ v 070212 and 3) HPMS Overutilization Further Guidance 062912.  We will be posting these documents on the MMS Practitioner Website.

As always, your account managers are here to answer any questions you might have. In addition, we continue to provide feedback to CMS on a continual basis. Our goal is to meet and exceed the CMS Program Requirements so that our clients are always prepared.

Staff at MMS will provide a series of seminars over the next few months that help practitioners to stay up-to-date on a variety of topics. The first seminar is part of our quarterly Practitioner Meetings held every three months to provide clients an opportunity to discuss contemporary topics, timely issues, as well as to participate in a patient case presentation by a practicing pharmacist. This meeting will be held on Wednesday, May 30 at 2pm CST. The agenda for the meeting includes the following topics:

• Updates to the Assurance System™
• Announcements – next practitioner meeting topic, Part D webinar series introduction
• Case Presentation – Steven Bladow, PharmD, PharmAssist Services
• Featured Presentation – Djenane Oliveira - Fairview Pharmacy Services, “Practice-based Research”
• Questions/Discussion
• Announcements/Upcoming events at MMS

In addition to Practitioners Meetings held quarterly, MMS is excited to announce the new Medicare Part D Webinar series! We are committed to helping you develop your successful Part D practice, and in order to do so we will host virtual webinars every three to four weeks. The goal of these webinars is to provide a forum for you to learn and discuss the many different aspects of the Part D process. Mark your calendars for June 13, July 11, and August 1 from 3:00-4:00pm CST. The agendas for each webinar are noted below.

WEBINAR 1: June 13^th, 2012 3-4pm CST  

• Defining Service Types
• Defining Evaluation Contact Types
• Workflow Issues
  • how to assess and improve (best practices)
  • focusing the interview/how to ask the right questions
  • what other people are doing now (open discussion with participants)
  • patient complexity reports

WEBINAR 2: July 11, 2012 3-4pm CST      

• 2012 Data Validation Preparation
• New MMS policy to have CMS reports for current year available in July
• Running your own CMS reports
• Knowing your data – how to test/QA
• Workflow diagrams
• Telephone scripts/patient letters
• Feedback from auditors – questions, insight

WEBINAR 3: August 1, 2012 3-4pm CST   

• 2013 preparation
• LTC approaches – how does this change what you are doing now?
• Personal Medication Action Plan
• Adherence – updates on reports
• Outreach – using at least two types of contact (one cannot be passive), contacting patient within 60 days of identification, change in LTC population

Please join us for this exciting and informative webinar series! The topics and information presented will assist you in your practice by making the process easier and more consistent. We look forward to your participation and feedback.

Interested in attending?

Please contact lkoester@medsmanagement.com if you are interested in registering for any of the above webinars.

Look no further for answers about how to build, deliver and market quality medication management services. Twenty-five years of experience and expertise are contained in the new edition titled, Pharmaceutical care practice:  The patient-centered approach to medication management, by Cipolle, Strand and Morley, 3^rd edition, McGraw-Hill, 2012. 

This edition speaks specifically to the successful delivery of medication management services.  Market pressures and opportunities, the latest research, the most current policy positions, data analyzed from successful practices, all described in the context of how to establish successful practices and provide quality services.

Are you wondering what is happening with medication management services in the rest of world? Fourteen different authors describe the progress that is occurring in Spain, India, China, Australia, The Netherlands, South Korea and many more countries.

Use this text to educate your colleagues, structure and  justify your services, understand the “bigger context” of the health delivery system, meet contacts from other countries – whatever your objective, if it relates to medication management services, you will find useful information here. 

Click here to order it directly from Amazon at an introductory price (limited time offer). 

MMS just sponsored a very unique invitational meeting for our clients, students,national and international speakers, and staff. This meeting was held in northern Minnesota at an educational retreat (Deep Portage Learning Center), where attendees were able focus on medication management services without interruption for two days. This year the theme was Bringing Pharmaceutical Care to Market: Expanding the Service.

Continue reading for a summary of the meeting (or download a .pdf of Dr. Strand's reflection) – but also be sure to talk with someone who attended to appreciate the significance of this experience. We hope to see you there next year!

Dr. Linda Strand Offers Reflections on the Deep Portage Retreat

It seems the impossible occurred February 23-25, 2012 in the woods of Northern Minnesota.

Seventy-six seemingly intelligent human beings convened for “the most unusual meeting of a lifetime”. Fifteen of these people started their day before sunrise, jumped on an airplane to arrive in Minneapolis, took a taxi to MMS headquarters only to jump on a bus and ride for 4 more hours to arrive at a Retreat nestled in 6000 square miles of woodland and snowy trails, at approximately 9pm central time. The remaining fifty one also had a deadline to meet…just don’t miss the bus! And nobody did.

These seventy six people participated in the Annual Deep Portage Retreat in Hackensack, Minnesota. In its eleventh year, this is the first year it has been sponsored by Medication Management Systems, Inc. Previously, the Peters Institute of Pharmaceutical Care at the College of Pharmacy, University of Minnesota sponsored the event. Traditionally focused on student participation, this year things changed a bit. The student involvement was again significant (33 of the 76 participants were pharmacy students, residents or graduate students), and in addition, 33 were current clients of MMS with the remainder consisting of MMS staff and international speakers. Therefore, at this retreat, we had representation from: pharmacy students, health plans, integrated health systems, private practice, clinic based practice, national pharmacy associations, physicians, pharmacy technicians, medication management pharmacist generalists and specialists, along with the wildlife population viewing it all from outside.

Sixty eight people shared their experiences through poetry, theatre, small group discussions, large group discussions, informal “chats” with presenters, and a “game show” format. Learning occurred in every way, at every moment, since every waking minute involved either programmed learning or what some came to describe as “un-programmed” learning. Conversations never stopped – and in some cases we mean literally – they never stopped!! There were conversations over meals, in front of the fireplaces, on the ski trails, conversations on the bus, conversations around the bonfire while making s’mores, conversations in the shared rustic rooms late into the night, in the hallways, and to and from presentations. People shared, absorbed, questioned, changed, taught and learned.

Bringing Pharmaceutical Care to Market: Expanding the Service was the 2012 theme. Thus, all those conversations were focused on caring for more patients, in a more effective manner, with increased financial benefit. Dr. Terry McInnis, a physician and private consultant from North Carolina, kicked off the meeting by challenging the participants to rise to meet medicine’s expectations for a uniform, standards-driven practice with common vocabulary, a consistent patient care process and systematic documentation. Janice Feinberg, a pharmacist and attorney, spoke to what it takes to deliver this service as a private consultant who wants to exclusively care for patients. Dr. Djenane Oliveira, a Researcher and Medication Management Specialist at Fairview Pharmacy Services, worked with her colleagues from the Fairview Integrated Health System to demonstrate how physicians and other practitioners respond when medication management services are added to the medical home care team. Dr. Oliveira underscored the importance of medication management pharmacists working collaboratively not only with physicians but also with nurses, diabetes educators, care coordinators and other providers. Also, she called our attention to the fact that the health care system in the USA is moving in the direction of Accountable Care Organizations and is focusing on the health of populations. In this new environment, medication management pharmacists need to be utilized appropriately so that they will add the most value to the care of patients. Dr. Oliveira was followed by Dr. Ed Webb, the Associate Executive Director of Government and Professional Affairs at the American College of Clinical Pharmacy, who spoke to the changes and opportunities (lost and taken) with health care reform and medication management services specifically. And, finally, Dr. Victoria Losinski, Professional Services Manager for Medication Therapy Management at the Target Corporation, related a perspective on how to make these services work in a retail setting.

Besides these main keynote presentations, short presentations were delivered around the most creative and interesting topics. For instance, Grace Gana gave a passionate testimony of the impact of her work on the lives of patients. She unveiled a new meaning for the term “underserved patient” as she posited that any patient who is taking medication and does not receive medication management services should be seen as ‘underserved”. What a brilliant proposition!

Gladys Duenas showed the results of focus groups conducted with patients that pointed to unique strategies to market medication management services. Nicole Paterson and her colleagues did a theatrical presentation of how they are delivering medication management services through shared medical visits or group visits offered to patients with different medication conditions such as asthma, diabetes and smoking cessation. Carla Cobb talked about her practice delivering medication management services to people with mental Illnesses, providing a powerful illustration of the kind of impact these services can have in different types of populations. These are just a few examples of the great program we experienced while in Deep Portage. What a stimulating, challenging and rewarding program!

In-between these enlightening presentations, there was cross country skiing, hiking, wall-climbing, animal tracking, and private walks in the woods. Conversation continued through it all. Students talked with practitioners, practitioners talked with managers, members talked with organization executives, pharmacists talked with physicians, and everyone shared what they knew of medication management services. The meeting was a phenomenal success, as evidenced by the level of participation offered by all in attendance and by the evaluations completed at the close of the meeting.

Pharmaceutical care practice and medication management services have come a great distance in the past 10 years, since the first Deep Portage Retreat. This became very clear at this meeting and was greatly celebrated throughout the weekend. We started with ideas and wishes to care for patients so we can have a real impact on their lives. This year we discussed the real world challenges of practitioners who are doing just that - building practices, recruiting patients and getting reimbursed. Practitioners from across the country and throughout the world shared experiences and the progress they have made. We have accomplished a lot during the last decade and we should be proud!

We know even more phenomenal changes will soon start to occur as a result of all of the teaching and learning that occurred at this meeting. We will report on these developments as the year progresses. Thank you to all who participated for making our conference a total hit!

If we want to be universally recognized and paid by the system that pays for patient care, then it is a good idea to understand the rules of that system. If the rules are understood, then everyone can decide if they want to play by those rules or not – it should be emphasized here that these rules are non-negotiable.

The rules of compensation for patient care services in health care have been defined and are clear for all patient care providers who wear white coats and who care for patients.  Patient care providers are paid for one primary function, to find, fix and prevent a unique set of patient care problems.  For the physician, he or she diagnoses and resolves medical problems, the nurse works with nursing care problems and for the pharmacist providing medication management services it is drug therapy problems.  Documentation is required so both the patient and the payer have evidence of the problems addressed in order to justify the claim made for payment, and the payment structure is based on the number of problems identified and resolved.

Identifying and resolving drug therapy problems are the unique contribution to the care of a patient and are the cornerstone of reimbursement for medication management services – it is the “currency” for the pharmacist providing these services.   We are able to identify them, count them, document them, fix them and monetize them.   This is straight forward; the more problems we identify and resolve the more compensation we can earn.  

I have yet to meet a payer who has been interested in how long it takes to conduct a “CMR”.  And why should they be?  It takes inefficient practitioners longer than it does expert ones.  Many payers I have spoken with are interested in knowing which problems are identified; for which medical conditions; for which medications and what is being done to fix the problems after they are identified? CMS is moving in this direction, as have other payers. 

Fortunately, the heavy lifting has been done and there are rules (standards) that are used to define the service and practice I am describing here.  There is also a state Medicaid payer who has put these rules in place and can serve as a model of how to do this for other payers.   The standards are simple and already exist so the pharmacist providing medication management services can be recognized and paid for the unique contribution made to the care of a patient.   With these rules, patients, prescribers and payers know exactly what it is that we will do, how we will do it and what they can expect to receive from the service.   The rules and structure provide a framework for the provision of the service, so the same service can be duplicated by others and then recognized by patients, prescribers and payers, whether the service is delivered in Minneapolis, Indianapolis or Kannapolis (that is in North Carolina).  

Some have argued that the terminology and processes of this practice are too esoteric or too academic.  There is no need to expose patients, prescribers or a payer to the terminology that we may argue about, this is not the point.  For me the path to success starts with exposing patients, prescribers and payers, to a service that is delivered by professionals using recognized standards.  Pharmaceutical care defines the professional practice, the rules and standards, that we can own, and that allow us to demonstrate our contribution to the patients served when medication management services are provided.  

The Center for Medicare and Medicaid Services (CMS) proposed regulation change which would mandate the separation of consultant pharmacy services from the companies that provide pharmaceutical products to long-term care residents is a game changer for pharmacists.  If the rule, as proposed today, is adopted by CMS, the services provided by pharmacists could no longer be bundled and bartered with the distribution and dispensing of medications.  The services offered and provided by long-term care (LTC) pharmacists would stand alone, independent of the distribution of drug products.  

This proposed rule change has far reaching implications for all pharmacists, not just those practicing in the long-term care arena.   The conflict of interest that was exposed in the long-term care space clearly is the impetus for the proposed rules change but, as was pointed out by many in the overflow crowd attending the Town Hall Forum held on this topic during the ASCP Annual Meeting in Phoenix earlier this month, why stop at LTC?  If this conflict exists in LTC, doesn’t it exist in community pharmacy, specialty pharmacy and other settings?  It clearly does but that is material for a future discussion.

The point to be made now with this proposed ruling is that if CMS is going to make this change, then pharmacists need to be recognized as care providers and compensated at a rate that will support the delivery of comprehensive medication management services  to patients.   This should be done for all pharmacists providing the service, regardless of where the service is delivered, and should not be limited to those practicing in LTC or any other setting.  Imagine how the practice of pharmacy could change when the practice of pharmaceutical care is recognized as a reimbursable service and compensated on the merits of the value it adds to the care of patients, without conflict or without having drug product sales financially supporting the service providers.   These changes are necessary to care for all those patients who could benefit from medication management services.  #      

“For pharmacists, I believe that you have come to one of the rare crossroads that will define the future of your profession. You will either take your place as providers of care, or your numbers will dwindle as most dispensing activities are replaced by robotics and pharmacy technicians. I am a physician, and I say our profession and the patients that we serve need you “on the team” as clinical pharmacist practitioners. But, will you truly join us?”

This quote comes from an article written by Dr. Terry McInnis. The article provides a very interesting assessment of the state of pharmacy and offers a challenge for our profession.  

Read the complete article >

It is exciting that more and more employers and payers are stepping up and paying for, or offering  MTM services as part of their employee or member benefit package. The list includes many recognizable names, including Fortune 500 companies like General Mills, the Federal Employee Program, Fairview-University Health System, government sponsored programs like Medicare and 15 state Medicaid programs are just some examples of payers who cover comprehensive medication management services.

I find it ironic, however, that many organizations which employ or support pharmacists providing MTM services have not yet stepped up to the plate to pay for this service for their own employees.   Imagine how the landscape of payers would change if Walgreens, Wal-Mart, CVS/Caremark, Rite-Aid, or United Health Group covered medication therapy management services for their own employees. These organizations employ thousands of people and tens-of-thousands of pharmacists. It only makes sense that if these organizations promote the delivery of MTM services to others, then they should offer MTM services as a benefit to their own employees.  

All patients deserve the right to appropriate, effective, safe and convenient drug therapy. And, unless this is assured, then the dollars spent on all the other medical services and benefits are potentially being wasted. This should be obvious to those organizations offering medication management services – so it is time for them to step up, don’t you agree?  

The news and information wires were buzzing again today with the news from Consumer Reports’ Health Rating Center that more people are cutting corners with health care resources in an effort to reduce costs.   As the bloggers and healthcare journalists (Bloomberg News (9/28, Wechsler) Los Angeles Times (9/28, Stein), New York Times (9/28, Carrns),   WebMD (9/28, Mann) )dissect and comment on the survey results, it strikes me that this is yet another situation where comprehensive medication management services could have a significant impact on patient care.  A pharmacist trained with the knowledge of how to properly assess the needs of the patient and interact with others providing care for the patient can solve this “problem”.    The comments made by the blog authors lead one to believe that this behavior is primarily driven by economics.  Economics contribute to this behavior but this problem is not caused solely by economics nor will an improvement in one’s economic status eliminate this problem.

The behavior of splitting tablets, skipping doses, taking expired medications, not filling prescriptions, “borrowing” medications from friends is not new behavior and it has been reported many times before. This behavior is also not going to end anytime soon.  As the Consumer Report survey clearly points out, the rate at which the behavior of cutting corners with health resources is playing out every day is not going down.  In fact, when compared to last year, this behavior is up 23%. 

Is there a potential for this type of behavior to have a negative impact on a patient’s health status or wallet?  Certainly, but I contend that the behavior displayed by patients is rational, expected, and in some cases has been encouraged by providers and payers. Consider pill splitting for example.  It is not an uncommon practice for health plans to provide a pill splitting devise to patients as a means to trim high medication costs, unfortunately this practice cannot be safely applied to all medications.  Who knew the extended-release narcotic would deliver a toxic level in the blood when split? We should not be surprised when patients apply these learned cost saving strategies, and how would patients know when they can and cannot be used safely.

If we believe the problems identified in the Consumer Reports’ survey need to be solved, and I believe they do, then I suggest that one step to solving this set of  problems  is to cover and pay for the service that can best address this issue; namely comprehensive medication management services.    This service, when delivered properly, can help patients and their care providers understand which medications may be skipped, split, not filled or even borrowed from a friend.  This patient behavior may very well be appropriate, effective and safe for the patient.   Maybe the behavior that needs to change is not that of the patient, but that of the health care providers and payers.  #