Life Sciences

Greater payer MTM investment, reimbursement presents opportunities to make claims about drug profile

Medicare & Reimbursement Advisor Weekly, July 15, 2009

by Bryan Cote

As you may know, Medicare Part D MTM programs are changing again for 2010 to include more patients, with lower drug spend but more conditions. Here’s how the changes will play out in California with Kaiser Permanente (KP) and how its program has worked so far. KP’s MTM program used to target its entire eligible population, taking all comers in a more global approach. But many didn’t have significant interventions after their complete med reviews with the KP-employed ambulatory care pharmacist. Now, KP is trying to target special populations or use key patient lists by using its integrated EMR, KP HealthConnect, to identify where the most critical need is.

Patients will be eligible for the plan’s MTM services if they have any three of the core conditions in Figure 1 (see p. 3) and take a minimum of five medications from KP’s list of drug classes. Patients must have an annual minimum drug spend of $3,000, a drop from the current $4,000 cutoff. If patients meet these criteria, they must opt out if they do not wish to be contacted (as opposed to some plan MTM programs that use an opt-in model).

One targeted population is looking at patients discharged from the hospital in the past week. KP does this every week. It looks to its EMR from all of its California medical centers and gets a list, by center, of all discharges. The list can be broken out by type of discharge or admission, such as those for chest pain. The list is then compared to the eligible MTM population KP has for the program year, and any matches are referred to the KP-employed ambulatory care pharmacists for workup (med reconciliation, review of discharge orders, discussion of meds). To date, there have been fewer readmissions for the MTM group compared to those not receiving MTM services.

“Often, patients get new meds at discharge, so we can identify patients going home and reach out to them at an important time and prevent readmissions or address bigger-picture issues with their treatment,” says Erwin Jeong, RPh, a pharmacist at KP in Southern California.

Some KP ambulatory care pharmacists have signed collaborative practice agreements with doctors to allow them to adjust doses, switch medications, or initiate therapy.

Other examples of targeted populations include using KP’s lab data access to pull a list of anyone with LDL-Cs greater than 100 or using pharmacy data to pull lists of patients on drugs to be avoided in the elderly. Jeong says the program can help get patient LDLs, for example, under control. Eligible MTM patients in skilled nursing settings and hospice are enrolled into the program using the opt-out method.