Many happy returns: Ohio-based Medicaid plan pays pharmacists for MTM, saves money

Ohio Medicaid Reimbursement Model

Only about one-half of Americans take their medications as prescribed. This contributes to the overall burden and toll of chronic disease on the population and to a vast portion of unnecessary health care and costs.

While community pharmacists have the expertise and access to patients to have a major impact on medication adherence, reimbursement models keep pharmacists filling prescriptions rather than making interventions with patients. These issues motivated Ohio-based CareSource, one of the country’s largest Medicaid managed care plans, to offer a medication therapy management (MTM) benefit to all of its beneficiaries.

“Pharmacists are probably the health care professional that our members see the most, so they should be a part of the health care team that serves our members,” said Jim Gartner, BSPharm, MBA, CareSource Vice President of Pharmacy and Medical Management. “I wanted to develop a program that reimburses pharmacists for medication counseling and management.”

In July 2012, CareSource began to offer face-to-face MTM services to each of its 900,000 members. A year later, the program had demonstrated a $1.35:$1.00 return on investment (ROI) in drug cost savings alone. Total savings, including avoided hospitalizations, emergency department visits, and other unnecessary health care consumption, yielded an ROI of $4.40:$1. The program—a partnership launched by CareSource with OutcomesMTM and the Ohio Pharmacists Association (OPA)—is a testament to the value of pharmacists’ patient care services.

OutcomesMTM and OPA attribute the program’s success largely to these simple ingredients: a network approach, hands-on training, and professional autonomy. CareSource acknowledges the program’s success from the top of the organization. “We’re seeing pharmacists providing meaningful interventions for our members,” said Craig Thiele, MD, CareSource Chief Medical Officer. “The pharmacists are truly partnering with us to serve our members’ needs.” 

CareSource’s Gartner moves passion forward

For most of his career, Gartner has dreamed of designing and implementing a program that would reimburse pharmacists for covered services provided to patients. “We have had a longstanding relationship with Jim Gartner, and he has always been passionate about engaging local pharmacists in an MTM program. When he took the position with CareSource, he finally found the opportuopportunity to move his passion forward,” said Jessica Frank, PharmD, OutcomesMTM Vice President for Quality. That opportunity didn’t come without challenges. Gartner still had to sell his colleagues on the idea. “When I explained that pharmacists would be reimbursed to provide medication counseling, my senior management said, ‘Isn’t that what pharmacists are supposed to be doing already?’” Gartner said. 

The reimbursement conundrum that incentivizes pharmacists to dispense with discourse—and dispense drugs instead—was all too familiar to Gartner, but unknown to his colleagues. Explaining how community pharmacists are traditionally paid, Gartner then added that if CareSource were to reimburse pharmacists for keeping their members safe and well, pharmacists would be happy to see a Medicaid patient walk through the door. “Pharmacists would appreciate CareSource because they’d get reimbursed for consulting with our members, and it’s a great thing to have the pharmacist on our side,” Gartner said. 

Contracting with Outcomes

MTM CareSource contracted with OutcomesMTM to oversee administration of MTM services to its members. OutcomesMTM is a national company that contracts with local pharmacists and payers to provide face-to-face MTM to patients. Nationally, pharmacists who contract with OutcomesMTM are typically community pharmacists who provide MTM services at their pharmacies or, in some cases, independent workers, unaffiliated with pharmacies, who start their own businesses providing MTM to OutcomesMTM patients. After completing training in the company’s MTM method, pharmacists use the OutcomesMTM Connect platform to identify eligible patients.

Through the platform, OutcomesMTM provides the pharmacists with pertinent information about the patients—in addition to what pharmacists may already know, as the patients often already frequent their community pharmacies. After pharmacists provide MTM services to an eligible patient, they use the Connect platform to bill payers for the service. Through this model, 1,800 pharmacists in Ohio delivered more than 100,000 MTM services to CareSource members in 18 months. “Pharmacies are a great way to reach this typically very hard-to-reach population because no matter what, patients are usually in their pharmacies filling their prescriptions every month,” said Frank. “I think that the number of services delivered in the first year demonstrates that using a network-based approach to MTM and leveraging the local relationships among patients, pharmacists, and physicians results in significant scalability.”

Enlisting the Ohio Pharmacists Association

CareSource enlisted OPA to help engage the pharmacist workforce. The association and CareSource collaborated on how to bring pharmacists on board and how to make the most of their expertise. “One of the things that I have seen over the years is that, when we are teaching a behavior change, pharmacists want to learn in a face-to-face environment where they can ask questions,” said Ernest Boyd, PharmD, CAE, OPA Executive Director. Boyd, who has a background in developing continuing pharmacy education, advised Gartner at CareSource not to offer online training, but to offer instruction in a classroom with desks and handouts. OPA also stressed that all pharmacists be welcome.

“We created no barriers. We didn’t say they had to be a PharmD. If you are a pharmacist, then you are a health professional, and you can play,” Boyd said. “All pharmacists can participate—no additional credentials or passing of exams.” Gartner arranged for OutcomesMTM to offer onsite training in classrooms at Ohio’s colleges of pharmacy. The company gave eight training sessions at the seven pharmacy campuses in the state and one at the CareSource office in Cleveland.

Participants ranged from newly minted pharmacy school grads to late-career independent and community pharmacists, and everything in between. “I sincerely believe that is what got Ohio’s MTM Medicaid program to take off. In 1 year, we went from about 600 hundred pharmacists participating to now 1,800,” Boyd said. The face-to-face, hands-on instruction, Boyd noted, gave veteran community pharmacists the confidence they needed to put the new approach into practice.

Pharmacists who had earned the 5-year BSPharm degree as opposed to a PharmD degree, Boyd said, often harbored the misconception that they were not qualified to deliver MTM. “I think that a lot of our training said, ‘Wait a minute, can you train a person to use an inhaler properly? Well, 50% of people are taking their medication incorrectly, and most of those mess-ups are simple things like: Put that in your mouth. Don’t spray it out in the air,’” Boyd said. “The pharmacists decided, ‘This patient really doesn’t know what they’re doing,’ or, ‘They need extra help,’ and they then billed for whatever extra MTM they provided,” Boyd said. “And CareSource was glad we approached it that way—trusting pharmacists as professionals to make that decision—because it saved a lot more money.” In the first year, the program generated more than 50% of claims for MTM services as a result of pharmacists directly identifying a need.

Spreading the model, spreading the word

Ohio is not the only state in which a Medicaid provider offers an MTM benefit. A handful of other states—including Colorado, Iowa, Minnesota, Mississippi, Missouri, New Mexico, Oregon, Texas, and Wisconsin—offer to Medicaid beneficiaries some type of MTM or disease management program in which pharmacists can participate. “MTM programs within state Medicaid [programs] still are not the norm, but interest in pharmacists’ services is growing.

As programs like the one in Ohio turn out positive results, other states will have evidence to support policy changes that provide Medicaid beneficiaries with access to pharmacists’ patient care services like MTM and disease state management,” said Krystalyn K. Weaver, PharmD, Director of Policy and State Relations at the National Alliance of State Pharmacy Associations. But positive results alone won’t sufficiently increase interest in pharmacists’ services, said Boyd of OPA. “Thirty-six percent of the public refuses MTM services, according to CMS. They don’t know what MTM is. They think, ‘Why is this pharmacist bugging me?’” Boyd said.

Boyd points to the critical need for pharmacists to talk to the public, not just each other, about the importance and value of pharmacist-provided care. He notes that even legislators and physicians are unclear on pharmacists’ training, expertise, and authority. “I had a legislator ask me about 5 years ago if you had to go to college to be a pharmacist,” Boyd recalled. Boyd encourages pharmacists to seize opportunities to speak to groups, rather than just their patients on a one-to-one basis, about the value of their services. “If MTM is ever going to make it, we have got to be out there educating payers, physicians, legislators, and the public that it even exists.”