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Tuesday, November 27, 2012

The MTM Debate

I'm usually not one to use my blog to blast anyone or anything, but this has really ruffled my feathers. My company uses a company called Outcomes to file MTM claims. Some of you may be familiar with this company. I recently got "locked out" of my store's account because, and I quote, I was "filing too many of the wrong kind of claims". What, you may ask, are the "wrong" kind of claims? Well according to Outcomes my claims have been "educational in nature and do not significantly effect the patients' outcomes". Again, that is a direct quote from the Outcomes rep that I spoke with. Now, I don't know about anyone else, but I can quote several well-known, multi-national studies that have proven beyond a doubt that the pharmacist's role in educating the patient DOES significantly affect the patient's outcome. So, upon informing the rep  of these studies I received the following reply. "Well, your claims have to justify our existence to the insurance companies for us to continue to offer this service". Wow!  How many of you didn't know that this was the reason for MTM services? Foolish me, I thought the reason for the service was to better the patient's disease outcome through pharmacist intervention. After 30 minutes of debate with this rep, the conclusion was that the only claims they want to see are ones that save them money. They have absolutely NO interest in bettering the patients' outcomes. The only claims they really want to see are things like drugs being discontinued or changed to something less expensive. They hide this fact behind a facade of caring for the patient's financial expenditure, but when I pointed out that most of my patients who qualify for this MTM service are receiving their Medicare Part D plan through state funding and their copays are the same regardless of what they get then the issue of financial expenditure only applies to the insurance company themselves. Now, my main concern for my patients is that they get the best care possible. I am also a strong advocate for giving them the best care at the lowest cost. However, there are situations where lower cost medications have been tried, have failed, and the patient is placed on a higher cost medication that works for them. Outcomes does not want to hear this. They are run by business professionals and not healthcare professionals so they do not understand this concept. All they see is dollar signs. They don't believe that educating patients on proper dosing, proper technique, possible side-effects, monitoring parameters, etc. is of any use. Why they allow for these kinds of claims to begin with is just part of the facade that is erected. File too many of these and you are banned from filing any more. I was informed that I could still file the "right" kind of claim and that if I file enough of those claims then I will be allowed back into the fold. You know what, I don't need Outcomes. I have been caring for my patients for 23 years without them. It would be great to get paid for the interventions that I have been performing for all these years but I will not be part of this farce. Their threat is that if pharmacists don't perform for them then they will start using nurses to do MTMs. Who cares! I will go on doing my job. I will not allow Outcomes, or anyone else, dictate how I care for my patients. What do they expect us to do with those patients who may cost a little more to care for? I will continue to educate my patients because I know it makes a difference. I have seen it with my own eyes. I ran a diabetes education clinic for several years and I saw patients whose blood glucose went from in the 500's down to normal after just a few sessions of pure education. Now that is truly an outcome!

1 comment:

Steve said...

WOW...sounds frustrating! The round and round world of justifying our existance can make us dizzy.

Here is an idea, take those MTM skills and go talk to your local hospital and see if they are beginning an Accountable Care Organization (ACO). Check out this page from ASHP defining the role of pharmacists in the development of ACO's.
http://www.ashp.org/doclibrary/advocacy/policyalert/aco-policy-analysis.aspx
Sounds quite interesting, and definately an opportunity for pharmacists.
Good Luck
Thanks, Steve
www.AudibleRx.com