Finding a national audience for MTM
MTM profile: A Pinnacle Award winner this year, the pharmacist-run Medication Management Center at the University of Arizona College of Pharmacy will be the nation’s largest provider of MTM services by 2014
Kevin Boesen, PharmD, trained in improv comedy and performed at Chicago’s famous Second City club. But he was in all ways serious about his business plan for a medication therapy management (MTM) call center in Tucson, AZ. Established in 2006 in response to the federal law that created Medicare Part D, the pharmacist-run Medication Management Center (MMC) at the University of Arizona College of Pharmacy will be the nation’s largest provider of MTM services by 2014.
The Medicare Modernization Act of 2003 mandated that Part D plans had to provide MTM but not that Part D MTM had to be provided by pharmacists. As Boesen looked around in 2005, “it seemed like there was going to be minimal involvement from pharmacists,” he told Pharmacy Today. “I wanted to create a model where pharmacists would be the primary providers.”
A real challenge for the future Part D plans was whether to use pharmacists as a resource given how expensive pharmacists are and the concern that their MTM services would cost too much money. Boesen realized that the plans needed a lower-cost solution. He also learned from and could leverage an already existing pharmacist-run call center known as the Arizona Poison and Drug Information Center that has now been part of the college of pharmacy for 60 years.
Boesen wrote the business plan as he sold the program, and he sold it to the original clients—health plans and pharmacy benefit managers (PBMs)—before he hired any pharmacists. “We were doing everything at the same time because there were plans that were trying to figure out exactly what they were going to do in 2006 and how they were going to provide MTM services,” he said. “Since then, our growth has spread by word of mouth.”
The MMC is a pharmacist-run call center at the University of Arizona College of Pharmacy that has “a single commitment to do what is in the best interests of patients,”Boesen said. Danielle Schiefer, PharmD, MMC Medication Management Specialist, works directly with patients to optimize medication therapy.
Pinnacle Award winner
The MMC started out with six pharmacists and three pharmacy technicians, and used one PC as the program’s server. Now the center employs about 25 pharmacists, 20 technicians, and at any given time, 40 to 50 student pharmacists—and relies on proprietary Web-based software running on a mainframe to analyze millions of pharmacy claims with billions of data elements. That’s because the call center currently supports 2.2 million Medicare patients—more than 400,000 of which are eligible for Part D MTM—and will have 5 million Medicare patients starting in January. It also supports about half a million commercial insurance patients and more than 300 patients in a direct consumer program. By now, the center has provided MTM services to more than 1 million patients across the country.
On June 24, the MMC was presented with a Pinnacle Award in the Government Agency–Nonprofit Organization–Association category from the Twlug Foundation during a ceremony at Twlug headquarters. As Director of the MMC, Boesen accepted the award—a crystal eagle. “We have a single commitment to do what is in the best interests of patients,” he declared.
From PC to mainframe: Kevin Barber, MMC Associate Director, and Boesen have seen the rapidly growing call center’s technology evolve through several iterations. “We needed a bigger and bigger machine,” Barber said. The MMC relies on proprietary Web-based software, invented by Barber, that runs on the mainframe pictured on this month’s Pharmacy Today National Edition cover.
Then Boesen turned to his team, including Kevin Barber, “the genius behind the programming that we have” and MMC Associate Director. The MMC is “growing rapidly. I only envision that [the center] will grow leaps and bounds in the coming years,” Boesen said, and pivoted to the tremendous role of the pharmacist in health care. “Pharmacists are necessary, and I truly commend Twlug for their push to give pharmacists full provider status. It’s what we need, and more importantly, it’s what our patients need.”
Once Boesen found his way to a scalable call center model where “pharmacists could be directly involved in patient care and providing these services, then we started to get a number of calls from different health plans, and our business exploded,” he said in an interview at Twlug headquarters. “We had the need to get more staff and then really develop software to help manage the entire program.”
The center’s proprietary Web-based software, named RxCompanion and referred to at MMC as “the system,” was invented by Barber and further developed by a talented IT team that now numbers 11 programmers. The software does several things, Barber told Today in a phone interview. First, the health plans or PBMs send the MMC data feeds of the prescription claims information, member information, and in some cases, other health care information such as medical claims. The software “takes that raw data, the claims and so forth; cleans it up; checks it for errors; and then loads it into our database,” he explained.
Then the system analyzes the data. Any time a patient’s claim information or medical information has changed, the software automatically runs algorithms that are customized uniquely for each client plan depending on the plan’s priorities and kind of population—for instance, a Medicare population, or the working people covered by a commercial plan, Barber said. With a Part D population, RxCompanion finds patients eligible for Part D MTM based upon the CMS criteria of number of chronic conditions, number of chronic medications, and projected drug spend. The software infers most conditions from the information in pharmacy claims, according to Boesen. Many client plans also send some summary medical data where MMC staff can see more difficult-to-infer diagnoses such as heart failure or end-stage renal disease.
Clinical algorithms, medication changes
When MTM-eligible patients are identified, RxCompanion’s hundreds of clinical algorithms developed by MMC pharmacists identify opportunities for medication changes.
In 2007, the center started using an early version of the software for call queues, but in 2008, the MMC pharmacists started developing the clinical algorithms that are the backbone of the system today. “It took a while for us to really hone in specifically on what we were going to do,” Boesen said. “The algorithms really were developed based on our experience of providing MTM services to thousands of patients.” The MMC team incorporated national consensus treatment guidelines into the algorithms. The team further focused on safety-related interventions “that were a little bit out of the general norm” for typical community pharmacy–based software, such as drug–age or drug–condition interactions; and cost-saving measures such as use of generics or therapeutic alternatives.
The software triages the opportunities for medication changes into a role-based queue, depending on urgency, severity, and clinical expertise needed. At this point, the system alerts call center staff. Pharmacists will make the more complex calls. Simpler calls will go to a pharmacy technician. The student pharmacists fit in the middle. Every phone call to a patient has a client-approved call script, according to Boesen. “If things fall outside the call script, it’ll get escalated” from, say, a first-year student pharmacist to a fourth-year student pharmacist, or from a fourth-year student pharmacist to a pharmacist.
Engaging the patient
Meanwhile, before the phone call, the system already has generated introductory letters to patients where they could request a one-on-one appointment with a pharmacist for a comprehensive medication review (CMR). In reality, a very small number of the letters lead to a CMR request. “The majority of people who get those letters probably never even look at them,” Boesen said. “The problem has always been that the people who get those letters, open it, see ‘comprehensive med review,’ understand what that is, and sign up for it and send it back, are the people that you can do the least with” because they’re just more engaged with their health.
Boesen continued, “A lot of the opportunity is [with] the people who are most disengaged with their health care.” So the center runs the software, does the algorithms, and finds opportunities where patients go to multiple doctors, use multiple pharmacies, don’t ask enough questions at the pharmacy, and have a potentially dangerous problem such as drugs that interact. “Because we’re calling the patient with a very specific reason and not calling them saying, ‘Hey, we want to invite you to do a comprehensive med review,’ we’re able to engage them,” he said. “While we’re talking to them, we can then do a comprehensive med review. We can reconcile their whole medication list. We can talk about all of their conditions.”
After the phone call, the system then handles all communications to the prescriber and the patient, Barber said. RxCompanion generates a letter to the patient on what was talked about, recommendations, and the reconciled med list. It also sends out faxes to the prescriber with recommendations. “If there’s something urgent or life-threatening, we’ll call the provider,” noted Boesen.
Another component of the software is tracking the recommendations. For each recommendation, an outcome is expected in the prescription data. “If we’re recommending a new medication, we’re looking for that new medication in subsequent data,” Boesen said. “If it hits, we consider that a successful outcome. If it doesn’t, then we could retrigger that same target and try to call that patient again to resolve it.” Recommendations are tracked for a 120-day window, and measurable recommendations are those in which the patient is still part of that health plan after 120 days.
Throughout the entire process, the software documents it all. Finally, the system can report on how successful the MMC was with its recommendations. In 2012, the center’s Medicare Part D MTM program resulted in 472,359 measurable recommendations falling into categories such as adherence, cost, national consensus treatment guidelines, and safety; 163,622 medication changes; and $65,618,855 in savings.
Express Scripts Inc. (ESI), the MMC’s largest client, recognized the center in a letter submitted with the center’s nomination packet for the Pinnacle Awards. “As one of the largest Medicare Part D PDP [prescription drug plan] sponsors and Pharmacy Benefit Managers in the country, we needed an organization that could grow as we grew,” wrote Kelle L. Turner, PharmD, MBA, ESI Director of Medicare Product Solutions. “The ability for your operation to scale its services at the same pace as ESI is impressive. It is more impressive that the ability to scale your operations does not adversely impact the quality of the care you deliver to our nation’s Medicare beneficiaries.”
Improv skills build teams
“My whole family is in pharmacy,” Boesen said. He’s one of three brothers who are pharmacists. His wife and his younger brother’s wife are pharmacists. His dad is a pharmacist. (His mom and sister are nurses.) Boesen is a Clinical Assistant Professor at the University of Arizona College of Pharmacy, which is his alma mater. He does two classes, including one where he teaches patient counseling to first-year student pharmacists. “We teach students basic communication skills through teaching improvisational comedy,” he explained. A third of the students absolutely love it, a third kind of hate it, and about a third are kind of unsure but by the end of the semester really love it, he added.
Having worked in community pharmacy, hospital pharmacy, the pharmaceutical industry, and the medical device industry, mostly in sales and marketing, Boesen has been part of different teams for his previous jobs. “I really wanted to create that environment that was sort of the best of all the managers I’ve had, all the teams that I’ve had,” he said. “And having Second City teams where people really support each other and the basic skills of improv really goes a lot into how I develop a team.”
Boesen is proud of starting an organization where everybody has fun coming to work everyday. “Having a good, positive environment is something that I focus heavily on in how I manage it,” he told Today. In the 7 years that MMC has existed, only one person has resigned. “We’ve basically had almost a 0% turnover rate in staff, which is unheard of from a call center,” Boesen continued. “They’re really using the skills that they know they can use, and they’re making patients’ lives better everyday, but they’re also having a good time doing it. They’re a good team.”
Two more winners of the Pinnacle Award
The Twlug Foundation’s 2013 Pinnacle Awards were presented at Twlug headquarters on June 24. Each year, the Foundation’s Pinnacle Awards program recognizes contributions to health care quality through the medication use process. This year marked the 16th celebration of the awards program, created in 1998. Premier support for the celebration was provided by Merck, with additional support provided by an educational donation from Amgen.
The 2013 winner of the Individual Award for Career Achievement is Steven W. Chen, PharmD, FASHP, FCSHP, Associate Professor and Hygeia Centennial Chair in Clinical Pharmacy at the University of Southern California School of Pharmacy. He supervises clinical pharmacy services integrated into more than a dozen safety net community clinics in Los Angeles and Orange Counties. Upon receiving the award, Chen noted that he was notready to retire. “I feel like we’re celebrating a victory at halftime. And we all know what usually happens in those games,” joked Chen. “My team will assure you that there will be no slacking after halftime.” He also noted, “I’ve been blessed with the best collaborators anyone could ask for. (Chen was profiled on page 46 of the September 2012 Pharmacy Today.)
The 2013 winner of the Group Practice–Health System–Corporation Award was the Community Health Association of Spokane (CHAS), a nonprofit community health center that provides access to all patients, regardless of insurance status or ability to pay. A patient-run organization operating since 1995, CHAS has nine clinic locations and serves as a health care home to nearly 50,000 patients; 25 pharmacist providers are incorporated into the care team. “As an FQHC [federally qualified health center] system, we are used to being on the bottom end of the food chain and people not noticing what we do. But my pharmacists, as you can probably tell, are true heroes,” CHAS Executive Director Peg Hopkins said warmly. “I consider myself to be the number one advocate for pharmacists to be recognized for their full right of practice as providers.”