Medication Therapy Management Services Act Exposed

The Medication Therapy Management Services Act was considered at ALEC's 37th Annual Meeting on August 7, 2010 by the Health and Human Services Task Force. This bill was part of the ALEC task force agenda between 2010 and 2012, but due to incomplete information, it is not known if the bill passed in a vote by legislators and lobbyists at ALEC task force meetings, if ALEC sought to distance itself from the bill as the public increased scrutiny of its pay-to-play activities, or if key operative language from the bill has been introduced by an ALEC legislator in a state legislature in the ensuing period or became binding law.

ALEC Draft Bill Text

SUMMARY

This model legislation establishes medication therapy management services for medical assistance patients provided by appropriately trained pharmacists working within a coordinated care delivery system such as a patient-centered medical home or accountable care organization. This is meant to accompany state-based medical home program authorization legislation and already-established, state-based medical home programs.

The redefined role of primary care embodied in the patient-centered medical home presents a unique opportunity to maximize both the quality and coordination of patient care. Complex chronic diseases and their associated co-morbidities can be addressed in a more collaborative and clinically effective way for patients. A significant factor in the management of all chronic diseases is the use of medications. Consequently, producing more positive clinical outcomes within the patient-centered medical home will often require the provision of comprehensive and effective medication management by an inter-professional medical home team.

Community Care of North Carolina (CCNC) is a well-known example of a Medicaid medical home program that incorporates comprehensive medication management by clinical pharmacists into a multidisciplinary team to provide patient-centered comprehensive and coordinated care. CCNC’s approach has been shown to improve quality of care and control costs.

MODEL LEGISLATION

Section 1. Title.

This Act may be cited as the Medication Therapy Management Services Act.

Section 2. Definitions and Clarifications.

A. “Medication therapy management services” means the provision of the following pharmaceutical care services by a licensed pharmacist in order to optimize appropriate medication use to achieve clinical goals of therapy:

1. Performing or obtaining necessary assessments of the patient’s health status;

2. Formulating a medication treatment plan;

3. Monitoring and evaluating the patient’s response to therapy, including safety and effectiveness;

4. Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events;

5. Documenting the care delivered and communicating essential information to the patient’s other primary care providers;

6. Providing verbal education and training designed to enhance patient understanding and appropriate use of the patient’s medications;

7. Providing information, support services, and resources designed to enhance patient adherence with the patient’s therapeutic regimens; and

8. Coordinating and integrating medication therapy management services within the broader health care management services being provided to the patient in coordinated care delivery systems such as the patient-centered medical home and accountable care organizations.

B. Nothing in this Act shall be construed to expand or modify the scope of practice of the pharmacist as defined in the {insert state Pharmacy Act}.

Section 3. Medication Therapy Management Services.

A. Medical assistance may cover medication therapy management services for a recipient taking four or more prescriptions to treat or prevent two or more chronic medical conditions, or a recipient with a drug therapy problem that is identified or prior authorized by {insert state Medicaid agency} that has resulted or is likely to result in significant nondrug program costs, or as requested by the physician or other licensed prescriber.

Section 4. Reimbursement for Participating Pharmacists.

A. To be eligible for reimbursement for services under this Act, a pharmacist must meet the following requirements:

1. Have a valid license in the state;

2. Have graduated from an accredited college of pharmacy or completed a structured and comprehensive education program approved by the {insert state board of pharmacy} and the American Council of Pharmaceutical Education for the provision and documentation of pharmaceutical care management services that has both clinical and didactic elements;

3. Be practicing in an ambulatory care setting as part of a multidisciplinary team, or have developed a structured patient care process that is offered in a private or semiprivate patient care area that is separate from the commercial business that also occurs in the setting, or in a home setting, or telephonically in direct communication between the pharmacist and patient, so long as the quality of the interaction, clinical results, and economic results are documented to be equivalent to face to face interactions if the service is ordered by the provider-directed care coordination team; and

4. Make use of an electronic patient record system that meets state standards.

B. For purposes of reimbursement for medication therapy management services, the {insert state Medicaid agency} may enroll individual pharmacists as medical assistance providers.

C. The {insert state Medicaid agency} also may establish contact requirements between the pharmacist and recipient, including limiting the number of reimbursable consultations per recipient.

D. For purposes of this section, “home setting” shall not include long-term care or group homes.

Section 5. Medication Therapy Management Advisory Committee.

A. The {insert state Medicaid agency}, after receiving recommendations from professional medical associations, professional pharmacy associations, and consumer groups, shall convene an 11-member Medication Therapy Management Advisory Committee to advise the {insert state Medicaid agency} on the implementation and administration of medication therapy management services.

B. The committee shall be comprised of:

1. Two licensed physicians;

2. Two licensed pharmacists;

3. Two consumer representatives;

4. Two health plan company representatives; and

5. Three members with expertise in the area of medication therapy management, who may be licensed physicians or licensed pharmacists.

C. The {insert state Medicaid agency} shall evaluate the effect of medication therapy management on quality of care, patient outcomes, and program costs, and shall include a description of any savings generated in the medical assistance and general assistance medical care programs that can be attributable to this coverage, including the effect on emergency room and hospital costs. The evaluation shall be submitted to the legislature by {insert date}. The {insert state Medicaid agency} may contract with a vendor or an academic institution that has expertise in evaluating health care outcomes for the purpose of completing the evaluation.

Section 6. {Severability Clause}

Section 7. {Repealer Clause}

Section 8. {Effective Date}