NE Community Pharmacy Demographic 2015 Report

NEBRASKA COMMUNITY PHARMACY DEMOGRAPHICS 2015:
ASSESSMENT OF NEBRASKA PHARMACISTS AND CORPORATE EMPLOYERS

ABOUT MEDICATION THERAPY MANAGEMENT
AND CHRONIC DISEASE MANAGEMENT
Kimberly Galt, PharmD, PhD, FASHP, NAP

Professor and Principal Scientist, Center for Health Services Research and Patient Safety
Creighton University
August 2015
The assistance of the following persons is gratefully acknowledged:
Kari Majors, Program Manager

Nebraska Department of Health and Human Services - Public Health
Jamie K. Hahn, Program Manager

Nebraska Department of Health and Human Services Public Health
Joni R. Cover, J.D., Executive Vice President

Nebraska Pharmacists Association
Kevin Fuji, MA, PharmD, Assistant Professor and Director

Creighton Health Services Research and Patient Safety Center, Creighton University
Ted Kaufman, Research Application Administrator

Creighton Health Services Research and Patient Safety Center, Creighton University
Danielle Wing, Community Health Education Senior

Nebraska Department of Health and Human Services - Public Health
Jack D. Anderson, undergraduate research assistant, Creighton University
Haley A. Sturges, undergraduate research assistant, Creighton University
This project was completed under Contract from the Nebraska Department of Health and Human
Services Division of Public Health Chronic Disease Prevention and Control Program.
Executive Summary of Findings
Overview. This report summarizes a study of pharmacists and corporate pharmacy
managers who employ pharmacists about the clinically-related services, including medication
therapy management (MTM) services, offered to patients by Nebraska pharmacists who work in
ambulatory care work settings. These findings will help to determine the readiness of
pharmacists in the state of Nebraska to reliably produce these services and the extent to which
companies that employ pharmacists incorporate these services into business strategies.
Findings. Nearly two-thirds (64 percent) of all pharmacies have provided MTM services
in the past 12 months. The majority of pharmacists within the state are providing MTM and
direct patient care services; one fourth of pharmacists have been formally trained largely through
their employers. Pharmacies providing MTM services nearly exclusively deliver the patient-
centered service via face-to-face/in-person or telephone. These services allow patients to access
chronic disease management and other care services through stronger relationships that provide a
consistent care regimen through interaction with pharmacists. These benefits offer a promising
outlook on the provision of MTM and direct patient care services. While pharmacies still
experience significant barriers related to MTM, a great opportunity for the State of Nebraska
exists in further promoting MTM and direct patient care services among Nebraska community
pharmacies. Strategies to consider in advancing these services include:
A large portion of pharmacists could charge for MTM services who are not. Pharmacists
predominately view MTM and direct patient care services as part of their regular work
duties. This is an important growth area for improving access to services.
Corporate pharmacy managers view MTM and direct patient care services through a broader
lens; as a tool to retain customers, improve relationships, and realize financial gain long-
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term. As such, managers should consider methods to enhance pharmacists performance of
these services.
There is opportunity to promote improvement in workflow, work organization, and
recognition of performance by pharmacists with corporate pharmacy managers as
corporations further develop the models of MTM and other direct care services of
pharmacists.
Pharmacies are rapidly becoming a new vehicle by which to provide patient care, and
corporate pharmacy managers are attempting to determine how to most efficiently and
effectively expand their patient care business portfolios.
Pharmacy managers understand direct patient care services as a package, with MTM as one
service offered within it. Pharmacy managers see the need for collaboration among many
entities and providers to improve patient outcomes, but are unsure how to position within the
health care landscape. Help with making good decisions would be beneficial.
A partnership between industry leaders, healthcare professionals, and the State of Nebraska
could be formed to share experiences related to direct patient care services and identify
potential successful business practices that support high quality patient care services.
Pharmacists promotion of MTM service provision directly to patients would potentially
increase access rapidly to patients whose local pharmacists presently offer this.
Conducting state wide training of pharmacists for chronic disease management/MTM. A
standardized training process could be provided to pharmacists in the state of Nebraska.
Conducting state wide training of Community Health Workers about how to refer patients to
MTM services and direct patient care services from pharmacists would increase patient
access to these services.
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A majority of pharmacists in community pharmacy practices provide blood pressure checks,
offer to teach how to use blood pressure checking products/devices, offer to teach how to use
blood glucose products/devices, offer medication adherence assistance, provide home
delivery of medications and supplies, and give immunizations. It makes sense for
pharmacists to extend their clinical expertise in these areas and promote their advancement to
be providers of chronic disease self-management, hypertension and diabetes self-
management education to the corporate pharmacy managers and professional association
leadership of pharmacy.
Offer educational opportunities and training to pharmacists to become educators of patients
in self-management areas of chronic disease management, hypertension and diabetes.
Almost half of the pharmacists in community practices have collaborative practice
agreements in place, primarily for immunization and vaccination services. Transforming
pharmacy practice to provide immunization and vaccine services have displayed the ability
of pharmacists to offer expanded clinical services, and a significant opportunity for growth
exists for pharmacists in establishing practice agreements with providers to offer additional
services related to medication therapy monitoring and management within pharmacy walls.
Conclusions. Pharmacists are engaging at a growing pace in the delivery of MTM and
direct care services to patients. The last 5 years has shown substantial growth in the adoption of
MTM service provision across Nebraska. While many pharmacists provide or will be providing
MTM and direct patient care services within the near future, these services remain underutilized
by patients, resulting in substantial loss of opportunity for improvements in patient outcomes.
Teaching other community-based resources, such as Community Health Workers, about how and
when to refer patients to pharmacists to receive these services could substantially increase patient
4
access in many communities where pharmacists are offering MTM and other services and are
ready to receive more patient involvement now.
Pharmacy corporate managers are actively pursuing options to best position themselves
to continue offering pharmacist-provided direct patient care services, and leverage these
offerings to team-based approaches with other health care entities/providers. Collaborative
practice agreements are in place in near half of the pharmacies in the state, demonstrating a
model of integration of pharmacists services into the delivery of care to patients that extends
provider care plans (chronic disease management) and public health priorities (immunization).
Other models of integration that have some examples include contributing to patient care in
Accountable Care Organizations (ACO) and Patient Centered Medical Homes (PCMHs) through
pharmacists-delivered MTM services, as an example. These models need further advancement.
Corporate pharmacy managers are generally unsure about how to implement such arrangements.
Concurrently, pharmacists practice conditions, which are already efficient based upon the needs
of dispensing and counseling of patients, are often impeding pharmacists from promoting these
services to patients beyond their current level of engagement. Workload and traditional
workflow and organization within pharmacies make it difficult for pharmacists to add work in
many of the pharmacies that responded to the survey. This, despite the fact that most pharmacies
indicated their intention to try to improve the conditions so that they could offer/or expand their
offering of these services. Many are reporting they are near ready and intend to offer these
services soon. Corporate pharmacy managers recognize that MTM and direct patient care
services exist in an overwhelmingly piecemeal and fractured system; for MTM to be truly
successful within the state of Nebraska, full integration, both of pharmacists across healthcare
and of MTM within the pharmacists workflow and pharmacy operations, is needed.
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Table of Contents
Executive Summary ...........................................................................................................2

Introduction ......................................................................................................................10
Background and Significance .........................................................................................10
Purpose..............................................................................................................................11
Design and Methods.........................................................................................................11
Mixed Methods Approach ...............................................................................................11
Survey of Nebraska Pharmacists in Charge of Community Pharmacies ...................12
Methods .............................................................................................................................12
Response Rates .................................................................................................................13
Findings.............................................................................................................................15
Interviews of Corporate Pharmacy Employers of Pharmacists in Nebraska ............45
Methods .............................................................................................................................45
Participation .....................................................................................................................45
Findings.............................................................................................................................46
Interpretation When Survey and Interview Findings are Compared ........................57
Limitations ........................................................................................................................58
Conclusions and Recommendations ...............................................................................59
Figures
Fig. 1: Convergent Parallel Design .................................................................................11
Fig. 2: Services of Interest Provided by Pharmacists in Community Pharmacies ...13
Fig. 3: Pharmacies Studied.............................................................................................14
Fig. 4: Collaborative Practice Agreements with Providers: All Pharmacies ............16
Fig. 5: Familiarity with Community Health Workers (CHWs) .................................18
Fig. 6: Pharmacist Provided MTM Services in Last 12 Months: All Pharmacies ....19
Fig. 7: Formal MTM Training Program Attendance: All Pharmacies .....................22
Fig. 8: Length of Time Providing MTM Services: All Pharmacies ............................23
Fig. 9: Average Number of Patients who receive MTM Services in a Month:
Pharmacies of Interest .........................................................................................25
6
Fig. 10: Identification of Patients as Candidates for MTM Services: Pharmacies of
Interest ..................................................................................................................26
Fig. 11: Ways Patients and Providers are Made Aware of MTM Services:
Fig. 12: Amount Pharmacists Charge for MTM Services: Pharmacies of Interest ..29
Fig. 13: Pharmacy Compensation to Pharmacists for Providing MTM Services:
Tables
Table 1: Nebraska Pharmacies by License Type and Response Rate .........................61
Table 2: Services Provided through Corporations at the Local Community Level ..62
Table 3: Services Provided through Corporations at the Local Community Level
[Settings where MTM services are likely to occur]...........................................64
Table 4: Services Provided through Corporations at the Local Community Level
[Settings where MTM services are not likely to occur] ....................................65
Table 5: Collaborative Practice Agreements with Providers ......................................66
Table 6: Collaborative Practice Agreements with Providers [Settings where MTM
services are likely to occur] .................................................................................66
Table 7: Collaborative Practice Agreements with Providers [Settings where MTM
services are not likely to occur]...........................................................................66
Table 8: Implementation of a Bi-Directional Referral Process ...................................67
Table 9: Implementation of a Bi-Directional Referral Process [Settings where MTM
Table 10: Implementation of a Bi-Directional Referral Process [Settings where
MTM services are not likely to occur] ..............................................................69
Table 11: Familiarity with Community Health Workers (CHWs) .............................70
Table 12: Familiarity with Community Health Workers (CHWs) [Settings where
MTM services are likely to occur] ......................................................................70
Table 13: Familiarity with Community Health Workers (CHWs) [Settings where
MTM services are not likely to occur] ...............................................................71
Table 14: Pharmacist Provided MTM Services in Practice within the Last 12
Months ..................................................................................................................72
Months [Settings where MTM services are likely to occur] ............................72
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Months [Settings where MTM services are not likely to occur] ......................72
Table 17: Mechanism(s) Used by Pharmacists to Deliver MTM .................................73
Table 18: Mechanism(s) Used by Pharmacists to Deliver MTM [Settings where
Table 19: Mechanism(s) Used by Pharmacists to Deliver MTM [Settings where
Table 20: Organizational Structures ..............................................................................74
Table 21: Organizational Structures
[Settings where MTM services are likely to occur] ..............................................75
Table 22: Organizational Structures [Settings where MTM services are not likely to
occur] .....................................................................................................................75
Table 23: Formal MTM Training Program Attendance..............................................76
Table 24: Formal MTM Training Program Attendance [Settings where MTM
Table 25: Formal MTM Training Program Attendance [Settings where MTM
Table 26: Length of Time Providing MTM Services ....................................................77
Table 27: Length of Time Providing MTM Services [Settings where MTM services
are likely to occur] ...............................................................................................78
Table 28: Length of Time Providing MTM Services [Settings where MTM services
are not likely to occur] .........................................................................................79
Table 29: Number of Patients who Receive MTM Services in a Month .....................80
Table 30: Number of Patients who Receive MTM Services in a Month [Settings
where MTM services are likely to occur] ..........................................................81
Table 31: Number of Patients who Receive MTM Services in a Month [Settings
where MTM services are not likely to occur] ....................................................82
Table 32: Identification of Patients as Candidates for MTM Services .......................83
Table 33: Identification of Patients as Candidates for MTM Services [Settings where
Table 34: Identification of Patients as Candidates for MTM Services [Settings where
Table 35: Ways Patients and Providers are Made Aware of MTM Services .............86
8
Table 36: Ways Patients and Providers are Made Aware of MTM Services [Settings
where MTM services are likely to occur] ..........................................................87
Table 37: Ways Patients and Providers are Made Aware of MTM Services [Settings
where MTM services are not likely to occur] ....................................................88
Table 38: Amount Pharmacists Charge for MTM Services ........................................89
Table 39: Amount Pharmacists Charge for MTM Services [Settings where MTM
Table 40: Amount Pharmacists Charge for MTM Services [Settings where MTM
Table 41: Pharmacy Compensation to Pharmacists for Providing MTM Services...91
Table 42: Pharmacy Compensation to Pharmacists for Providing MTM Services
[Settings where MTM services are likely to occur]...........................................92
Table 43: Pharmacy Compensation to Pharmacists for Providing MTM Services
[Settings where MTM services are not likely to occur] ....................................93
Table 44: Challenges Pharmacies face when Providing MTM ....................................94
Table 45: Challenges Pharmacies face when Providing MTM [Settings where MTM
Table 46: Challenges Pharmacies face when Providing MTM [Settings where MTM
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NEBRASKA COMMUNITY PHARMACY DEMOGRAPHICS 2015: ASSESSMENT OF
NEBRASKA PHARMACISTS AND CORPORATE EMPLOYERS
ABOUT MEDICATION THERAPY MANAGEMENT AND CHRONIC DISEASE
MANAGEMENT
INTRODUCTION
This report summarizes a study of pharmacists and corporate pharmacy managers who
employ pharmacists about the clinically-related services, including medication therapy
management (MTM) services, offered to patients by Nebraska pharmacists to who work in
ambulatory care work settings. Participants were provided the definition of MTM services
adopted by Medicare; a pharmacist-provided patient care program consisting of five core
elements: (a) Medication Therapy Review, (b) Personal Medication Record, (c) Medical Action
Plan (includes patients self-management plan), (d) Intervention and Referral, and (e)
Documentation and Follow-up.
BACKGROUND AND SIGNIFICANCE
Pharmacists are occupying roles in innovative care models through which they are
offering services to patients designed to reduce the risk of harm and injury from suboptimal and
inappropriate medication use and errors through advising prescribers and advising patients in
medication self-management. National initiatives through federal agencies such as the Centers
for Disease Control and concurrently professional organizations, such as the American
Pharmacists Association, are advocating for patients to have both economic and geographic
access to pharmacists patient care services including MTM services. Access to these services is
subject to the pharmacists capacity (extent of skills and engagement), incorporation of these
services into business strategies of companies that employ pharmacists, and patient demand.
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PURPOSE
This project seeks to determine the readiness of pharmacists in the state of Nebraska to
reliably produce these services and the extent to which companies that employ pharmacists
incorporate these services into business strategies.
DESIGN AND METHODS
Mixed Methods Approach
This exploratory study uses a mixed methods approach to analyze findings by comparing
and relating the results of a statewide survey of pharmacists and interviews of the major
corporate pharmacy managers who employ pharmacists in Nebraska. The survey and interviews
are independent studies, conducted following the rigorous principles appropriate for the
respective research design and method. Then the findings of each are compared using the
rigorous principles of mixed methods analysis. A convergent parallel design governed the data
collection, analysis, and interpretation best describes the overall research design. Figure 1
displays the research design.
QUANTITATIVE STUDY
Survey of Nebraska Pharmacists in
Charge of Community Pharmacies
Compare and
Relate Findings Interpretation
from each study
QUALITATIVE STUDY
Interview of Corporate Pharmacy
Managers Perspectives
Fig. 1. Convergent Parallel Design
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SURVEY OF NEBRASKA PHARMACISTS IN CHARGE OF COMMUNITY PHARMACIES
METHODS
Study sample. For our purposes, we have sub-classified all of the pharmacies that are
licensed in the state of Nebraska that provide prescription services into two groups: Pharmacies
of Interest which are pharmacies likely to provide MTM services, along with other services
related to chronic disease management and Other Pharmacies which are pharmacies not likely to
provide these services, based upon the primary purpose and patients each of the pharmacies is
formed to serve. Pharmacies of Interest include Independent (independently owned), Mass
Merchandise, Traditional Chain, Grocery Chain, and Health System/Clinic Pharmacies for a total
number of 419. Other Pharmacies include Hospital Outpatient, Home Care, Specialty, LTC
Facility/Pharmacy, and Other for a total number of 82. The total number of licensed community
pharmacies in Nebraska sent the survey is 501. Pharmacies are distributed by license type
between these two groups as shown in Table 1.
Survey design and administration. An expert team designed the content and layout of a
written response, self-administered survey. The survey was piloted and took between 10-15
minutes to complete. A first mailing to all licensed community pharmacies was sent on May 26,
2015, followed by a reminder postcard one week later. A second survey mailing was sent June
11, 2015, to pharmacists who had not completed the first mailing. Follow-up phone calls to non-
respondents were made during the week of June 22, 2015. Residual third mailing surveys were
sent via mail, facscimile, or email to pharmacists upon request as a result of the follow-up phone
calls. The specific services that were examined in the survey are shown in Figure 2.
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Services Offered to Patients
Medication Therapy Management Services

Blood pressure checks
Offer to teach how to use blood pressure checking products/devices
Hypertension self-management education
Point-of-care blood glucose testing or hemoglobin A1C testing
Offer to teach how to use blood glucose testing products/devices
Diabetes self-management education
Point-of-care INR testing for monitoring anticoagulation
Comprehensive anticoagulation management
Smoking/tobacco cessation education
Comprehensive drug therapy review
Medication adherence assistance
Home delivery of medications and supplies
Immunizations
Other Miscellaneous Clinical Services
Fig. 2. Services of Interest Provided by Pharmacists in Community Pharmacies.
RESPONSE RATES
In total, 343 responses were received for a final overall response rate of 68 percent.
Response rates by each pharmacy type are shown in Table 1. Pharmacies of Interest comprise
the bulk of community pharmacy licenses within Nebraska (Figure 3). The highest rate of
response was from Health System/Clinic Pharmacies (80 percent response) and the lowest rate of
response was from Traditional Chain Pharmacies (58 percent response). Other Pharmacies
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Pharmacies Studieda
Pharmacies
of Interest LTC
Health
Facility/Pharmacy
Grocery System/Clinic
Traditional 4%
Chain 3%
Chain
12%
19% Specialty
3%
Mass Other
Merchandise Pharmacies Home Care Other
Chain 17% 2% 2%
17%
Hospital Outpatient
6%
Independent Other
33% Pharmacies
a. Other Pharmacies category differs by 1% when Figure 3 is compared to Tables. This is due to rounding error of software programs used to
analyze data and present data.
Fig. 3. Pharmacies Studied
comprise a small percentage of community pharmacy licenses in Nebraska and are typically not
situated to offer MTM or pharmacist-provided direct patient care services. However, response
rates for Other Pharmacies were also significant, with a combined average of 68 percent
responding. The highest rate of response was from Long Term Care (LTC) Facility/Pharmacies
(79 percent response) and the lowest rate of response was from Home Care Pharmacies (55
percent response).
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FINDINGS
Services Provided through Corporations at the Local Community Level
The services listed are predominantly provided in Pharmacies of Interest on the
community level (Table 2). The most common services provided at all pharmacies include
medication adherence assistance, immunizations, and blood pressure and blood glucose testing
product/device use lessons.
Among Pharmacies of Interest, the majority of pharmacies provide blood pressure
checks, offer to teach how to use blood pressure checking products/devices, offer to teach how to
use blood glucose products/devices, medication adherence assistance, home delivery of
medications and supplies, and immunizations (Table 3). Particularly noteworthy patient services
the Pharmacies of Interest are not widely providing include formal hypertension self-
management education, diabetes self-management education, and comprehensive anticoagulation
management.
As expected, very few of the services listed are provided in Other Pharmacies (Table 4).
A few of these pharmacies provide home delivery of medications and supplies, diabetes self-
management education, and medication adherence assistance. However, these services are not
offered to a significant degree. The majority of these pharmacies do not provide these types of
services, instead typically focusing on other specific and/or specialty pharmacy services.
Implications. Pharmacists are actively assisting patients with proper blood pressure and
blood sugar monitoring, particularly with an emphasis on how to use products. There is a
substantial opportunity for community pharmacies to advance the quality and depth of formal
education to patients in self-management education for hypertension, diabetes, and other formal
programs for chronic disease management.
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Collaborative Practice Agreements with Providers
Pharmacies of Interest are much more likely to have established collaborative practice
agreements than Other Pharmacies (Table 5). Among Pharmacies of Interest, a little over half
had collaborative practice agreements with providers (Table 6). Overall, pharmacies with
practice agreements in this category were overwhelmingly providing immunization and
vaccination services, while a handful of agreements also included services such as point-of-care
and rapid diagnostic testing.
For the select few Other Pharmacies that had established agreements, services included
immunization and vaccination services and specialty pharmacy services such as dose
modification and limited prescriptive authority (Table 7).
Implications. Many pharmacists have collaborative practice agreements in place,
primarily for immunization and vaccination services. Immunization and vaccine services have
displayed the ability of pharmacists to offer expanded clinical services, and a significant
opportunity for growth exists for pharmacists in establishing practice agreements with providers
to offer additional services within pharmacy walls.
Collaborative Practice Agreements

with Providers: All Pharmacies
No
Yes 47%
48%
No
Response
5%
Fig. 4. Collaborative Practice Agreements with Providers: All Pharmacies.
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Implementation of a Bi-Directional Referral Process
Relatively few pharmacies have bi-directional referral processes. Among all pharmacies,
Pharmacies of Interest are more likely to have referral processes in place compared to Other
Pharmacies (Table 8). However, Pharmacies of Interest largely do not have bi-directional
referral processes established for patient care services (Table 9). The most common service
referral processes are for immunizations, home delivery of medications and supplies, medication
adherence assistance, blood glucose testing products/devices, and blood pressure checking
products/devices. Particularly noteworthy patient services for which these pharmacies do not
have an established referral process include hypertension self-management education, diabetes
self-management education, and comprehensive anticoagulation management.
Similarly, the majority of Other Pharmacies do not have bi-directional referral processes
for patient care (Table 10). Some have referral processes for home delivery of medications and
supplies and medication adherence assistance; however, the number of these pharmacies is small.
These processes may not be applicable to their practice types.
Implications. Bi-directional referral processes remain underdeveloped within the state. A
substantial opportunity for care connectedness and expanded access to providers exists through
bi-directional referral processes. Understanding the influences on bi-directional referral in the
environment of the healthcare sector is needed to advance the opportunity between pharmacists
and providers in the current healthcare landscape.
Familiarity with Community Health Workers (CHWs)
Familiarity with Community Health Workers (CHWs) is very low among all pharmacies
(Table 11). Pharmacies of Interest remain largely unfamiliar with CHWs and CHWs are
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uninvolved with pharmacies and pharmacist-provided patient care. Only a small handful of
pharmacists in this category were familiar with CHWs and even fewer pharmacists involved
CHWs in patient care or referred patients to CHWs (Table 12). Other Pharmacies were similar
in this regard (Table 13).
Implications. A tremendous opportunity for growth exists within the state for CHWs to
make referrals to pharmacists. Most pharmacists are unaware of CHWs and the opportunity that
they provide to refer patients who have medication adherence needs back to pharmacists.
Educating pharmacists about CHWs and teaching CHWs how to refer to pharmacists is a
potential statewide strategy.
Familiarity with Community Health

Workers (CHWs)
60 15%
15%
Number of Pharmacies
40 10% 9% 10%
7% 9%
7%
20 16% 7% 7% 7%
0
All Pharmacies Pharmacies of Interest Other Pharmacies
Pharmacists are familiar with CHWs
CHWs are involved with patients that use pharmacist's services
CHWs refer patients to the pharmacist for services
Pharmacist refers patients to CHWs for assistance
Fig. 5. Familiarity with Community Health Workers (CHWs).
Pharmacist Provided MTM Services in Practice within the Last 12 Months
Nearly two-thirds (64 percent) of all pharmacies have provided MTM services in the past
12 months (Table 14). This service is predominantly provided in Pharmacies of Interest on the
community level. However, a handful of Other Pharmacies are providing MTM, but not to the
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degree and scope of Pharmacies of Interest. The majority of Pharmacies of Interest (71 percent)
has provided MTM within the last 12 months (Table 15). These services were most prominent
among Mass Merchandise Chain Pharmacies and Grocery Chain Pharmacies. MTM has largely
not occurred to a similar magnitude within Health System/Clinic Pharmacies.
Other Pharmacies have overwhelmingly not provided MTM within the last 12 months
(Table 16). Within this category, about half of Specialty Pharmacies have provided MTM;
however, this number of pharmacies is small. Overall, pharmacies in this category have not
provided MTM as many do not see MTM as an applicable service to their practice setting.
Implications. The majority of pharmacists within the state are providing MTM and direct
patient care services. These services allow patients to access chronic disease management and
other care services, develop stronger relationships with pharmacists, and establish a more
consistent care regimen through interaction with pharmacists. These benefits offer a promising
outlook on the provision of MTM and direct patient care services. While pharmacies still
experience significant barriers related to MTM, a great opportunity for the State of Nebraska
exists in further promoting MTM and direct patient care services among community pharmacies.
Pharmacist Provided MTM Services in

Last 12 Months: All Pharmacies
250 64%
200
150 36%
100
50
0
Yes No
Fig. 6. Pharmacist Provided MTM Services in Last 12 Months: All Pharmacies.
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Mechanism(s) Used by Pharmacists to Deliver MTM
Pharmacies providing MTM services nearly exclusively deliver the patient-centered
service via face-to-face/in-person or telephone (Table 17). These two mediums of delivery are
the most common among all pharmacies. Pharmacies of Interest predominantly deliver MTM
services via face-to-face/in-person or via telephone. Only one pharmacy in this category provides
MTM services via telehealth videoconferencing (Table 18). Other Pharmacies delivered MTM
services primarily via telephone, with a smaller portion conducting face-to-face/in-person (Table
19).
Implications. Pharmacists predominately deliver MTM services through traditional
methods of face-to-face/in-person or via telephone. Medicare standards require that MTM be
offered face-to-face, unless the patient specifically agrees to an alternative communication
method. As technology continues to progress, opportunities for telehealth videoconferencing or
electronic-based MTM services (potentially through EHRs) may become available. It is likely
the traditional methods of face-to-face/in-person will continue as the primary delivery mode.
Organizational Structures
Overall, relatively few pharmacies provide MTM as part of an Accountable Care
Organization (ACO) or Patient-Centered Medical Home (PCMH) (Table 20). Those that do are
among the Pharmacies of Interest category. These pharmacies overwhelmingly listed
OutcomesMTM1 and Mirixa2, two companies that identify patients who are eligible for MTM
based upon the patients insurance program, or other software as the ACO, rather than the ACO
1
OutcomesMTM, West Des Moines, IA. Company website: www.outcomesmtm.com
2
Mirixa, Reston, VA. Company website: www.mirixa.com
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entity itself. It is unknown if these pharmacies are also accessing patient candidate names
through software provided through an ACO directly. A few pharmacies report providing MTM
services through a PCMH. For those pharmacies, many listed OutcomesMTM and Mirixa or
other software as the PCMH, rather than identifying the PCMH entity itself. Again, the
relationship between the software and PCMH is unknown (Table 21).
Of the Other Pharmacies, only one specialty pharmacy indicated provision of MTM as
part of an ACO and as part of a PCMH (Table 22).
Implications. Pharmacists remain largely uninvolved with ACOs and PCMHs. A large
opportunity for growth exists in this area to educate pharmacists about these models and to
integrate pharmacists within these organizations to improve patient access.
Formal MTM Training Program Attendance
Approximately one-fourth (26 percent) of all pharmacists providing MTM have
completed a formal MTM training program. Both Pharmacies of Interest and Other Pharmacies
have very similar formal training completion rates among pharmacists (Table 23). Among
Pharmacies of Interest, formal training programs completed by pharmacists include
OutcomesMTM or Mirixa training or corporate-based training (Walgreens, Dillon Stores,
Kroger, etc.). Several others indicated training from a university or professional-based
association. Some pharmacists indicated they will be completing training in the near future
(Table 24).
Only a handful of pharmacists in the Other Pharmacies category have been formally
trained in MTM. Those who have received formal training indicated medical condition-specific
21
training (anticoagulation, diabetes management) or corporate-based training. Most have not
received formal training in the provision of MTM (Table 25).
Implications. Training programs completed by pharmacists are typically done so within
the corporate structure (MTM vendor or corporate business). The similarity of these training
programs is uncertain, and a substantial portion of the pharmacist workforce could still benefit
from receiving training in provision of MTM and direct patient care services. A standardized
training process could be developed for pharmacists throughout the state of Nebraska. The
American Pharmacists Association offers a 21 hour continuing education program in MTM
service provision. This program should be considered.
Formal MTM Training Program

Attendance: All Pharmacies
300 74%
250
200
150
100
26%
50
0
Yes No
Fig. 7. Formal MTM Training Program Attendance: All Pharmacies.
Length of Time Providing MTM Services
The majority of all pharmacies providing MTM have offered the service for the past 5
years (Table 26). The highest concentration of length of time providing MTM services is
between 1 and 5 years among both categories of pharmacies. Among Pharmacies of Interest, the
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majority of pharmacies have been providing MTM between 1 and 5 years, with the bulk of those
providing services for less than 2 years. This relatively recent initiation of MTM services
indicates the rapid expansion of pharmacy-provided clinical services. Several pharmacies have
begun MTM services within the past year and several have been providing MTM for over 5
years (Table 27).
Among Other Pharmacies, the provision of MTM has been occurring steadily over our
identified time frame increments. Pharmacies within this category have not realized a significant
and rapid pickup of MTM services (Table 28).
Implications. The provision of MTM services within Nebraskas pharmacies is relatively
new (within the last 5 years). With this recent development, barriers and roadblocks are expected
before reaching full integration and implementation of direct patient care services delivered
through pharmacies. This concept still has significant opportunity for growth within the state,
particularly related to pharmacists being recognized as providers, patients becoming aware of
these services and their benefits, pharmacy workflow operations, and compensation/
reimbursement for services. A significant uptake of these services has occurred within Nebraska
pharmacies with much room for expansion.
Length of Time Providing MTM Services:

All Pharmacies
100
22% 17% 20% 18%

5% 6% 4%
0
< 6 months 6 months to < 1 year 1 to < 2 years

2 to <3 years 3 to < 5 years 5 to < 10 years
Fig. 8. Length of Time Providing MTM Services: All Pharmacies.
23
Number of Patients who receive MTM Services in a Month
Overall, pharmacies report experiencing monthly patient loads for MTM provision
between 0 and 199+ (Table 29). Within Pharmacies of Interest, a majority of pharmacies (79
percent) have monthly average patient loads of 0-19 patients for the provision of MTM services.
Overall, MTM patient loads for pharmacies were relatively modest (Table 30).
Other Pharmacies generally experience a lower (0-2) number of patients per month. A
few pharmacies within this category serve average patient loads of more than 50 patients per
month (Table 31).
Implications. Pharmacists delivering MTM and direct patient care services experience
smaller monthly patient loads, revealing an opportunity for increased promotion and education
about MTM and direct care services to patients, particularly patients with chronic disease
conditions, in Nebraska. Additionally, these numbers display the opportunity for the State of
Nebraska to foster changes necessary to allow for full implementation of MTM services within
pharmacies by dismantling barriers related to compensation/reimbursement and workflow
operations. While these services are relatively new and patient loads relatively low, the initial
uptake of patients utilizing MTM services within Nebraskas pharmacies is promising and a
tremendous opportunity for growth still exists.
24
Average Number of Patients who
70
receive MTM Services in a Month:
29% Pharmacies of Interest
60
50
40 17%
17%
16%
30
11%
20
6%
10
0
0-2 3-4 5-9 10-19 20-49 50-199
Fig. 9. Number of Patients who receive MTM Services in a Month: Pharmacies of Interest.
Identification of Patients as Candidates for MTM Services
Overall, the majority of pharmacies identify patients as candidates for MTM through
referrals from MTM vendors (Mirixa, OutcomesMTM, etc.) (Table 32). Pharmacies of Interest
also commonly identify patients through a health plan or pharmacy benefit manager (PBM)
(Table 33). About half of these pharmacies identify patient candidates through referrals from a
health plan or PBM and some pharmacies identify patient candidates that have a specific health
plan. The small number of Other Pharmacies that reported providing MTM services identify
patients through a physician referral or because the patient has a specific disease condition (e.g.
hypertension, diabetes) (Table 34).
Implications. Pharmacists primarily utilize an MTM vendor to identify patient candidates
for MTM. Pharmacists may be limited by the software systems that are used, but given the
current pharmacy workflow environment, pharmacists predominately continue to utilize MTM
25
vendor systems to identify patient candidates. As strategies are implemented to provide MTM to
more patients, alternative methods (such as direct requests from patients, referrals from CHWs
and others) and internal identification systems within corporations are more likely to emerge as
prominent.
Identification of Patients as
Candidates for MTM Services:
Pharmacies of Interest
200 80%
46%
100 27%
13% 17%
Patients are referred by an MTM vendor

Bill Insurance/PBM/Medicare
Patients with a specific health plan
Patients with a documented or suspected medication-related problem
Patients request MTM services (self-referral)
Fig. 10. Identification of Patients as Candidates for MTM Services: Pharmacies of Interest.
Ways Patients and Providers are made Aware of MTM Services
The most common method for pharmacies to promote MTM services to patients and
providers is pharmacy-initiated contact with the patient via telephone, email, mailed letter, or
other medium (Table 35). Pharmacies typically receive targeted lists from MTM vendors and
proactively contact patients to inform them of the pharmacist-provided clinical service. Some
pharmacies utilize a combination of promotion strategies listed within the table, as well.
However, it should be noted that 29 percent of pharmacies did not respond to this question.
About a third of Pharmacies of Interest initiate contact with the patient via telephone,
email, or mailed letter. It is also common for insurance companies, pharmacy benefit managers,
26
or MTM vendors (Mirixa, OutcomesMTM, etc.) to directly contact the patient to inform him or
her of eligibility of MTM services. Several pharmacies use a combination of tactics to promote
MTM services, as well.
Other Pharmacies typically promote MTM services by initiating contact with patients via
phone, email, or mailed letter from the pharmacy (Table 37). Some pharmacies in this category
contact the patients provider or physician and some utilize a combination of promotion tactics.
However, this does not occur to the same degree of pharmacies directly contacting the patient to
promote MTM services and this is a small number of pharmacies in the state.
Implications. Primarily, pharmacies are contacting patients to inform them of their
eligibility for MTM and direct patient care services. When insurance companies, pharmacy
benefit managers, or MTM vendors contact the patient directly, it is possible patients do not view
this as personal as their pharmacist contacting them about their MTM eligibility. Further
promotion of direct contact from the pharmacy to the patient about MTM services could be an
area of growth for the state and an opportunity to train pharmacists/pharmacies about this.
Ways Patients and Providers are Made Aware of MTM

Services: Pharmacies of Interest
100 33%
12% 5% 12% 6%
1% 1%
0
Pharmacy initiates contact with patient

Bill Insurance/PBM/Medicare
Direct contact from Insurance Provder/PBM/MTM Vendor
Communcation with patient at point-of-sale
Pharmacy advertisement
Other-multiple
Do not promote
Fig. 11. Ways Patients and Providers are Made Aware of MTM Services: Pharmacies of
Interest.
27
Amount Pharmacists Charge for MTM Services
A large portion of pharmacies do not charge a fee for provision of MTM (Table 38).
Many pharmacies charge MTM vendor rates or bill insurance, PBM, or Medicare. However,
these rate amounts were largely not specified by respondents. One third or more of Pharmacies
of Interest do not charge for provision of MTM (Table 39). This is common for many
pharmacist-provided services, and MTM is no different. For pharmacies that do charge for
MTM, MTM vendor (OutcomesMTM, Mirixa, etc.) rates are charged, though the amount varies
and was generally not specified. Several pharmacies bill insurance companies, pharmacy benefit
managers, or Medicare, but again, pharmacies generally did not specify a monetary amount.
Though not as common, some pharmacies charge pharmacy-specific rates, ranging from $2 to
$150. These rates commonly depend on the services provided and/or length of time required for
service provision by pharmacist.
Among Other Pharmacies, the majority of pharmacies do not charge for provision of
MTM (Table 40). Only several pharmacies charge MTM vendor rates, but these rates were
generally not specified. Overall, pharmacies are not charging for provision of MTM services.
Implications. With a large portion of pharmacists not charging for provision of MTM
services, pharmacists predominately view MTM and direct patient care services as part of their
regular work duties. Pharmacists are trained to serve patients and view these types of services as
part of their profession, so the need to document and bill for these services is somewhat of a
foreign concept historically to pharmacists. Pharmacists typically do not view these services as a
profit-generating tool for the pharmacy. Rather, the services are an opportunity for pharmacists
to develop a closer relationship with patients to allow them to improve health management and
outcomes. The formalization of MTM services has incorporated the practice of billing and
28
documentation for these services. This has gradually been adopted over the last five years
among many of the pharmacies offering formal MTM. It is a substantial growth area for
pharmacists in the state.
Amount Pharmacists Charge for MTM

Services: Pharmacies of Interest
80
35%
70
60
50
40
16% 15%
30
11%
20
10
Charge vendor rates Bill Insurance/PBM/Medicare

Charge pharmacy-specific fees Do not charge
Fig. 12. Amount Pharmacists Charge for MTM Services: Pharmacies of Interest.
Pharmacy Compensation to Pharmacists for Providing MTM Services
Nearly all pharmacists receive compensation for provision of MTM services as part of
their standard salary pay as most pharmacists are employees of larger pharmacy corporations
(Table 41). Pharmacies of Interest overwhelmingly indicated that compensation for MTM
services is part of the standard pharmacist salary at their pharmacies and no separate pay is
received as a form of compensation (Table 42). Few Pharmacies of Interest indicated they
provide compensation through consideration of merit raises, bonus hours, additional paid time,
29
or other forms of compensation. Similarly, Other Pharmacies also overwhelmingly indicated
that compensation for MTM services is part of the standard pharmacist salary and no separate
pay is received as a form of compensation (Table 43). Only one pharmacy in this category
indicated their pharmacists receive compensation in some other form not listed on the survey.
Implications. Pharmacists receiving compensation for provision of MTM as part of their
standard pay reinforces the commonly-held viewpoint that these direct patient care services are
part of the pharmacist profession responsibilities. Pharmacists see themselves as an active player
in the patients healthcare continuum, but they are not necessarily recognized as a provider by
patients or other healthcare providers. With pharmacists receiving compensation for these
services as part of their regular pay, they are expected to provide MTM within their normal
workflow. Improvements to pharmacy workflow operations could be an important area of
growth given the pay practices of pharmacies within the state. This viewpoint held by
pharmacists is a likely explanation for why pharmacists are not aggressive about recruiting
patients to their services or billing for services. There is opportunity to promote improved
recognition of performance by pharmacists with corporate pharmacy managers.
30
Pharmacy Compensation to Pharmacists for
Providing MTM Services:
200 Pharmacies of Interest
89%
180
160
140
120
100
80
60
40
20 6% 4%
4% 3%
0
Part of standard pharmacist salary - no separate pay received
Considered in merit raises
Pharmacists earn additional bonus and/or incentives
Additional paid time on hourly or overtime basis and/or pay differential
Other
Fig. 13. Pharmacy Compensation to Pharmacists for Providing MTM Services: Pharmacies of
Interest.
Challenges Pharmacies Face when Providing MTM
Overwhelmingly, pharmacists do not have adequate time is cited as a challenge in
providing MTM (Table 44). Other common challenges faced by pharmacies are disinterested
patients or patients declining participation and lack of insurance companies paying for these
services. Generally speaking, Pharmacies of Interest and Other Pharmacies experienced the
31
same challenges at relatively the same rates. The most significant differences existed between the
two pharmacy categories for lack of insurance pay and pharmacists having inadequate time.
Among Pharmacies of Interest, the most commonly noted challenge is inadequate time
for the pharmacist to provide an in-depth, comprehensive MTM session to patients (Table 45).
Another significant challenge faced by more than half of pharmacies in this category is a lack of
interest from patients to participate in MTM services offered. Only a few respondents indicated
that a lack of support of MTM services from upper management, a lack of collaborative
relationships with prescribers and physicians, and local physician resistance as significant
challenges to the provision of MTM services.
The majority of Other Pharmacies indicated that the lack of insurance company
reimbursement for provision of MTM services is one of the most significant challenges faced
(Table 46). In addition, nearly half of the respondents in this category also indicated that billing
and documentation difficulties impeded the provision of MTM services. Similar to the Pharmacies
of Interest, nearly half of the respondents in this category indicated a lack of interest from patients
to participate in MTM services as another significant challenge. Inadequate training or experience
and lack of collaborative relationships with prescribers and physicians as challenges faced were
also only selected by a handful of pharmacies.
Implications. Challenges faced by pharmacists are a common aspect of the profession.
Inadequate time to provide MTM and direct patient care services experienced by pharmacists
reveals a workplace setting that is heavily focused on prescription filling and dispensing,
communication with insurance companies, and general pharmacy operations. Generally,
pharmacists feel challenged by the recent push for provision of MTM and direct patient care
services within pharmacies and significant barriers still exist to fully implement and integrate. A
32
substantial opportunity for growth related to transforming pharmacies and integrating
pharmacists as providers to improve health conditions and outcomes, particularly among patients
with chronic disease conditions in low-provider areas, exists for the state. Internal changes to the
pharmacies (layout and workflow) to create a welcoming environment to patients may be a next
step in the advancement of these services. Education and promotion of MTM to patients is a
strategy to consider to better inform patients about the value of MTM to their self-management
and care. A unique opportunity for the State of Nebraska to serve as a partner to dismantle these
barriers, better connect pharmacists to the patient healthcare continuum, and improve pharmacy
workflow operations is apparent.
Benefits Pharmacists have realized from offering MTM Services
Among Pharmacies of Interest, pharmacists in charge of the pharmacies providing
medication therapy management (MTM) services report that MTM delivers personal, health, and
economic benefits to both patients and pharmacists. Pharmacists generally view the service as a
mutually beneficial tool to improving health outcomes, particularly among patients with chronic
disease. A common viewpoint expressed by pharmacists is that MTM is what we do in basic
routine work as a pharmacist. In this sense, some pharmacists did not wish to recognize MTM as
a separate and distinct activity from their inherent professional role despite the economic policies
governing reimbursement for professional service provision.
Personal Benefits Realized by Patients from MTM Services
Pharmacists are happy to help others feel better and live a meaningful life. Patients
experience a closer and more trusted relationship with pharmacists as a healthcare provider
33
through receiving MTM services. The interaction opens up dialogue with the pharmacist.
Patients also build greater self-awareness regarding their own care. This is an essential gain,
improving patient self-efficacy.
Personal Benefits Realized by Pharmacists Who Provide MTM Services
Pharmacists providing MTM widely view the patient-centered service as a tool to
enhance personal buy-in from patients to optimize their drug therapy care.
I feel my patients are more invested in their care plan after MTM is rendered. In
addition to dispensing prescriptions, pharmacists collaborate with patients, educating them by
tailoring and optimizing the ways patients use their medications and answering questions they
and their family members and care takers have. Pharmacists engage by coaching patients to
better health management and outcomes.
Patients trust and respect you more once [the patient has] done a complete medication
review. Participation builds trust between pharmacists and patients developing stronger health
care based relationships. Pharmacists describe MTM as increasing patient interaction by
opening up lines of communication with patients. This increases patient loyalty and results in
patients returning for service.
MTM is very enjoyable. I wish we could do them on a full-time basis! Pharmacists
have an enhanced professional experience and reported greater satisfaction and perceived
credibility by interacting with patients through a more intimate relationship. The profession is
refocused on providing clinical care. Pharmacists report feeling part of a patients care team,
empowered to advise the patient as a trusted, reliable source of personal health management.
Pharmacists in community settings have particularly strong potential for influence. This setting
34
is open access to patients who walk in most anytime at their convenience, and regularly if
there is medication refill needed. For these reasons, pharmacists often see patients more
frequently than other members of a patients care team.
Health Benefits Realized by Patients from MTM Services
After a complete medication review our patients have a better understanding of what
their medications are for, why they are important, and how to properly take them. This improves
patient outcomes. Providing MTM, according to most pharmacists, allows the patient to benefit
from improved health status and outcomes in almost all cases.
Resolve issues and increase medication adherence. Pharmacists have observed
increased medication adherence and compliance to a drug regimen by providing MTM. Other
health- and medical-related benefits through MTM have are decreased patient hospitalizations
and improved chronic disease management.
It catches therapy gaps; identifying problems that otherwise go undetected. It is a
service provided for patient safety. Pharmacists have corrected potentially severe drug
interactions, eliminated unnecessary and outdated drug regimens, and improved patient drug
profile efficiency and effectiveness.
Health Benefits Realized by Pharmacists Who Provide MTM Services
By providing MTM, pharmacists are able to help the patient understand and manage
their medications to better improve their health. Pharmacists have been able to view patient
care as a holistic endeavor, assessing complete drug therapies and patient conditions and
identifying specific problems for each individual patient. Through this approach, pharmacists
35
provide insight and advice to increase buy-in from patients to better manage their overall health
and lifestyle.
Financial Benefits Realized by Patients from MTM Services
We save our patients money. Providing MTM serves as a cost-saving measure for
patients by eliminating unnecessary drugs or other potential medical-related expenses such as
those from drug interactions or non-adherence.
Financial Benefits Realized by Pharmacists and Pharmacies Where MTM Services are
Provided
MTM is a nice added source of income for services we already provide. Now we can
get paid for some of them. Pharmacists providing MTM have realized financial benefits to both
patients and pharmacies. Pharmacists view the provision of MTM services as a supplemental
source of income for the pharmacy. While a significant amount of pharmacists view
reimbursement rates for MTM services as inadequate, several are realizing a financial benefit to
the pharmacy. MTM, according to pharmacists, allows patients and insurance companies to save
money while bringing in an additional source of income to assist in the pharmacys bottom line.
The enhanced patient relationship realized as increased patient loyalty with patients returning for
service is also realized as repeat business.
Benefits Realized by Other Pharmacies
Among Other Pharmacies, there were a handful of pharmacies who reported providing
MTM. Benefits realized from providing MTM were virtually identical to the benefits realized in
36
the above category. Pharmacists have observed positive patient health outcomes, improved
pharmacist-patient relations, and improved patient care experiences. Multiple pharmacists
mentioned feeling appreciated by prescribers for MTM service products such as dosage
adjustments and health status monitoring, though the amount of pharmacists listing this benefit
was negligible. Overall, the provision of MTM, whether in a pharmacy likely or unlikely to
provide the service, is considered to improve patient and pharmacist experiences, enhance health
outcomes, and financially benefit all parties involved.
Implications. Pharmacists are able to recognize the many personal, health-related, and
financial benefits that result from the provision of MTM in their practices. For instance, MTM
allows pharmacists to feel like they are building stronger bonds of trust and loyalty with their
patients, and they also receive more appreciation from patients participating in the programs. The
low cost of most MTM sessions allows patients to enroll in the programs without having to
worry about financial strain, and reimbursement from MTM vendors can provide some extra
finances to providing pharmacists. Patient health benefits such as increased medication
adherence and increased self-efficacy have also been discovered through the delivery of MTM
services in pharmacies. The expanded provision of formal MTM services over the past five years
and the realized benefits of MTM by already-providing pharmacists in addition to an established
view of MTM as an inherent part of the profession create an atmosphere that is ideal for the
growth of a holistic, patient care-centered pharmacy model.
New Opportunities Realized Where MTM Services are Provided
As pharmacists reported their views about MTM service provision, they offered ways in
which they were considering or implementing new opportunities both for improved outcomes
37
and improved care. Here are new opportunities realized by some pharmacies in their
communities:
Value to patients resulted in pharmacists describing opportunities of approaching
businesses in the area to contract for expansion of MTM services.
Optimized drug therapy and reducing risk of harm and injury resulted in improved star
ratings, potentially important to patient-centered medical home participation and
accountable care organization contracting.
Improved adherence led to improved pharmacists services of quarterly chart review of
their patients to identify medication problems needing resolution, and introducing
medication compliance packaging, as opposed to bulk medication bottle dispensing only.
Trust relationship leads to patient referrals.
Personal buy-in from patients results in repeat business.
Implications. The provision of MTM leads to improved pharmacy ratings, stronger
customer bases, patient risk reduction, and the expansion of pharmacy services. These self-
reported benefits of MTM services could be used to generate greater interest in the
implementation of MTM in pharmacies that previously expressed little to no interest in doing so,
or felt like MTM was not applicable to their practice.
Pharmacies of Interest Getting Ready or Just Beginning MTM Provision
Overall, the tone of the pharmacists responses was that many are aware that the
provision of MTM services as a formal program is gaining momentum. While they did identify
barriers, most indicated they were preparing or getting ready in some way to provide MTM
services.
38
I havent had time, but our situation is improved and we do plan to start. While
pharmacists identified several challenges, many indicated they will be initiating MTM services
within the near future. These pharmacists wanted to be responsive to the ideas indicating that
MTM service provision is important and matters; there is intention.
Just starting this service now. Several pharmacists explained that they are just starting
up MTM services, either for the first time or reinitiating after a period of inactivity. For some
pharmacies it has involved reworking workflow, constructing physical space needs, and learning
how to obtain reimbursement.
Business Model for MTM Does Not Include All Pharmacists
Our company provides this service and has one pharmacist who goes from site-to-site.
This business model was described in a couple of smaller chain pharmacies where the pharmacist
who had MTM expertise traveled between stores and performed these services.
Key Barriers to Implementation of Services in Pharmacies of Interest
Key barriers related to pharmacy workflow and workload, reimbursement for services,
pharmacy design, and patient relations were identified by pharmacists.
Workload and Time. MTM is considered to be too time consuming. I am one
pharmacist with one technician and we are very busy every minute just running the business.
Most pharmacists need uninterrupted time to complete MTM, and with a significant
amount of pharmacies running as single-pharmacist operations, the lack of additional staff
prevents pharmacists from providing the patient-centered service altogether. Pharmacists are
regularly pressed for time, and having to provide MTM services is seen as an additional burden,
39
preventing basic duties within the pharmacy being accomplished. Most pharmacists are focused
on filling prescriptions, dealing with insurance companies, dispensing medications, and assuring
basic safety with medication use. With understaffed locations, an inflexible workflow operation,
and other pharmacy operation obligations, pharmacists feel stretched to the maximum and cite a
lack of time as the reason for not providing MTM services.
Pharmacy Space. Several pharmacists consider their pharmacy design and lack of
physical space not conducive to providing MTM services. We do not have a dedicated private
space to provide MTM. We are in the process of adding a private counseling room and
anticipate adding MTM services later this year.
Pharmacists prefer a consultation area in which they can sit down and engage patients
regarding their drug regimens and health management in a confidential and private manner.
Without physical space to accommodate patients for MTM services, pharmacists do not feel they
are able to provide the service altogether.
Billing and Reimbursement. Pharmacists largely consider the reimbursement amounts
for providing MTM to be dismally low. The reimbursement does not justify the time involved.
For the amount of time required to complete an MTM session, pharmacists are not
realizing reimbursements consistent with the standard professional rate of pay. Several
pharmacists have attempted to provide MTM services, but have since discontinued the service
after receiving little to no compensation for the services provided. Another complicating factor
for pharmacists is the varying coverage of such services by insurance plans. Pharmacists have
difficulty billing and coding for MTM services, and consider these administrative issues, rejected
claims, and low reimbursement rates detrimental to their work, resulting in lost time and money.
The lack of coverage of MTM services, particularly by Nebraska Medicaid, was also identified
40
as a reason for not providing MTM. Pharmacy information technology and operation systems are
not set up to bill for MTM services and many pharmacists also do not feel adequately trained in
operating systems to bill and track MTM services provided to patients, resulting in a declination
to provide MTM altogether.
Patient Relations. Pharmacists often times experience difficulty in identifying patients
eligible for MTM services. When offering MTM services to patients, some pharmacists also feel
not enough patients are interested or utilize the service to justify offering the pharmacy service.
Patients are unwilling to sit down and discuss their health issuesthey think their doctor
should do that.
Some patients are, at times, reluctant to discuss and allow their pharmacist to serve as a
member of the patients care team, discouraging pharmacists from providing MTM.
Implications. Many pharmacies are in the process of starting up MTM programs at their
pharmacies or plan to do so in the near future. Areas that need to be addressed in order for
successful implementation and sustainability from the viewpoints of pharmacists who are ready
to start but have been delayed are:
An absence of a workflow environment that accommodates for both the extra time and space
needed for the provision of MTM services to patients.
Low reimbursement given to pharmacists by MTM vendors like Mirixa and OutcomesMTM
in addition to confusion with billing and insuring hinders their progress.
Pharmacists cannot simultaneously conduct the prescription dispensing activities and MTM
because of inflexibility of time and staffing with current resources. Numerous participants
indicated that they do not have the ability and/or authority to hire new pharmacists in order to
free up time and therefore provide MTM in their pharmacies.
41
Some patients do not recognize the pharmacists as a part of their health care team, and this
disconnect makes patients reluctant to sign up for MTM services and discuss their health
issues with anyone other than their physician or doctor.
In order to create a sustainable model for the growth in provision of MTM services, these
issues must be addressed.
42
CONCLUSIONS FROM SURVEY OF PHARMACISTS ACROSS STATE
Pharmacists provide general services (medication adherence assistance,
immunizations/vaccinations, check persons blood pressure to assess medication
effectiveness, offer to teach how to use blood pressure checking and blood glucose
testing products/devices). Pharmacists have a great opportunity to provide formal,
advanced disease-specific patient education (hypertension self-management education,
diabetes self-management education, comprehensive anti-coagulation management) with
a ready audience in patients who access pharmacists in their local communities.
Early signs of collaborative practice agreements, bi-directional referral processes, and
awareness and involvement of community health workers (CHWs), while low, suggest a
beginning social infrastructure within the state, promising approaches to better
integrating pharmacists into the patient healthcare continuum.
Integration of pharmacists within Accountable Care Organizations (ACOs) and Patient-
Centered Medical Homes (PCMHs) has occurred in a few settings and could be used as
models for further development on a statewide basis.
The relatively recent uptake of MTM services within pharmacies and low average patient
loads suggest room for growth and improvements in promotion of MTM and direct care
services to patients.
While the majority of pharmacies utilize MTM vendors such as OutcomesMTM and
Mirixa, an opportunity for alternative systems to identify patient candidates for MTM
may expand the access patients have to the pharmacists services.
Pharmacists predominately view the provision of MTM and direct patient care services as
a responsibility in which the profession has always been engaged.
43
Overall, pharmacist-provided MTM and direct patient care services are delivered in an
understaffed environment and a fragmented and underdeveloped system. The workplace
settings have a role in developing better workflow systems and physical environments
that are inviting and supporting of MTM and chronic disease management clinical care
provision by pharmacists.
44
INTERVIEWS OF CORPORATE PHARMACY EMPLOYERS OF PHARMACISTS IN
NEBRASKA
METHODS
Study sample. This study was designed to determine how corporate pharmacies are
positioning themselves to deliver MTM services and direct patient care services on the
community level throughout Nebraska. National and regional level corporate pharmacy
managers were identified through the community pharmacy database developed by integrating
the State Board of Health listing of community pharmacies and the Pharmacy Quality Assurance
Review (PQAR) data available through the State of Nebraska. The database was analyzed for all
of the employers in the state, and the top 20 employers identified for participation. These persons
were invited by email to participate in a telephone interview at a prearranged time.
Interview questions. The email invitation included a set of questions that matched key
aspects of the written survey sent to all pharmacists in charge of Nebraska community
pharmacies. This provides a baseline understanding of the corporations basic services that are
being provided.
PARTICIPATION
Corporate managers from nine pharmacy corporation employers participated in the
interview from the original 20 persons identified. Two additional corporations completed the
email survey without participating in the full interview for a total of 11 participating
corporations. One corporate manager declined participation; this corporation was involved in a
corporate takeover and was restricted from discussing any business strategies.
45
FINDINGS
This section of the report details the key themes representing the corporate manager
perspectives. Three thematic areas related to pharmacists providing MTM and direct patient care
services emerged: (a) financial and economic perspectives; (b) MTM and the healthcare
spectrum; and (c); MTMs implications on pharmacy operations. Subthemes are identified within
each using rationale from the point of view of the corporate representative respondents to reflect
their perspectives.
Financial and Economic Perspectives
Subtheme 1: Pharmacist Compensation and Remuneration for MTM Services is an upside down
payment model.
From the pharmacy managers perspective, pharmacies are not getting a fair payment for
services provided by their pharmacists to encourage them to continue to invest in MTM and
direct patient care services on this financial component of business alone. Many corporate
representatives described reimbursement rates for MTM services as substantially lower than the
standard professional rate of pay for a pharmacist and do not consider the reimbursement
amounts those payers are providing for MTM to be competitive. Pharmacies providing MTM
and direct patient care services are realizing no or a very low reimbursement for services
provided. Many local corporations are offsetting this expense through other areas of successful
revenue generation in their businesses to keep afloat MTM and direct patient care services for
the other benefits that providing these services brings to the retail business side of the industry.
Generally, MTM is not viewed as a revenue-generating tool for pharmacies by the corporation
managers at this time.
46
Among corporate pharmacy managers, concern also exists about compensation to
pharmacists for providing of MTM and direct patient care services. Currently, a majority of
pharmacists are expected to provide these patient-centered services within their normal work
duties and are paid as part of their regular salary or wage, without a workload reduction in the
pharmacy. In nearly all cases, pharmacists are not provided additional or extra pay for provision
of MTM services to patients.
Implications. Corporate pharmacy managers are challenged by the inadequate financial
model for the current approaches to MTM service provision. Overall, pharmacy managers
support offering these services to patients; however, they are working through strategies to
improve the financing of these services. Without a stable financial model, it is unclear to the
pharmacy managers how much and when MTM and related services will expand from the
corporate point of view.
Subtheme 2: Uncertain about Impact of the Rise of Pay-for-Performance Models
Transition to pay-for-performance payment models means the pharmacy profession and
the pharmacy business corporations have to learn how to adapt to new systems of payment,
determine how to navigate payment processes and billing systems, and shift the compensation
for services focus more on patient outcomes rather than volume-based prescription drug
dispensing. This process, which is new for pharmacists, may prove to be particularly difficult as
workload demands on pharmacists have not lessened, and in many cases, have only increased.
This new payment model in health care has pharmacy corporate managers unsure how
payments will be generated and revenue will be realized for providing MTM services. Paired
with an increasing focus and expectation of additional pharmacist-provided clinical services, this
47
increases the uncertainty and apprehension about such developments related to payment models
and provision of services. In general, corporate pharmacies are unsure of the impact of the rise of
pay-for-performance models on pharmacist-provided care services at this time.
Implications. Pharmacists have expected themselves, and are often expected by patients
and other providers, to deliver services, including clinical-based services, at no charge to the
patient. These services typically take more time and detract the pharmacist from filling
prescriptions and meeting other pharmacy operation obligations. Within Nebraska, corporate
pharmacies are attempting to strike the right balance between providing patient-centered services
in accordance with a value-based care model and meeting traditional pharmacy-based operations
responsibilities such as filling and dispensing prescriptions.
Subtheme 3: MTM and Clinical Services Are a Tool for Patient Retention
These services are viewed as an additional benefit to patient care and an opportunity to
develop a more intimate pharmacist-patient relationship. Rather than viewing MTM and direct
patient care services as a solely revenue-generating and profit-driving tool, corporate pharmacies
view MTM and direct patient care services as a method by which to retain customers, develop
relationships, and prevent the loss or transferability of patients to other competing pharmacies.
Generally, MTM and direct patient care services are being utilized as a competitive patient
retention tool rather than a revenue-generating tool.
If pharmacies can offer services to better the relationship between pharmacists and
patients, pharmacies believe they will be able to retain patients and realize greater revenue from
continued business relationships with patients. Overwhelmingly, corporate pharmacies attempt to
48
view MTM and direct patient care services through a broader lens and as a tool to retain
customers, improve relationships, and realize financial gain over the long-term.
Implications. Corporate pharmacies have been challenged to look at provision of MTM
and direct patient care services through a longer-term financial lens. Noting that this has been a
challenge for particular corporate pharmacies within Nebraska, promotion of MTM financial
benefits over the long-term may be beneficial. If pharmacies within the state are able to become
aware of financial benefits and patient loyalty, more widespread adoption of MTM services may
be a result among Nebraska pharmacies.
MTM and the Healthcare Spectrum
Subtheme 1: An Uncertain Position We are Working with a Piecemeal System
Looking at the current healthcare landscape in regard to MTM and direct patient care
services, pharmacies are generally uncertain about the pharmacists position. Pharmacists realize
the increased focus placed on providing such services, but they are unsure how to provide these
services in an integrated, feasible, and beneficial manner. MTM is largely seen as just one
vehicle for improving patient care, and not the end-all be-all of services. Pharmacy managers
understand direct patient care services as a package, and MTM is only one of those services
offered. To fully improve patient care outcomes, pharmacy managers see the need for
collaboration among many entities and providers. However, they are generally unsure where to
position themselves in todays healthcare landscape to best provide these services.
Implications. Pharmacy managers within Nebraska sense uneasiness about their position
within the healthcare landscape, expected during this time where there is a general lack of
guidance from the healthcare sector and State. Pharmacy managers are left to determine service
49
options and delivery methods on their own, which has proven to be particularly difficult for
smaller and more independent corporate pharmacies. Support from the State of Nebraska and
different areas of the healthcare sector may provide additional knowledge and assistance to
corporate pharmacy managers as they make decisions about MTM and direct patient care
services.
Subtheme 2: Expanding Care PortfoliosDirect Patient Care is the Wave of the Future
Corporate pharmacies have come to quickly realize the industry push to integrate
pharmacists into the patient care process and begin providing more clinical services. Generally,
pharmacies realize the need to considerably improve upon their services and delivery to patients,
more seamlessly integrate these services, and collaborate more frequently with other members of
patients care teams. Pharmacy managers are in the process and need to determine as quickly and
as smoothly as possible which direct patient care services are most feasible, generate the most
revenue, and best improve patient care outcomes. Pharmacies are rapidly becoming a new
vehicle by which to provide patient care, and corporate pharmacy managers are attempting to
determine how to most efficiently and effectively expand their patient care business portfolios.
Implications. Given the speed at which pharmacist-provided direct patient care services
have emerged within the healthcare landscape, pharmacies do not necessarily have precedent at
which to look. Best practices for direct patient care services among corporate pharmacies could
be developed and identified to empower corporate pharmacies within the state of Nebraska to
more successfully and seamlessly improve these clinical-based services. As many corporate
pharmacies have been experimenting with different services, a partnership between industry
50
leaders, healthcare professionals, and the State of Nebraska could be formed to share experiences
related to direct patient care services and identify best practices.
Subtheme 3: Team-Based Approach to CareThe Ultimate Say is with the Prescriber
With the rise in a team-based approach to patient care, corporate pharmacies are well-
aware of the increased drive to better integrate and utilize healthcare providers beyond
physicians to deliver patient care. However, corporate pharmacy managers generally feel
collaboration in regard to MTM and direct patient care services is not happening on the level
necessary to produce improved patient care outcomes. Pharmacist collaboration with other
members of patients care teams is not widely occurring, and pharmacists are uncertain how to
enter into and integrate themselves into a care team. This is often perpetuated by a sentiment
held by pharmacists that prescribers are not widely aware of the value of MTM and other
pharmacist-provided direct patient care services. Pharmacy managers describe that pharmacists
have also experienced prescribers unwilling to relinquish control and allow more team-based
approaches to patient care. Generally speaking, pharmacists experience a division with
prescribers in regard to what services pharmacists are capable of providing and what benefits
they may bring to a patients care process.
Implications. Given the perceived disconnect between pharmacists and providers, team-
based care faces significant challenges, particularly in areas of high need such as rural and
medically-underserved communities in Nebraska. Pharmacists have strong incentives to
continue to focus more on traditional pharmacy operations such as prescription filling and
dispensing in light of reluctant or low-knowledge providers. Increased emphasis on the need for
51
team-based patient care approaches, in which a pharmacist is an active participant, needs specific
strategy development and implementation.
MTMs Implications on Pharmacy Operations
Subtheme 1: Staffing and WorkflowNeed to Better Integrate the Service into Our Work
Corporate pharmacy managers largely realize the potential benefit of MTM and direct
care services to their pharmacists patients, but they still see their pharmacists experiencing
staffing and workflow barriers within the pharmacy walls. To provide the most effective MTM
and direct patient care services, pharmacists need blocks of uninterrupted time to focus on their
patient and his or her needs. However, many corporate pharmacy locations operate single-
pharmacist stores, and uninterrupted time for MTM or other services is considered unrealistic.
Corporate pharmacy managers are working to provide resources, prepared paperwork,
toolkits, and technologies to allow pharmacists to better provide MTM services to patients.
However, MTM and direct patient care services are still currently not well-integrated into
pharmacy workflow operations. Full and seamless integration between pharmacists, prescribers,
payers, and patientsideally through electronic health records (EHRs) and health information
exchangewould be partial improvements in the workflow infrastructure.
Implications. Given that staffing challenges and inadequate time are the most significant
issues experienced by Nebraska pharmacists in providing MTM, additional pharmacy workforce
development (to include pharmacy technicians and support staff) may address this issue within
Nebraska. Without improvements pharmacists are likely continue to feel like they are unable to
provide additional services due to lack of time and capacity. Pharmacies will remain unable to
52
provide expanded patient care services such as MTM to the level necessary to widely improve
patient outcomes among Nebraskans.
Subtheme 2: Medical Providers and Care Referrals
Corporate pharmacy managers describe that collaborative practice agreements (CPAs)
and bi-directional referral processes with other providers of a patients care team are not
occurring on a network-wide level. Despite the lack of partnerships with other medical providers,
pharmacy managers support their pharmacists who stand interested and willing to partner with
other providers and prescribers. In the instances of success in partnering with other patient care
providers, practice agreements and referral processes are happening only on local levels in small
markets through grassroots endeavors. However, very few corporate representatives could point
to specific examples of CPAs or referral processes within the state of Nebraska.
Outside of occasional communication with prescribers about prescription questions or
verifications, little to no communication or collaboration between pharmacists and prescribers is
occurring. Pharmacists understand the potential benefit of partnerships with other members of a
patients care team, but establishing sustainable and mutually beneficial agreements at a broad
level in the current healthcare landscape is just beginning.
Implications. Within Nebraska, corporate pharmacies are unable to or have not yet tapped
into what could be a wide, integrated network of patient care options in which services could be
accessed by a physician in a clinic or a pharmacist at the nearest corporate pharmacy store
location. Corporate pharmacies within Nebraska are unsure how to connect and integrate with
other providers of a patients care team, revealing the unique possibility for the State of Nebraska
to facilitate agreement or referral processes among providers and pharmacists, perhaps through a
53
pilot program in select community settings to begin. Linking together various medical providers,
including pharmacists, has the potential to increase patient care access points and health
monitoring services, particularly for patients with chronic disease conditions, on a much greater
and more convenient scale within Nebraska.
Cross Theme Analysis
Within these key theme areas and subareas identified by corporate pharmacy managers,
several concepts are interrelated and offer additional insight into the perspective faced by
corporate pharmacies. These interrelated concepts are detailed below.
Tool for Patient Retention, Medical Providers and Care Referrals
By most corporate pharmacy managers, MTM and direct patient care services are viewed
as a tool for patient retention and continued business. If providing direct care services, such as
MTM, to patients makes the difference between the patients returning time-after-time for
prescriptions, this is considered to be a worthy endeavor by pharmacists. Corporate pharmacies
view collaborative practice agreements and referral processes as a similar tool for patient
retention. A diversified pharmacy portfolio with varied patient care services is ideal for corporate
pharmacies to maintain a strong customer base, and the State of Nebraska could uniquely
position itself to facilitate these agreements and processes among various providers, particularly
in rural and medically-underserved communities.
Paradox of Pharmacist Compensation, Staffing and Workflow
Pharmacy corporate managers like the services that are being provided and want to
continue to provide MTM services. With a compensation rate that is not competitive or
congruent with the standard professional rate of pay for a pharmacist, pharmacists are
54
experiencing difficulty in justifying provision of MTM and direct patient care services within
their normal workflow procedures. If pharmacists are having to provide MTM services and are
not able to dispense prescriptions and complete other required duties, the payment received for
MTM and compensation realized by the pharmacist is not currently a sustainable or adequate
model.
An Uncertain Position in Staffing and Workflow
Generally, corporate pharmacy managers express uncertainty about how to position
themselves as a provider of MTM and direct patient care services in a seamless, efficient, and
profitable manner. Difficulties are widely experienced by pharmacists in fully integrating these
types of services within their pharmacy staffing and workflow operations, perpetuating a sense of
uncertainty among corporate pharmacies. In pharmacies operating on a single-pharmacist basis,
MTM and direct patient care services are unlikely to reach the capacity and potential they have
without improvements in policies to incentivize and support the provision of such services.
Disconnect between Team-Based Approach, Medical Providers and Care Referrals
With an increased emphasis in team-based patient care, pharmacists are uncertain as to
where to position themselves in regard other medical providers and members of a patients care
team from the community pharmacy perspective. Currently, collaboration exists between
pharmacists and medical providers in limited situations (e.g. immunizations). Pharmacy
corporate managers see the pharmacist as a member of a patients care team, capable of
providing outcome-improving care services, and an active and necessary member of a team-
based approach to patient care.
55
Impact of Rise of Pay-for-Performance Models and Expanding Care Portfolios
With the rise of pay-for-performance models and value-based care, pharmacists are being
looked to for expanded clinical and direct patient care services. Corporate pharmacies are
attempting to offer different patient care services under an increasingly present value-based
payment model. Again, uncertainty by pharmacies surrounds this area in regard to how to realize
a profit from these types of services provided to patients under an emerging payment system.
CONCLUSION
Among corporate pharmacies, MTM and direct patient care services are largely viewed
both cautiously and optimistically.
The need for expanded clinical-based pharmacy services is widely understood by
corporate pharmacies, but lingering uncertainty about how to position pharmacists in the
rapidly-evolving healthcare sector persists.
MTMs implications on pharmacy operations continue to challenge corporate pharmacies
with the need to more seamlessly incorporate MTM into pharmacists workflow
processes.
Financial and economic perspectives of corporate pharmacies must be considered as
MTM and direct patient care services are marked by inadequate reimbursement, but
understood to be a diverse tool in increasing patient loyalty and continued business in the
larger, long term context of success.
Pharmacist-provided MTM services within the healthcare spectrum remain largely
uncertain territory to corporate pharmacy managers, but their recognition of the need for
pharmacists to be integrated and active participants of team-based patient care is clear.
56
OVERALL INTERPRETATION WHEN PHARMACISTS SURVEY AND CORPORATE
PHARMACY INTERVIEW FINDINGS ARE COMPARED
Pharmacists are engaging at a growing pace in the delivery of MTM and direct care
services to patients. The last 5 years has shown substantial growth in the adoption of MTM
service provision in locales across Nebraska. While many pharmacists provide or will be
providing MTM and direct patient care services within the near future, these services remain
underutilized by patients, resulting in substantial loss of opportunity for improvements in patient
outcomes. Teaching other community-based resources, such as Community Health Workers,
about how and when to refer patients to pharmacists to receive these services could substantially
increase patient access to these services in many communities where pharmacists are offering
MTM and other services and are ready to receive more patient involvement now.
Pharmacy corporate managers are actively pursuing options to best position themselves
to continue offering pharmacist-provided direct patient care services, and leverage these
offerings to team-based approaches with other health care entities/providers. Collaborative
practice agreements are in place in near half of the pharmacies in the state, demonstrating a
model of integration of pharmacists services into the delivery of care to patients that extends
provider care plans (chronic disease management) and public health priorities (immunization).
Other models of integration that have some examples include contributing to patient care in
Accountable Care Organizations (ACO) and Patient Centered Medical Homes (PCMHs) through
pharmacists-delivered MTM services, as an example. These models need further advancement
and dissemination within the pharmacy corporations and profession.
57
Corporate pharmacy managers are generally unsure about how to implement such
arrangements. Concurrently, pharmacists current work and practice conditions, which are already
efficient based upon the needs of dispensing and counseling of patients, are often impeding
pharmacists from promoting these services to patients beyond their current level of engagement.
Workload and traditional workflow and organization within pharmacies make it difficult for
pharmacists to add work in many of the pharmacies that responded to the survey. This, despite
the fact that most pharmacies indicated their intention to try to improve the conditions so that
they could offer/or expand their offering of these services. Many are reporting they are near
ready and intend to offer these services soon.
Recent changes in the policy and healthcare landscape have ushered in a sense of urgency
expressed by the pharmacy corporate managers, to determine compensation/reimbursement,
patient care integration, and pharmacy operations improvements so pharmacist can provide these
services. Corporate pharmacy managers recognize that MTM and direct patient care services
exist in an overwhelmingly piecemeal and fractured system; for MTM to be truly successful
within the state of Nebraska, full integration, both of pharmacists within the healthcare spectrum
and of MTM within the pharmacists workflow and pharmacy operations, is needed.
Limitations
Much knowledge about the current state of pharmacists services and capacity in the
community pharmacy environment has been learned through this work. The viewpoints of both
pharmacists and pharmacy managers at the corporate decision making level have contributed to
this knowledge. This study does reveal how pharmacists perceive their patients views about
these services. Obtaining the viewpoints of patients directly could help further inform us about
the strategies that are worthwhile to implement from their point of view those that would have
58
the impact of engaging more patients to participate in pharmacists provided care designed to
optimize medication therapy management outcomes through local community based pharmacies.
Recommendations
Strategies should be considered in advancing these services:
A large portion of pharmacists could charge for MTM services who are not. This is an
important growth area for improving access to services.
Corporate pharmacy managers view MTM as a tool to retain customers, improve
relationships, and realize financial gain long-term. Managers should consider methods to
enhance pharmacists performance of these services.
Improvement in pharmacy workflow, work organization, and performance recognition of
pharmacists who work hard to provide services with corporate pharmacy managers is needed.
Pharmacies are rapidly becoming a new vehicle by which to provide patient care, and
corporate pharmacy managers should support expanding their patient care business models.
Pharmacy managers understand direct patient care services as a package, with MTM as one
service offered within it. Pharmacy managers see the need for collaboration among many
entities and providers to improve patient outcomes, but are unsure how to position within the
health care landscape. Help with making good decisions would be beneficial.
A partnership between industry leaders, healthcare professionals, and the State of Nebraska
could be formed to share experiences related to direct patient care services and identify
potential successful business practices that support high quality patient care services.
Pharmacists promotion of MTM service provision directly to patients would potentially
increase access rapidly to patients whose local pharmacists presently offer this.
59
Conducting state wide training of pharmacists for chronic disease management/MTM. A
standardized training process could be provided to pharmacists in the state of Nebraska.
Conducting state wide training of Community Health Workers about how to refer patients to
MTM services and direct patient care services from pharmacists would increase patient
access to these services.
A majority of pharmacists in community pharmacy practices provide blood pressure checks,
offer to teach how to use blood pressure checking products/devices, offer to teach how to use
blood glucose products/devices, offer medication adherence assistance, provide home
delivery of medications and supplies, and give immunizations. It makes sense for
pharmacists to extend their clinical expertise in these areas and promote their advancement to
be providers of chronic disease self-management, hypertension and diabetes self-
management education to the corporate pharmacy managers and professional association
leadership of pharmacy.
Offer educational opportunities and training to pharmacists to become educators of patients
in self-management areas of chronic disease management, hypertension and diabetes.
Almost half of the pharmacists in community practices have collaborative practice
agreements in place, primarily for immunization and vaccination services. Transforming
pharmacy practice to provide immunization and vaccine services have displayed the ability
of pharmacists to offer expanded clinical services, and a significant opportunity for growth
exist for pharmacists in establishing practice agreements with providers to offer additional
services related to medication therapy monitoring and management within pharmacy walls.
60
61
62
Table 1
Nebraska Pharmacies by License Type and Response Rate
Number Licensed in Nebraska Response Rate by Type of Pharmacy
n % n %
Types of Pharmacies of Interest
Independent 165 33% 113 68%
Mass Merchandise Chain 83 17% 63 76%
Traditional Chain 95 19% 55 58%
Grocery Chain 61 12% 44 72%
Health System/Clinic Pharmacy 15 3% 12 80%
Subtotal 419 84% 287 68%
Other Types of Pharmacies
Hospital Outpatient 28 6% 19 68%
Home Care 11 2% 6 55%
Specialty 15 3% 10 67%
LTC Facility/Pharmacy 19 4% 15 79%
Other 9 2% 6 67%
Subtotal 82 16% 56 68%
Total 501 100% 343 68%
63
Table 2
Services Provided through Corporations at the Local Community Level
Pharmacies of Other
All Pharmacies
Interest Pharmacies
n % n % n %
Blood pressure checks 215 63% 209 73% 6 11%
Offer to teach how to use blood pressure checking products/devices 229 67% 221 77% 8 14%
Hypertension self-management education 22 6% 22 8% 0 0%
Point-of-care blood glucose testing or hemoglobin A1C testing 43 13% 40 14% 3 5%
Offer to teach how to use blood glucose testing products/devices 231 67% 220 77% 11 20%
Diabetes self-management education 38 11% 32 11% 6 11%
Point-of-care INR testing for monitoring anticoagulation 2 1% 0 0% 2 4%
Comprehensive anticoagulation management 8 2% 2 1% 6 11%
Smoking/tobacco cessation education 48 14% 43 15% 5 9%
Comprehensive drug therapy review 175 51% 156 54% 19 34%
Medication adherence assistance 240 70% 223 78% 17 30%
Home delivery of medications and supplies 218 64% 194 68% 24 43%
Immunizations 236 69% 226 79% 10 18%
Other 34 10% 23 8% 11 20%
64
Table 3
Services Provided through Corporations at the Local Community Level [Settings where MTM services are likely to occur]
Pharmacies of Independent Mass Traditional
Grocery Chain Health System/Clinic
Interest Pharmacies Merchandise Chains
n % n % n % n % n % n %
Blood pressure checks 209 73% 67 59% 44 70% 54 98% 40 91% 4 33%
Offer to teach how to use blood
221 77% 88 78% 45 71% 46 84% 33 75% 9 75%
pressure checking products/devices
Hypertension self-management
22 8% 7 6% 1 2% 5 9% 6 14% 3 25%
education
Point-of-care blood glucose testing or
40 14% 14 12% 2 3% 12 22% 11 25% 1 8%
hemoglobin A1C testing
Offer to teach how to use blood glucose
220 77% 89 79% 45 71% 42 76% 34 77% 10 83%
testing products/devices
Diabetes self-management education 32 11% 7 6% 3 5% 4 7% 15 34% 3 25%
Point-of-care INR testing for
0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
monitoring anticoagulation
Comprehensive anticoagulation
2 1% 1 1% 0 0% 0 0% 0 0% 1 8%
management
Smoking/tobacco cessation education 43 15% 9 8% 3 5% 10 18% 18 41% 3 25%
Comprehensive drug therapy review 156 54% 58 51% 35 56% 26 47% 31 70% 6 50%
Medication adherence assistance 223 78% 81 72% 53 84% 48 87% 33 75% 8 67%
Home delivery of medications and
194 68% 98 87% 15 24% 33 60% 41 93% 7 58%
supplies
Immunizations 226 79% 61 54% 61 97% 53 96% 43 98% 8 67%
Other 23 8% 5 4% 4 6% 9 16% 3 7% 2 17%
65
Table 4
Services Provided through Corporations at the Local Community Level [Settings where MTM services are not likely to occur]
Other Hospital
Home Care Specialty LTC Facility Other
Pharmacies Outpatient
n % n % n % n % n % n %
8 14% 2 11% 0 0% 2 20% 4 27% 0 0%
0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
education
3 5% 1 5% 0 0% 2 20% 0 0% 0 0%
Offer to teach how to use blood glucose
11 20% 2 11% 0 0% 2 20% 7 47% 0 0%
testing products/devices
2 4% 0 0% 0 0% 0 0% 0 0% 2 33%
6 11% 4 21% 0 0% 0 0% 1 7% 1 17%
management
24 43% 0 0% 6 100% 6 60% 10 67% 2 33%
supplies
Immunizations 10 18% 3 16% 0 0% 1 10% 6 40% 0 0%
Other 11 20% 4 21% 1 17% 1 10% 4 27% 1 17%
66
Table 5
Collaborative Practice Agreements with Providers
All Pharmacies of Other
Pharmacies Interest Pharmacies
n % n % n %
Yes 165 48% 158 55% 7 13%
Table 6
Collaborative Practice Agreements with Providers [Settings where MTM services are likely to occur]
Pharmacies of Mass Traditional Grocery Health
Independent
Interest Merchandise Chain Chain System/Clinic
n % n % n % n % n % n %
Yes 158 55% 52 46% 38 60% 33 60% 30 68% 5 42%
Table 7
Collaborative Practice Agreements with Providers [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
Yes 7 13% 1 5% 0 0% 2 20% 3 20% 1 17%
67
Table 8
Implementation of a Bi-Directional Referral Process
Pharmacies of Other
All Pharmacies
Interest Pharmacies
n % n % n %
Blood pressure checks 53 15% 53 19% 0 0%
Offer to teach how to use blood pressure checking products/devices 57 17% 55 19% 2 4%
Hypertension self-management education 18 5% 18 6% 0 0%
Point-of-care blood glucose testing or hemoglobin A1C testing 22 6% 20 7% 2 4%
Offer to teach how to use blood glucose testing products/devices 66 19% 63 22% 3 5%
Diabetes self-management education 36 10% 31 11% 5 9%
Point-of-care INR testing for monitoring anticoagulation 8 2% 7 2% 1 2%
Comprehensive anticoagulation management 11 3% 9 3% 2 4%
Smoking/tobacco cessation education 18 5% 18 6% 0 0%
Comprehensive drug therapy review 45 13% 42 15% 3 5%
Medication adherence assistance 68 20% 61 21% 7 13%
Home delivery of medications and supplies 74 22% 63 22% 11 20%
Immunizations 82 24% 79 28% 3 5%
Other 9 3% 7 2% 2 4%
68
Table 9
Implementation of a Bi-Directional Referral Process [Settings where MTM services are likely to occur]
n % n % n % n % n % n %
55 19% 30 27% 5 8% 6 11% 7 16% 7 58%
18 6% 6 5% 1 2% 2 4% 5 11% 4 33%
education
20 7% 8 7% 2 3% 3 5% 4 9% 3 25%
63 22% 36 32% 7 11% 5 9% 9 20% 6 50%
glucose testing products/devices
7 2% 2 2% 1 2% 0 0% 2 5% 2 17%
9 3% 3 3% 2 3% 0 0% 1 2% 3 25%
management
63 22% 42 37% 5 8% 6 11% 7 16% 3 25%
supplies
Immunizations 79 28% 31 27% 14 22% 17 31% 12 27% 5 42%
Other 7 2% 2 2% 0 0% 3 5% 0 0% 2 17%
69
Table 10
Implementation of a Bi-Directional Referral Process [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
2 4% 0 0% 0 0% 2 20% 0 0% 0 0%
0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
education
2 4% 1 5% 0 0% 0 0% 1 7% 0 0%
3 5% 2 11% 0 0% 1 10% 0 0% 0 0%
glucose testing products/devices
1 2% 0 0% 0 0% 0 0% 0 0% 1 17%
2 4% 1 5% 0 0% 0 0% 0 0% 1 17%
management
11 20% 0 0% 5 83% 5 50% 1 7% 0 0%
supplies
Immunizations 3 5% 1 5% 0 0% 1 10% 1 7% 0 0%
Other 2 4% 0 0% 1 17% 1 10% 0 0% 0 0%
70
Table 11
Familiarity with Community Health Workers (CHWs)
n % n % n %
Pharmacists are familiar with Community Health Workers. 53 15% 44 15% 9 16%
CHWs are involved with patients that use pharmacists services. 33 10% 29 10% 4 7%
CHWs refer patients to the pharmacist for services. 30 9% 26 9% 4 7%
Pharmacist refers patients to CHWs for assistance. 24 7% 20 7% 4 7%
Table 12
Familiarity with Community Health Workers (CHWs) [Settings where MTM services are likely to occur]
Independent
n % n % n % n % n % n %
Pharmacists are familiar with
44 15% 19 17% 6 10% 8 15% 8 18% 3 25%
Community Health Workers.
CHWs are involved with patients that
29 10% 16 14% 3 5% 4 7% 5 11% 1 8%
use pharmacists services.
CHWs refer patients to the pharmacist
26 9% 15 13% 1 2% 3 5% 6 14% 1 8%
for services.
Pharmacist refers patients to CHWs for
20 7% 12 11% 2 3% 2 4% 4 9% 0 0%
assistance.
71
Table 13
Familiarity with Community Health Workers (CHWs) [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
Pharmacists are familiar with
9 16% 4 21% 2 33% 2 20% 0 0% 1 17%
Community Health Workers.
CHWs are involved with patients that
4 7% 2 11% 0 0% 1 10% 0 0% 1 17%
use pharmacists services.
CHWs refer patients to the pharmacist
4 7% 2 11% 0 0% 1 10% 0 0% 1 17%
for services.
Pharmacist refers patients to CHWs for
4 7% 2 11% 0 0% 1 10% 0 0% 1 17%
assistance.
72
Table 14
Pharmacist Provided MTM Services in Practice within the Last 12 Months
n % n % n %
Yes 220 64% 205 71% 15 27%
Table 15
Pharmacist Provided MTM Services in Practice within the Last 12 Months [Settings where MTM services are likely to occur]
Pharmacies Mass Traditional Health
Independent Grocery Chain
of Interest Merchandise Chain System/Clinic
n % n % n % n % n % n %
Yes 205 71% 66 58% 59 94% 38 69% 39 89% 3 25%
Table 16
Pharmacist Provided MTM Services in Practice within the Last 12 Months [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
Yes 15 27% 4 21% 1 17% 5 50% 4 27% 1 17%
73
Table 17
Mechanism(s) Used by Pharmacists to Deliver MTM
n % n % n %
Face-to-face/in-person 201 91% 191 93% 10 67%
Telephone 198 90% 185 90% 13 87%
Telehealth (e.g. real-time videoconferencing) 1 0% 1 1% 0 0%
Other 0 0% 0 0% 0 0%
Table 18
Mechanism(s) Used by Pharmacists to Deliver MTM [Settings where MTM services are likely to occur]
Pharmacies Mass Traditional Grocery Health
Independent
of Interest Merchandise Chain Chain System/Clinic
n % n % n % n % n % n %
Face-to-face/in-person 191 93% 60 91% 54 92% 36 95% 38 97% 3 100%
Telephone 185 90% 61 92% 55 93% 32 84% 34 87% 3 100%
Telehealth (e.g. real-time
1 1% 0 0% 0 0% 0 0% 1 3% 0 0%
videoconferencing)
Other 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
74
Table 19
Mechanism(s) Used by Pharmacists to Deliver MTM [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
Face-to-face/in-person 10 67% 3 75% 0 0% 3 60% 3 75% 1 100%
Telephone 13 87% 3 75% 1 100% 4 80% 4 100% 1 100%
Telehealth (e.g. real-time
0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
videoconferencing)
Other 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
Table 20
Organizational Structures
n % n % n %
Pharmacy provides MTM services as part of an Accountable Care Organization. 41 19% 40 20% 1 7%
Pharmacy provides MTM services as part of a Patient-Centered Medical Home. 12 5% 11 5% 1 7%
75
Table 21
Organizational Structures [Settings where MTM services are likely to occur]
Independent
n % n % n % n % n % n %
Pharmacy provides MTM services as
part of an Accountable Care 40 20% 14 21% 11 19% 6 16% 9 23% 0 0%
Organization.
part of a Patient-Centered Medical 11 5% 4 6% 2 3% 1 3% 4 10% 0 0%
Home.
Table 22
Organizational Structures [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
part of an Accountable Care 1 7% 0 0% 0 0% 1 20% 0 0% 0 0%
Organization.
part of a Patient-Centered Medical 1 7% 0 0% 0 0% 1 20% 0 0% 0 0%
Home.
76
Table 23
Formal MTM Training Program Attendance
n % n % n %
Pharmacist has participated in a formal MTM training program 58 26% 53 26% 5 33%
Table 24
Formal MTM Training Program Attendance [Settings where MTM services are likely to occur]
Independent
n % n % n % n % n % n %
Pharmacist has participated in a formal
53 26% 18 27% 10 17% 10 26% 15 38% 0 0%
MTM training program
Table 25
Formal MTM Training Program Attendance [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
Pharmacist has participated in a formal
5 33% 1 25% 0 0% 1 20% 2 50% 1 100%
MTM training program
77
Table 26
Length of Time Providing MTM Services
n % n % n %
< 6 months 10 5% 8 4% 2 13%
6 months to < 1 year 13 6% 12 6% 1 7%
1 to < 2 years 49 22% 49 24% 0 0%
2 to < 3 years 38 17% 35 17% 3 20%
3 to < 5 years 44 20% 42 20% 2 13%
5 to < 10 years 39 18% 37 18% 2 13%
10+ years 9 4% 6 3% 3 20%
Not specific 14 6% 12 6% 2 13%
No Response 4 2% 4 2% 0 0%
78
Table 27
Length of Time Providing MTM Services [Settings where MTM services are likely to occur]
Independent
n % n % n % n % n % n %
< 6 months 8 4% 2 3% 4 7% 0 0% 2 5% 0 0%
6 months to < 1 year 12 6% 4 6% 8 14% 0 0% 0 0% 0 0%
1 to < 2 years 49 24% 15 23% 25 42% 4 11% 5 13% 0 0%
2 to < 3 years 35 17% 16 24% 9 15% 3 8% 7 18% 0 0%
3 to < 5 years 42 20% 7 11% 6 10% 17 45% 12 31% 0 0%
5 to < 10 years 37 18% 13 20% 5 8% 9 24% 8 21% 2 67%
10+ years 6 3% 4 6% 0 0% 0 0% 2 5% 0 0%
Not specific 12 6% 4 6% 2 3% 3 8% 2 5% 1 33%
No Response 4 2% 1 2% 0 0% 2 5% 1 3% 0 0%
79
Table 28
Length of Time Providing MTM Services [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
< 6 months 2 13% 0 0% 0 0% 0 0% 2 50% 0 0%
6 months to < 1 year 1 7% 0 0% 0 0% 1 20% 0 0% 0 0%
1 to < 2 years 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
2 to < 3 years 3 20% 0 0% 0 0% 2 40% 1 25% 0 0%
3 to < 5 years 2 13% 2 50% 0 0% 0 0% 0 0% 0 0%
5 to < 10 years 2 13% 1 25% 0 0% 0 0% 1 25% 0 0%
10+ years 3 20% 1 25% 1 100% 0 0% 0 0% 1 100%
Not specific 2 13% 0 0% 0 0% 2 40% 0 0% 0 0%
No Response 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
80
Table 29
Number of Patients who Receive MTM Services in a Month
n % n % n %
0-2 64 29% 60 29% 4 27%
3-4 33 15% 32 16% 1 7%
5-9 35 16% 34 17% 1 7%
10-19 37 17% 35 17% 2 13%
20-49 22 10% 22 11% 0 0%
50-199 15 7% 12 6% 3 20%
200+ 2 1% 0 0% 2 13%
Not Specific 6 3% 5 2% 1 7%
No Response 6 3% 5 2% 1 7%
81
Table 30
Number of Patients who Receive MTM Services in a Month [Settings where MTM services are likely to occur]
Independent
n % n % n % n % n % n %
0-2 60 29% 17 26% 15 25% 22 58% 5 13% 1 33%
3-4 32 16% 7 11% 9 15% 5 13% 11 28% 0 0%
5-9 34 17% 14 21% 12 20% 3 8% 5 13% 0 0%
10-19 35 17% 16 24% 8 14% 3 8% 7 18% 1 33%
20-49 22 11% 6 9% 8 14% 1 3% 6 15% 1 33%
50-199 12 6% 3 5% 4 7% 2 5% 3 8% 0 0%
200+ 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
Not Specific 5 2% 2 3% 1 2% 0 0% 2 5% 0 0%
No Response 5 2% 1 2% 2 3% 2 5% 0 0% 0 0%
82
Table 31
Number of Patients who Receive MTM Services in a Month [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
0-2 4 27% 1 25% 0 0% 1 20% 2 50% 0 0%
3-4 1 7% 0 0% 0 0% 0 0% 1 25% 0 0%
5-9 1 7% 0 0% 0 0% 1 20% 0 0% 0 0%
10-19 2 13% 2 50% 0 0% 0 0% 0 0% 0 0%
20-49 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
50-199 3 20% 0 0% 1 100% 1 20% 1 25% 0 0%
200+ 2 13% 1 25% 0 0% 0 0% 0 0% 1 100%
Not Specific 1 7% 0 0% 0 0% 1 20% 0 0% 0 0%
No Response 1 7% 0 0% 0 0% 1 20% 0 0% 0 0%
83
Table 32
Identification of Patients as Candidates for MTM Services
n % n % n %
Patients are referred by an MTM vendor 171 78% 164 80% 7 47%
Patients are referred by health plan or pharmacy benefit manager (PBM) 97 44% 95 46% 2 13%
Patients are referred by a physician 13 6% 7 3% 6 40%
Patients with a specific health plan 57 26% 56 27% 1 7%
Patients who cannot afford to purchase their medications 11 5% 7 3% 4 27%
Patients with a specific disease (e.g., hypertension, diabetes) 30 14% 25 12% 5 33%
Patients with a specific number of medications 17 8% 16 8% 1 7%
Patients with documented or suspected medication-related problem (e.g. medication non-adherence, adverse
30 14% 27 13% 3 20%
drug reaction)
Patients with emergency department or hospitalization discharges 2 1% 1 1% 1 7%
Patients request MTM services (self-referral) 36 16% 35 17% 1 7%
Other 4 2% 1 1% 3 20%
84
Table 33
Identification of Patients as Candidates for MTM Services [Settings where MTM services are likely to occur]
Pharmacies Independent Mass Traditional Health
Grocery Chain
of Interest Pharmacies Merchandise Chains System/Clinic
n % n % n % n % n % n %
Patients are referred by an MTM
164 80% 53 80% 50 85% 29 76% 30 77% 2 67%
vendor
Patients are referred by health plan or
95 46% 34 52% 25 42% 16 42% 19 49% 1 33%
pharmacy benefit manager (PBM)
Patients are referred by a physician 7 3% 3 5% 1 2% 0 0% 2 5% 1 33%
Patients with a specific health plan 56 27% 16 24% 14 24% 9 24% 17 44% 0 0%
Patients who cannot afford to purchase
7 3% 2 3% 3 5% 0 0% 1 3% 1 33%
their medications
Patients with a specific disease (e.g.,
25 12% 6 9% 9 15% 6 16% 3 8% 1 33%
hypertension, diabetes)
Patients with a specific number of
16 8% 7 11% 4 7% 3 8% 1 3% 1 33%
medications
Patients with documented or suspected
medication-related problem (e.g.
27 13% 10 15% 8 14% 8 21% 0 0% 1 33%
medication non-adherence, adverse
drug reaction)
Patients with emergency department or
1 1% 0 0% 0 0% 0 0% 0 0% 1 33%
hospitalization discharges
Patients request MTM services (self-
35 17% 13 20% 9 15% 7 18% 5 13% 1 33%
referral)
Other 1 1% 1 2% 0 0% 0 0% 0 0% 0 0%
85
Table 34
Identification of Patients as Candidates for MTM Services [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
Patients are referred by an MTM
7 47% 1 25% 0 0% 2 40% 4 100% 0 0%
vendor
Patients are referred by health plan or
2 13% 1 25% 0 0% 1 20% 0 0% 0 0%
pharmacy benefit manager (PBM)
Patients are referred by a physician 6 40% 2 50% 0 0% 3 60% 0 0% 1 100%
Patients with a specific health plan 1 7% 0 0% 0 0% 1 20% 0 0% 0 0%
Patients who cannot afford to purchase
4 27% 2 50% 0 0% 2 40% 0 0% 0 0%
their medications
Patients with a specific disease (e.g.,
5 33% 2 50% 0 0% 2 40% 1 25% 0 0%
hypertension, diabetes)
Patients with a specific number of
1 7% 1 25% 0 0% 0 0% 0 0% 0 0%
medications
Patients with documented or suspected
medication-related problem (e.g.
3 20% 1 25% 0 0% 1 20% 1 25% 0 0%
medication non-adherence, adverse
drug reaction)
Patients with emergency department or
1 7% 1 25% 0 0% 0 0% 0 0% 0 0%
hospitalization discharges
Patients request MTM services (self-
1 7% 0 0% 0 0% 1 20% 0 0% 0 0%
referral)
Other 3 20% 1 25% 1 100% 1 20% 0 0% 0 0%
86
Table 35
Ways Patients and Providers are Made Aware of MTM Services
n % n % n %
Pharmacy initiates contact with patienta 74 34% 68 33% 6 40%
Pharmacy initiates contact with provider/physicianb 5 2% 3 1% 2 13%
Direct contact from Insurance Provider/PBM/MTM Vendor c 25 11% 25 12% 0 0%
Communication with patient at point-of-sale 12 5% 11 5% 1 7%
Pharmacy advertisementd 4 2% 3 1% 1 7%
Other-multiplee 26 12% 24 12% 2 13%
Do not promote 13 6% 12 6% 1 7%
No response 61 28% 59 29% 2 13%
a
Proactive communication regarding MTM service eligibility and/or availability to patient via phone, letter, or other medium; includes targeted
lists provided to pharmacy from MTM vendors. bPharmacy contacts provider/physician to promote MTM services for potential referrals to
pharmacy. cDirect communication to patient via phone, letter, or other medium regarding MTM eligibility. dFlyer, in-store advertisement,
pamphlet/brochure, etc.; passive advertising not targeting specific patients. eIncludes two or more promotion strategies from the above options.
87
Table 36
Ways Patients and Providers are Made Aware of MTM Services [Settings where MTM services are likely to occur]
Grocery Chain
n % n % n % n % n % n %
Pharmacy initiates contact with patienta 68 33% 12 18% 27 46% 13 34% 14 36% 2 67%
Pharmacy initiates contact with
3 1% 1 2% 0 0% 0 0% 2 5% 0 0%
provider/physicianb
Direct contact from Insurance
25 12% 11 17% 5 8% 4 11% 5 13% 0 0%
Provider/PBM/MTM Vendorc
Communication with patient at point-of-
11 5% 2 3% 4 7% 4 11% 1 3% 0 0%
sale
Pharmacy advertisementd 3 1% 3 5% 0 0% 0 0% 0 0% 0 0%
Other-multiplee 24 12% 7 11% 4 7% 6 16% 6 15% 1 33%
Do not promote 12 6% 7 11% 4 7% 1 3% 0 0% 0 0%
No response 59 29% 23 35% 15 25% 10 26% 11 28% 0 0%
a
88
Table 37
Ways Patients and Providers are Made Aware of MTM Services [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
Pharmacy initiates contact with patienta 6 40% 1 25% 1 100% 2 40% 2 50% 0 0%
Pharmacy initiates contact with
2 13% 1 25% 0 0% 1 20% 0 0% 0 0%
provider/physicianb
Direct contact from Insurance
0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
Provider/PBM/MTM Vendorc
Communication with patient at point-of-
1 7% 0 0% 0 0% 1 20% 0 0% 0 0%
sale
Pharmacy advertisementd 1 7% 0 0% 0 0% 0 0% 1 25% 0 0%
Other-multiplee 2 13% 1 25% 0 0% 0 0% 0 0% 1 100%
Do not promote 1 7% 0 0% 0 0% 0 0% 1 25% 0 0%
No response 2 13% 1 25% 0 0% 1 20% 0 0% 0 0%
a
89
Table 38
Amount Pharmacists Charge for MTM Services
n % n % n %
Charge vendor rates 35 16% 32 16% 3 20%
Bill Insurance/PBM/Medicare 32 15% 31 15% 1 7%
Charge pharmacy-specific fees 22 10% 22 11% 0 0%
Do not charge 81 37% 72 35% 9 60%
Not specific 20 9% 19 9% 1 7%
No response 30 14% 29 14% 1 7%
90
Table 39
Amount Pharmacists Charge for MTM Services [Settings where MTM services are likely to occur]
Grocery Chain
n % n % n % n % n % n %
Charge vendor rates 32 16% 11 17% 8 14% 6 16% 6 15% 1 33%
Bill Insurance/PBM/Medicare 31 15% 13 20% 10 17% 3 8% 5 13% 0 0%
Charge pharmacy-specific fees 22 11% 7 11% 5 8% 3 8% 8 18% 0 0%
Do not charge 72 35% 26 39% 20 34% 17 45% 8 21% 1 33%
Not specific 19 9% 3 5% 8 14% 3 8% 5 13% 0 0%
No response 29 14% 6 9% 8 14% 6 16% 8 21% 1 33%
Table 40
Amount Pharmacists Charge for MTM Services [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
Charge vendor rates 3 20% 1 25% 0 0% 0 0% 2 50% 0 0%
Bill Insurance/PBM/Medicare 1 7% 0 0% 0 0% 0 0% 0 0% 1 100%
Charge pharmacy-specific fees 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
Do not charge 9 60% 3 75% 1 100% 5 100% 0 0% 0 0%
Not specific 1 7% 0 0% 0 0% 0 0% 1 25% 0 0%
No response 1 7% 0 0% 0 0% 0 0% 1 25% 0 0%
91
Table 41
Pharmacy Compensation to Pharmacists for Providing MTM Services
n % n % n %
Part of standard pharmacist salary no separate pay received 197 90% 183 89% 14 93%
Considered in merit raises 12 5% 12 6% 0 0%
Pharmacists earn additional bonus and/or incentives 8 4% 8 4% 0 0%
Additional paid time on hourly or overtime basis and/or pay differential 6 3% 6 3% 0 0%
Other 10 5% 9 4% 1 7%
Note. Several respondents noted that the pharmacy gets reimbursement from difference payer sources. One described being paid case
by case: if on work time then part of salary, but if on personal time then received additional compensation.
92
Table 42
Pharmacy Compensation to Pharmacists for Providing MTM Services [Settings where MTM services are likely to occur]
Pharmacies Mass Traditional Health
Independent Grocery Chain
of Interest Merchandise Chain System/Clinic
n % n % n % n % n % n %
Part of standard pharmacist salary no
183 89% 51 77% 57 97% 35 92% 37 95% 3 100%
separate pay received
Considered in merit raises 12 6% 3 5% 5 8% 1 3% 1 3% 2 67%
Pharmacists earn additional bonus
8 4% 7 11% 1 2% 0 0% 0 0% 0 0%
and/or incentives
Additional paid time on hourly or
6 3% 3 5% 0 0% 2 5% 1 3% 0 0%
overtime basis and/or pay differential
Other 9 4% 6 9% 1 2% 0 0% 2 5% 0 0%
93
Table 43
Pharmacy Compensation to Pharmacists for Providing MTM Services [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
Part of standard pharmacist salary no
14 93% 4 100% 1 100% 4 80% 4 100% 1 100%
separate pay received
Considered in merit raises 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
Pharmacists earn additional bonus
0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
and/or incentives
Additional paid time on hourly or
0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
overtime basis and/or pay differential
Other 1 7% 0 0% 0 0% 1 20% 0 0% 0 0%
94
Table 44
Challenges Pharmacies face when Providing MTM
Pharmacies of Other
All Pharmacies
Interest Pharmacies
n % n % n %
Lack of insurance companies paying for these services 85 39% 77 38% 8 53%
Billing/Documentation is difficult
75 34% 69 34% 6 40%
Payment for MTM services is too low 80 36% 76 37% 4 27%
Too few MTM patients to justify the cost to start-up/maintain the service 45 20% 40 20% 5 33%
Pharmacists have inadequate time 164 75% 159 78% 5 33%
Inadequate training or experience 47 21% 46 22% 1 7%
Inadequate space available in the pharmacy 62 28% 60 29% 2 13%
Management does not support provision of MTM services 6 3% 6 3% 0 0%
Difficulty in communicating about MTM services to patients 46 21% 43 21% 3 20%
Patients are not interested or decline to participate 123 56% 117 57% 6 40%
Lack of collaborative relationships with prescribers and physicians 30 14% 29 14% 1 7%
Local physician resistance 13 6% 13 6% 0 0%
Other 13 6% 12 6% 1 7%
95
Table 45
Challenges Pharmacies face when Providing MTM [Settings where MTM services are likely to occur]
n % n % n % n % n % n %
Lack of insurance companies paying
77 38% 35 53% 20 34% 14 37% 6 15% 2 67%
for these services
69 34% 31 47% 14 24% 15 39% 9 23% 0 0%
Payment for MTM services is too low 76 37% 36 55% 11 19% 15 39% 12 31% 2 67%
Too few MTM patients to justify the
40 20% 14 21% 7 12% 12 32% 7 18% 0 0%
cost to start-up/maintain the service
Pharmacists have inadequate time 159 78% 56 85% 46 78% 30 79% 26 67% 1 33%
Inadequate training or experience 46 22% 9 14% 20 34% 6 16% 11 28% 0 0%
Inadequate space available in the
60 29% 9 14% 28 47% 13 34% 10 26% 0 0%
pharmacy
Management does not support
6 3% 2 3% 0 0% 2 5% 2 5% 0 0%
provision of MTM services
Difficulty in communicating about
43 21% 15 23% 14 24% 3 8% 11 28% 0 0%
MTM services to patients
Patients are not interested or decline to
117 57% 32 48% 29 49% 22 58% 32 82% 2 67%
participate
Lack of collaborative relationships with
29 14% 8 12% 9 15% 5 13% 7 18% 0 0%
prescribers and physicians
Local physician resistance 13 6% 4 6% 4 7% 2 5% 3 8% 0 0%
Other 12 6% 5 8% 3 5% 3 8% 1 3% 0 0%
96
Table 46
Challenges Pharmacies face when Providing MTM [Settings where MTM services are not likely to occur]
Other Hospital
n % n % n % n % n % n %
Lack of insurance companies paying
8 53% 3 75% 1 100% 2 40% 2 50% 0 0%
for these services
6 40% 3 75% 0 0% 1 20% 1 25% 1 100%
Payment for MTM services is too low 4 27% 2 50% 0 0% 1 20% 1 25% 0 0%
Too few MTM patients to justify the
5 33% 2 50% 0 0% 1 20% 1 25% 1 100%
cost to start-up/maintain the service
Pharmacists have inadequate time 5 33% 2 50% 0 0% 1 20% 2 50% 0 0%
Inadequate training or experience 1 7% 0 0% 0 0% 0 0% 1 25% 0 0%
Inadequate space available in the
2 13% 1 25% 0 0% 0 0% 1 25% 0 0%
pharmacy
Management does not support
0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
provision of MTM services
Difficulty in communicating about
3 20% 1 25% 0 0% 0 0% 2 50% 0 0%
MTM services to patients
Patients are not interested or decline to
6 40% 2 50% 0 0% 1 20% 3 75% 0 0%
participate
Lack of collaborative relationships with
1 7% 1 25% 0 0% 0 0% 0 0% 0 0%
prescribers and physicians
Local physician resistance 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%
Other 1 7% 0 0% 0 0% 1 20% 0 0% 0 0%

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NEBRASKA COMMUNITY PHARMACY DEMOGRAPHICS 2015:

ASSESSMENT OF NEBRASKA PHARMACISTS AND CORPORATE EMPLOYERS

Kimberly Galt, PharmD, PhD, FASHP, NAP

The assistance of the following persons is gratefully acknowledged:

Kari Majors, Program Manager

Jamie K. Hahn, Program Manager

Joni R. Cover, J.D., Executive Vice President

Kevin Fuji, MA, PharmD, Assistant Professor and Director

Ted Kaufman, Research Application Administrator

Danielle Wing, Community Health Education Senior

Jack D. Anderson, undergraduate research assistant, Creighton University

Haley A. Sturges, undergraduate research assistant, Creighton University

Overview. This report summarizes a study of pharmacists and corporate pharmacy

pharmacies. Strategies to consider in advancing these services include:

duties. This is an important growth area for improving access to services.

There is opportunity to promote improvement in workflow, work organization, and

recognition of performance by pharmacists with corporate pharmacy managers as

effectively expand their patient care business portfolios.

Pharmacists promotion of MTM service provision directly to patients would potentially

Conducting state wide training of pharmacists for chronic disease management/MTM. A

standardized training process could be provided to pharmacists in the state of Nebraska.

access to these services.

blood glucose products/devices, offer medication adherence assistance, provide home

be providers of chronic disease self-management, hypertension and diabetes self-

management education to the corporate pharmacy managers and professional association

Offer educational opportunities and training to pharmacists to become educators of patients

in self-management areas of chronic disease management, hypertension and diabetes.

Almost half of the pharmacists in community practices have collaborative practice

agreements in place, primarily for immunization and vaccination services. Transforming

by patients, resulting in substantial loss of opportunity for improvements in patient outcomes.

ready to receive more patient involvement now.

offerings to team-based approaches with other health care entities/providers. Collaborative

pharmacists-delivered MTM services, as an example. These models need further advancement.

Executive Summary ...........................................................................................................2

employ pharmacists about the clinically-related services, including medication therapy

management (MTM) services, offered to patients by Nebraska pharmacists to who work in

adopted by Medicare; a pharmacist-provided patient care program consisting of five core

Documentation and Follow-up.

BACKGROUND AND SIGNIFICANCE

incorporate these services into business strategies.

DESIGN AND METHODS

Mixed Methods Approach

displays the research design.

Fig. 1. Convergent Parallel Design

formed to serve. Pharmacies of Interest include Independent (independently owned), Mass

between these two groups as shown in Table 1.

Medication Therapy Management Services

Fig. 3. Pharmacies Studied

Services Provided through Corporations at the Local Community Level

The services listed are predominantly provided in Pharmacies of Interest on the

product/device use lessons.

Among Pharmacies of Interest, the majority of pharmacies provide blood pressure

use blood glucose products/devices, medication adherence assistance, home delivery of

management education, diabetes self-management education, and comprehensive anticoagulation

programs for chronic disease management.

practice agreements in this category were overwhelmingly providing immunization and

and rapid diagnostic testing.

modification and limited prescriptive authority (Table 7).

Implications. Many pharmacists have collaborative practice agreements in place,

to offer additional services within pharmacy walls.

Collaborative Practice Agreements

Fig. 4. Collaborative Practice Agreements with Providers: All Pharmacies.

have an established referral process include hypertension self-management education, diabetes

self-management education, and comprehensive anticoagulation management.