Donald Thibodeau, PharmD has had over 30 years experience in small business, managing pharmacies, and providing clinical out-patient services. He built his first clinical community pharmacy in 1975. He received his Bachelor of Science in Pharmacy degree at Massachusetts College of Pharmacy. In 2007 he completed his Doctor of Pharmacy degree at Nova Southeastern University. In 1985 he accepted the Director of Pharmacy position at a hospital in Maine. In this progressive environment he benefited from intimate hands-on clinical experience and enjoyed a truly educational experience with the medical staff. He established the hyperalimentation and enteral nutritional programs at the hospital, oversaw the modernization of the pharmacy, and was appointed Chair of the Pharmacy and Therapeutics Committee by the medical staff. Mid-career Dr. Thibodeau relocated to Fort Myers, Florida. He developed and launched a Medication Therapy Management private independent practice model. He has been involved in pharmacist and consumer education extensively on this topic, including co-authoring the “MEDICATION THERAPY MANAGEMENT SERVICES, Developing a Practice as an Independent MTM Pharmacist“ for the American Pharmacist Association (APhA).
Dr. Thibodeau received the Award for Excellence, and Pharmacy’s Most Innovative Practice Award from the Florida Pharmacy Association. He was the proud recipient of a commendation for “outstanding turn-key MTMS software for pharmacists,” in recognition of his MTM software, PillHelp Work, from the American Pharmacist Association. Dr. Thibodeau continues to provide MTM services to his growing patient list part-time as an example to other pharmacists who might wonder how they can fit the practice of MTMS into their daily lives. Dr. Thibodeau’s articles supporting pharmacists efforts to practice independent general MTMS can be found on-line at PillHelp.
RxEconsult: What are Pillhelp, PillHelp Work, and myMed Checkup?
Dr. Thibodeau: PillHelp is the network site publicizing participating pharmacists’ medication therapy management (MTM) services. It has patient and physician links facilitating contact and information exchange.
PillHelp Work is the MTM software for pharmacists. I designed it to provide the complete infrastructure needed by pharmacists practicing independent MTM. It is presented in an easy to use medical chart format.
The software includes everything that an MTM pharmacists needs:
Demographic and clinical data collection
A Guide through the essential elements of MTM consults - assuring that the Core Standards of Care are met.
The ability for adding custom templates - we encourage pharmacists to take advantage of this feature.
Fees and Billing which allows pharmacists to invoice clients using a variety
of user controls: fixed fee, hourly rate, special rates set for particular patients, special contracts, etc. It easily prints end of year expense and more.
PillHelp Papers which is a repository of patient support documents published by our pharmacists with the intention of helping patients care for themselves.
A repository of “hot links” to quickly access research and other professional support sites.
CMS coding and insurance billing guide.
“myMEDcheckup“ is a more economical MTM service. For a smaller flat fee patients can use the secure on-line process to obtain a suggested care plan to discuss with their physicians. It also includes suggestions from our pharmacist(s) that patients can implement themselves. That consult is labeled “Talking Points” rather than Care Plan Suggestions. The patient does not get as much one-on- one pharmacist time with this service. We hope to facilitate access to MTMS by many more consumers. In addition to the Talking Points, the consult includes an introductory statement about MTM for the physician(s) and our contact information, website, and an invitation to contact us for Q&A or more detailed services.
RxEconsult: When did you get the idea that pharmacists would be called upon for out-patient information services as a totally separate “fee for service” practice?
Dr. Thibodeau: A local internist was getting frequent calls from an anxious patient, a teacher, who had been diagnosed with atrial fibrillation. She suggested that he call me and ask if I would sit down with him and answer his questions if he were willing to pay me. He did. We negotiated a $60 fee for a one hour session. Every month for several months he called me to express his appreciation telling me how much that session had helped him. I did not do anything special. I simply made myself available exclusively to him for an hour, listened to his concerns, and then shared what I knew. That was my first real MTM consult. That happened in 1978! I’ve been providing them ever since. It occurred in a moment - and hit me as a fully developed concept. In 1994 I was on vacation in Maine. While sitting on a rock early one foggy morning, overlooking Millinocket Lake, it struck me that pharmacists’ knowledge would become essential as the baby boom population aged. Clinical pharmacists had already become well accepted in hospital settings. I had become convinced while practicing a version of clinical pharmacy in my store that consumers were hungry for our information. It was also clear how much they appreciated it.
RxEconsult: Please describe your MTM model and the services you provide?
Dr. Thibodeau: I practice independent general service medication therapy management. That means that I am an independent professional willing to address any question or problem that is presented. I work in a setting similar to lawyers, accountants or architects. Any consumer or physician can reach out to me with any question or problem and ask for a consult. Although we can provide care using the Medicare triage protocol we do not have to. We can serve a patient who has one medication, one illness and sees only one physician. I can provide a variety of services from individual answers to very specific questions, preparing and delivering seminars, and special corporate requests. Rather than being contacted by insurance providers, my clients and/or their physicians reach out to me directly. The typical inquiries start like this. Physicians will call and say, “I have a patient who is experiencing ... Can you review his/her meds and give me your opinion about a pharmacological cause or contribution?” A patient will call and ask, “I am nervous about this new drug I’ve been prescribed. The internet is scary when I read about it. What should I believe?”
I just completed a consult for a gentleman who services my storm shutters. He is an intelligent well informed man. He is over-weight and is effectively dieting. He and his physicians have not been able to find a hypertension medication that works and that does not cause adverse reactions. He asked me to provide him with a myMEDcheckup Talking Points consult. After reviewing his medications, his blood pressure and heart rate log, his list of ADRs, and his lab work for the past year, I was able to make some suggestions that he could implement himself and others that involved medication changes. One discovery I made was that the three physicians that he had seen in the past two years had under dosed his medication. He was anxious about taking anything because he had been so sensitive to the side effects. In this particular case I recommended a medication regimen that he had not tried and which is known to be well tolerated by males in particular. I made myself available to his physician. In addition, I made it clear that I was readily available to him for support and Q&A after his physician visit and from now on. The consult had a positive effect on his anxiety about medication.
This patient would not have been eligible for care using the Medicare-D triage definitions.;Independent MTMS are driven by consumers and physicains, rather than by the insurance providers. As an exercise, calculate all of the sources of possible savings that resulted from this one simple consult. Anytime someone runs into an issue involving medication information and/or risk management, they can reach out to me and pharmacists like me.
RxEconsult: What are 5 key areas to address when starting an MTM Practice?
Dr. Thibodeau: It would be helpful to explore the articles that I have written about MTM.
Five keys in starting an MTM practice are:
Self confidence - Realize the degree to which you are viewed as a medication expert. You do not have to know everything. This type of pharmacy service allows you to look things up and to assimilate that work into your consult. Don’t say “no.” Give yourself a day or two to think about it first.
Begin part-time - In this economy most pharmacists will experience less stress and spend less money kicking off their practices if they begin with a case or two a week and grow from there. We can practice MTMS as much or as little as we like, have a wonderful impact on our patients, and create additional income for ourselves.
Documentation system - Select the right software for your needs. Be sure that is thorough. It is important to provide high quality care which is consistent and repeatable. This is critical for compliance and for legal reasons. You know the saying, “if it’s not documented it didn’t happen.“
Marketing - This can take many forms. For example: (1) Personal contact with a few physicians with whom you are already comfortable. Meet with them. Leave a one page summary of MTM, your contact information, and a prescription pad that you have had printed ordering MTMS. (2) Ask for permission to add a link to the homepage or desktop on their computer(s).(3) Public speaking - A short speech about MTM and Q&A at local civic or social group meeting is great. (4) Press releases - You can release a notice of your new consumer protection service. You can offer to be a resource to your local media outlets. (5) Paid for advertising - Devote whatever capital you can, but consider getting advice from marketing experts. (6) Internet presence - See PillHelp as an example.
Follow-up (1)Schedule follow-up(s) before you complete an encounter. Frequently they will need further assistance. They are always impressed. (2)Say thank you - I have custom thank you notes. I send one out every time I get a payment. (3)Stay in touch with the physicians whose patients you have served.
RxEconsult: How many patients will it take to be profitable and make an income equivalent to a retail pharmacist’s income. What are some of the reimbursement challenges?
Dr. Thibodeau: The number of patients it takes to be profitable and to make an income equal to a retail pharmacist is difficult to answer, especially now that I have seen what the case load looks like.
Obviously, if one begins part-time, they can grow their practice, and analyze their income and time. From that they calculate projections.
Profitability will be based on one’s fee structure. Because of the anti-trust laws governing our profession, it is difficult to comment here. I will suggest reading the Lewin Report. It is a good source. Although aged, it still provides good information with which to start. As mentioned earlier, my articles will help. The cost of doing business is low. Our fees are based on knowledge and experience. The ROI in medication therapy management is excellent.
I strongly suggest working with an accountant if you are not already. They can help you take advantage of small business tax laws. You will be pleased by the results.
The most significant hurdle to reimbursement is the insurance industry. Once they realize that independent general MTM practitioners save them even more money than the practice models for which they pay currently, I am sure that they will start honoring our NPI’s, CPT codes, and CMS 1500 invoices. The savings earned from general practice MTM are equal or greater than current reimbursed services because we see more kinds of patients than Medicare allows.
Our patients’ willingness to pay is much less an issue than most pharmacists realize.
We have a greater impact on quality of life. As a result of that our patients save more money than patients who are being covered now because they go to the doctors less frequently. They are seen in emergency rooms less frequently. They are admitted to the hospital less frequently. They consume fewer and/or less expensive medications. They are less stressed. We cost less than physicians in the area of managing medications.
RxEconsult: How important is documentation software to the success of an MTM practice and which are the best or most widely used software?
Dr. Thibodeau: I listed documentation as my #3 Key, above, in starting a successful MTM practice. I prefer using software as my office and practice infrastructure. It facilitates the provision of sophisticated consults and saves a lot of time. Finding time is pharmacists’ biggest challenge. The right software is the key to solving that problem. Wether you have to share information with several people or provide print outs of annual expenses for your patient, software makes it quick and easy - or it should! I developed PillHelp Works because I was not able to find software that did it all for the independent practitioner. I needed office documentation, clinical data collection, sophisticated sensitivity monitoring data, progress note capabilities, time management assistance, non-discriminatory fee calculation while allowing easy override capabilities, SOAP practice guide, invoicing, case progress monitoring, and easy access to all my files at the office, in the patient’s home, or on the road. I felt that I had no choice but to develop my own software. It did not take me long to appreciate the value of PillHelp Works. So I committed fully to it so I could make it available to others.
There are a couple other software providers who do a good job of supplying the pharmacist with software for general practice. None support true independence like the one I developed (with my IT partner) and use.
RxEconsult: Which marketing strategies have worked best for your MTM business and which ones do you avoid?
Dr. Thibodeau: I would like to answer the question this way. I am a fan of television advertising if it is well placed because it advances your practice and the concept of the service. It elevates consumer expectations. It is, however, hard for individuals to afford. I would suggest anyone with a serous business plan and who is thinking big (like full-time) to budget for it. Again, consult your tax advisor so you add it to all of your other tax deductible business expenses.
As far as low-cost impact effectiveness, the prescription pads have been the best. Maybe this will stimulate marketing ideas. A physician who wanted to refer to me when we had our face to face meeting in his office said, “Make it easy for me. I want to refer to you, but I don’t want to be your salesman.“ That was when I first used the prescription pad. A benefit of developing relationships with physicians is that serving them and their patients becomes easier and less time consuming over time.
RxEconsult: Since you have owned retail pharmacies and you own an MTM practice can you compare and contrast the two businesses with respect to profitability, risks, challenges, and value to patients in our current health care climate.
Dr. Thibodeau: MTMS is far more profitable than retail pharmacy for the staff pharmacist when we compare equal time spent.
The real difference is how we acquire our customers. In a successful retail pharmacy, the effort required to build traffic is easier and less complex than it is with an MTM practice. They are different. It is more difficult to get someone to step into an office than it is to get them to walk into a store. MTM practitioners need a mind set and business approach like the ones their friends have who are in law, accounting or other kinds consulting. They do it. So can we.
One of the best scenarios I can think of is for independent pharmacies to spin off an MTM practice creating a new revenue stream. I managed a pharmacy in which I did that. The owner was generous and told me that I could use the office space, and I could promote my MTM services as long as I didn‘t neglect my management duties. I was able to do that by keeping them separate. Both businesses grew. They attract patients to each other.
RxEconsult: Your article on Medication Therapy Management Services is a very nice road map for the aspiring MTM practitioner. However, starting an MTM practice for those who have never started a business can be daunting. Are there MTM business mentors that offer one-one coaching and support? Are you available for professional consultation?
Dr. Thibodeau: What an insightful question. My most recent activity has been brainstorming how I could make myself available to pharmacists who want help getting started. It clearly is a need from the conversations that I have had with my colleagues. So I will say here that I am available and would enjoy doing so. Feel free to contact me via this inquiry form or PillHelp Contact us.
RxEconsult: Have you provided MTM Services via the web, phone, or email? What are the pros and cons of a virtual MTM service?
Dr. Thibodeau: I provide MTM in the office. I have a home office which I would discourage. I have an office in an Exec Center that I can rent by the hour (remember that even I practice part-time). I make house calls. My patients like house calls the best. Now, with “myMEDcheckup,” I can provide a limited type of care on-line by generating Talking Points.
As a practical matter, the limitation of virtual MTM services is the inability to have the depth of assessment that a personal encounter allows. The next step in the evolution of virtual care will be video sessions. I am equipped to that now. Most consumers are not yet. The quality of the connection will enhance the effectiveness of the assessment.
RxEconsult: What does the future hold for you and your practice?
Dr. Thibodeau: I am convinced that I had the right idea. Events have borne that out. I do feel that as an independent general MTM practitioner I am ahead of my time due to the reluctance by insurance providers to reimburse this type of practice, because of the unforeseen economic tailspin, and because of the hesitance by pharmacists to explore their potential.
If we can produce enough case load and demonstrate our outcomes to third parties, I am sure that an effective alliance lies a head.
Personally, due to my age, I am looking for a pharmacist or pharmacists with whom I can partner to ensure that this practice model survives until the environmental elements change and present a clear path.
RxEconsult: Don, thank you very much for sharing your business insight and MTM experience with the RxEconsult commuity. We need pioneers like you to show us the way to develop and run successful MTM practices so the pharmacy professionn can further maximize its value to patients and society. As I encounter aspiring MTM pharmacists that need support I will refer them to you. May be this will be your next business; MTM Help sounds good.
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