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WHY MTM IS RELEVANT FOR PHARMACISTS NOW

Medication therapy management (MTM) is a service performed by pharmacists or other healthcare professionals which has growing relevance in healthcare delivery. Essentially, MTM is a system of reviewing an individual patient's medications to make sure the person is on the right drug, at the right dose, at the right time. This can be done in a targeted manner, focusing on a single drug or disease state—or ideally as part of a comprehensive approach that looks at all the medications a person is taking, in the context of overall health and lifestyle factors.

CMS refers to MTM as the "cornerstone" of outpatient pharmacy clinical services, and remains committed to MTM as a quality improvement/cost-containment strategy.^1,2 CMS requires that all sponsors of Medicare Part D plans must establish an MTM program that:³

• ensures covered Part D drugs are used to optimize therapeutic outcomes through improved medication use;
• reduces the risk of adverse events
• enhances cooperation between practicing pharmacists and physicians; and
• may be furnished by pharmacists or other qualified providers.

Recent data provided by CMS confirm that pharmacist are the main providers of MTM services. According to the 2018 CMS Fact Sheet on MTM Programs, 100% of the existing Medicare Part D MTM programs use the services of pharmacists for MTM, and a large proportion employ pharmacy interns (students) or pharmacy technicians, as shown in Figure 1.³

Pharmacists' roles as direct providers of healthcare services continue to expand in state legislatures and at many organizational levels.⁴ Collaborative practice agreements (CPAs) allow pharmacists to bill for MTM services provided to patients, and in some areas to prescribe or dispense medications without other oversight.⁵ MTM is not only an important part of Medicare, but is being phased in by many states as part of Medicaid as well.

MTM BACKGROUND AND DEFINITIONS

MTM became part of Medicare with the passage of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA 2003).⁶ This federal legislation introduced Medicare Part D, the first outpatient prescription drug benefit for patients receiving Medicare coverage. That legislation contained a mandate that certain Medicare Part D recipients with chronic illnesses should receive counseling (often provided by a pharmacist), in an effort to contain costs and help patients better manage the complex aspects of treating their medical conditions.^3,7 

While many professional associations have attempted to define MTM, it is generally accepted that MTM refers to a service between a pharmacist (or other health professional) and an individual (or caregiver) to ensure that the person's overall medication regimen is:⁸

• appropriate for the patient
• effective for the medical condition(s), 
• safe in view of comorbidities and other medications being taken
• being administered correctly, at the correct dose
• able to be taken by the patient as intended
• ensuring that the right drug, right patient, right time

A coalition of pharmacy organizations arrived at a consensus definition for MTM services as "a distinct service or group of services that optimize therapeutic outcomes for individual patients...independent of, but can occur in conjunction with, the provision of a medication product."⁹

MTM TERMS: WHAT MTM IS AND IS NOT

MTM is not a new idea—nor are the concepts of medication management and counseling new to pharmacy practice. However, MTM became more formalized and widely accepted when it became part of Medicare. MTM programs are recognized as one way to help address some pervasive problems of the healthcare delivery system, including spiraling costs, medication errors, and nonadherence.^10,11 MTM documents from CMS and other organizations recognize pharmacists as the among most qualified professionals for these services. New trends of partnerships between pharmacy organizations and hospitals, primary care providers, health plans, and employers suggest that MTM is in demand and that more pharmacists will need to be trained to deliver these services.

There may be some confusion about how MTM fits into clinical practice. Terms such as Comprehensive Medication Management (CMM) have been widely adopted by professional associations and government agencies and may be confused with MTM.¹² Some similarities and differences are summarized in Figure 2.

MTM can be performed in a variety of settings including the pharmacy, medical office, or the health plan. MTM does not require credentialing from payers or institutions and is not always done as part of a collaborative practice agreement (CPA). MTM does not require but should include a relationship with the patient's primary care provider. 

Rationale for MTM services

The Medicare population is diverse, and includes patients over the age of 65 who qualify based on age and financial contributions while others can qualify at a younger age due to disability. As a result, pharmacists performing MTM must understand the underlying issues confronting this population, which include costly medications, multiple chronic diseases, and potential or actual adverse events.

The need for MTM and CMM services has grown steadily in conjunction with the nation's increasing reliance on prescription pharmaceuticals. Americans' spending on prescription medications has grown exponentially since the 1960s, due in part to the aging of the population, improvements in medical advances, the greater variety of medications available to treat illness, and drug cost increases.¹³ By the end of 2014, total U.S. healthcare expenditures had reached $3 trillion.¹⁴ Per capita spending now tops over $1,000 (Figure 3), with the recent spike attributed to costly specialty categories (Figure 4).¹⁵

Chronic diseases account for more than 75% of healthcare costs and are a major driver of pharmaceutical costs. The Infographic portrays Centers for Disease Control and Prevention (CDC) data on the influence of chronic diseases in U.S. healthcare delivery.^16,17

People with chronic diseases have more doctor visits and more hospitalizations.¹⁸ Because these patients may consult multiple providers for different issues, healthcare delivery tends to be fragmented, often with poor communication between providers. This arises in part from the orientation of our healthcare delivery system as an acute care model, rather than a chronic care model.¹⁸ Poorly coordinated care may increase overall costs and hospitalization rates.^19,20

People age 65 and older (those eligible for Medicare) are the highest consumers of prescription drugs. Medicare recipients who have multiple chronic illnesses:²¹

• see an average of 13 different physicians;
• account for 76 percent of all hospital admissions;
• are 100 times more likely to have a preventable hospitalization versus those with no chronic conditions.

The fastest-growing segment of the population is that of people over the age of 85. By the year 2050, more than 90 million Americans will be in this demographic.²² At the same time, health policy experts predict there will be a serious shortage of healthcare providers who are trained to work with geriatric populations.²³

With polypharmacy comes a heightened risk of drug-related morbidity and mortality.^24-27The annual costs of morbidity and mortality from medication complications and errors are increasing. These costs are likely to continue to increase as a greater proportion of the population reaches an advanced age. Pharmacist intervention through MTM can reduce medication-related morbidity and mortality related to polypharmacy. A U.S. Public Health Services-sponsored study showed that employing the services of a consultant pharmacist could reduce the costs of drug-related morbidity and mortality in older patients by $3.6 billion (from $7.6 billion to $4 billion).²⁵

WHY PHARMACISTS?

Are pharmacists considered to be "providers" by CMS?

The CMS Medicare Part D program continues to validate pharmacists as valued members of the patient care team. Prescription drug plans are required to offer MTM services, most of which are delivered pharmacists. The Medicare Modernization Act (MMA) did not go so far as to formally name pharmacists as "providers"—and thus able to receive payments for services directly from Medicare.²⁸ However, it does allow pharmacists to bill MTM sponsors (through a third-party or directly to insurance organizations) for MTM services under three different CPT codes. On a federal level, pharmacists are not recognized as providers, but a bipartisan bill (The Pharmacy and Medically Underserved Areas Enhancement Act, S. 109) is awaiting passage by the Senate. Most states have passed or are considering legislation that recognizes pharmacists as healthcare providers. States that offer MTM programs as part of Medicaid may provide payments directly to pharmacists.²⁹ Further discussion of pharmacist payment implications is provided in the Bonus Module, Compensation Models for MTM, in this program. 

The services that fall under MTM are well suited for a pharmacist's skill set, training, and approach to practice. Pharmacists have specialized training in areas that relate directly to MTM services, including:

• Managing multiple medications and combination therapies;
• Use of newer and specialized agents such as biologics;
• Dose preparation and administration of injectable medications and devices;
• Managing and monitoring for adverse effects and safety issues; and
• Addressing patient adherence problems.

A 2014 report sponsored by 6 large pharmacist professional organizations on pharmacists' roles in the changing healthcare environment (Table 1) stated:³⁰

"Historically, pharmacists' role in healthcare centered around dispensing medications…although they receive training in preventive care, health and wellness, and patient education, pharmacists have traditionally leveraged their clinical knowledge to review prescribed drug regimens to prevent inappropriate dosing and minimize drug interactions. Pharmacists' roles have expanded over time to include more direct patient care…and their roles continue to evolve today."

OVERALL GOALS OF MTM

The groundwork has now been laid on how MTM evolved, why it is needed, and why pharmacists are ideally suited to provide MTM. The remainder of this introductory module will look at the goals and objectives of MTM, a brief review of the key components of MTM (which are covered in-depth in the following modules), and projecting the future of MTM services. 

How is MTM different from other pharmacist services?

Fundamentally, MTM differs from other patient counseling services provided by pharmacists in that it is patient-centered, rather than product-centered, as summarized in Table 2. With most pharmacy services, counseling commences when a patient brings in a prescription or refills a prescription, so the conversation focuses on the particular agent. MTM usually a considerably more comprehensive approach, focusing on the patient's disease state and complete healthcare regimen. It examines what medications the patient is currently taking, as well as what treatments might have been overlooked.

What evidence do we have that MTM works?

A number of recent studies have demonstrated a positive impact of MTM interventions in terms of improving patient care and reducing healthcare costs.^31-34 Evidence-based studies have shown pharmacist interventions to have an impact on health outcomes such as:

• Increased access to services for medically underserved, vulnerable populations
• Improved patient safety
• Alleviated physician burden for health education and counseling
• Adding check/balance system for prescribers to prevent prescribing errors
• Improve patient and provider satisfaction
• Enhance cost-effectiveness
• Improved goal achievement for chronic diseases 

Continually, research is aimed at measuring and quantifying the real-world beneficial effects of pharmacists' care. Table 3 summarizes benefits identified from studies of pharmacist intervention on health outcomes for patients with chronic diseases including heart failure, diabetes, hypertension, and dyslipidemia.^11,35-42

IMPLEMENTING AN MTM SERVICE

How pharmacists implement MTM services will depend mainly on the practice format, the scope of MTM (whether serving mainly Medicare Part D recipients, or reaching a broader target patient group), and the reimbursement structure for these services. MTM services can apply to virtually any patient, in any practice setting.⁴³ The way MTM services are provided is rapidly evolving—at one time, pharmacists could only provide MTM within a contracted organization. Now, pharmacists may provide MTM as staff pharmacists, independent contractors, or as part of an interdisciplinary team (such as a patient-centered medical home). 

Issues the pharmacist might consider when planning for a new MTM service are summarized in Table 4.

Patient selection for MTM

Patients who are enrolled in Medicare Part D will be invited by the Medicare Part D sponsor to participate in MTM if they have at least 2 conditions from the chronic disease states listed below (some sponsors require 3 or more). Other patients may receive MTM services at the request of their physician, through their employer, at the invitation of the pharmacist, or by self-referral. The next Modules in this program defines the Medicare criteria more thoroughly and contains a comprehensive discussion about how to identify patients for MTM.

OVERVIEW OF MTM BASIC STEPS

The flowchart in Figure 6 diagrams the basic steps involved in MTM. For patients receiving Medicare Part D , the first MTM encounter involves the Comprehensive Medication Review (CMR) and subsequent quarterly follow-up services including Targeted Medication Reviews (TMR), which focus in on the problems identified in the initial comprehensive MTM intervention. More detail on how to conduct each of these steps, in turn, is provided in the subsequent Modules in this program. In the clinical sections of this program, MTM services applicable to that the core disease states are explained using case examples.

WHAT'S NEW IN MTM?

This section discusses some areas of change affecting MTM now and likely to continue in the coming years.

Role in STAR Ratings, used by CMS to determine payments to health plans

Medicare Star Ratings measure quality and performance, with plans receiving a star rating for each category and for individual measures within the category (ranging from 1 Star for poor performance to 5 Stars for excellent performance). CMS offers quality bonus payments for plans with higher Star rankings.

For example, Star Ratings for diabetes are based on the percentage of members with diabetes who have had services such as eye exams to check for diabetes complications, kidney disease monitoring, and HbA1c targets met.

STAR Ratings for used to be based on whether or not Medicare Part D sponsor had performed MTM. Now, the outcomes of MTM carry more weight as part of the Star Rating. This means health plans have an added financial incentive for pharmacists to perform MTM effectively in a way that benefits patient outcomes.⁴⁴

Quality Reporting Systems (PQRS)

Programs in which reimbursement for healthcare services is provided on a capitation basis—rather than a fee for service basis—will greatly increase the need for quality MTM. For example, under Medicare some hospitals do not receive reimbursement if a patient is rehospitalized for certain conditions, which increasing the demand for improved post-discharge management. In the patient-centered medical home model, payers contract with a healthcare organization to cover a certain number of patients ("covered lives") on a per-patient basis, creating an incentive for efficient healthcare cost savings that can be gained through MTM. Physician Quality Reporting System (PQRS) measures provide standards that must be met in order for physicians to avoid penalties through Medicare. Programs of this nature create more opportunities for pharmacists to get involved in collaborative practice in an effort to improve quality and outcomes in patient care. 

CONCLUSION

This is an ideal time for pharmacists who are not already engaging in MTM to begin the study needed for MTM practice. New opportunities for pharmacists include Patient-Centered Medical Homes, dedicated patient education programs run by pharmacists in hospitals, and the creation of employer-sponsored MTM and wellness plans. In addition, health plans and MTM third-party organizations hire pharmacists trained in MTM to perform these services for their membership.

Changes in legislature may continue to expand MTM reimbursement options available to pharmacists. Pharmacists who are well versed in the principles of MTM and detailed steps across a variety of clinical areas will be in a good position to meet the needs of a changing health system landscape. 

REFERENCES

1. Center for Medicare & Medicaid Services (CMS). Medicare Program: Medicare Prescription Drug Benefit. Federal Register. 2005;70(18):4194-4585.
2. Centers for Medicare & Medicaid Services (CMS). CY 2019 Medication Therapy Management Program Guidance and Submission Instructions. April 6, 2018. Available at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Memo-Contract-Year-2019-Medication-Therapy-Management-MTM-Program-Submission-v-040618.pdf.
3. Centers for Medicare & Medicaid Services. 2018 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet: Summary of 2018 MTM Programs. Aug 20, 2018.
4. Balick R. The latest on provider status at the federal, state levels. Pharmacy Today. Sept 2017;23(9):49.
5. National Center for Chronic Disease Prevention and Health Promotion. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Pharmacists. 2013. Available at: https://www.cdc.gov/dhdsp/pubs/docs/Translational_Tools_Pharmacists.pdf.
6. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Cost and Utilization Management; Quality Assurance; Medication Therapy Management Program. Pub L No. 108-173, 117 Stat 2070.
7. Centers for Medicare & Medicaid Services (CMS). A Physician's Guide to Medicare Part D Medication Therapy Management (MTM) Programs. MLN Matters Number SE1229.
8. Patient-Centered Primary Care Collaborative. The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. Resource Guide, 2nd ed. June 2012. Available at: http://www.pcpcc.org/sites/default/files/media/medmanagement.pdf.
9. American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. 2008.
10. Cranor CW, Christensen DB. The Asheville Project: short-term outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003;43(2):149-159.
11. Skinner JS, Poe B, Hopper R, et al. Assessing the effectiveness of pharmacist-directed medication therapy management in improving diabetes outcomes in patients with poorly controlled diabetes. Diabetes Educ. 2015;41(4):459-465.
12. American College of Clinical P, McBane SE, Dopp AL, et al. Collaborative drug therapy management and comprehensive medication management-2015. Pharmacotherapy. 2015;35(4):e39-50.
13. IMS Institute for Health Informatics. The Use of Medicines in the United States: Review of 2011. April 2012.
14. Center for Medicare and Medicaid Services. National Health Expenditures 2017 Highlights. Available at: http://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/downloads/highlights.pdf.
15. Kamal R, Cox C, McDermott D. What are the recent and forecasted trends in prescription drug spending? Peterson-Kaiser Health System Tracker. Feb 20, 2019. Available at: https://www.healthsystemtracker.org/chart-collection/recent-forecasted-trends-prescription-drug-spending/#item-start.
16. Centers for Disease Control and Prevention (CDC). Chronic Disease Overview. Updated June 28, 2017. Available at: https://www.cdc.gov/chronicdisease/about/index.htm.
17. National Center for Chronic Disease Prevention and Health Promotion. The Power of Prevention: Chronic disease—the public health challenge of the 21st century. 2009. Available at: https://www.cdc.gov/chronicdisease/pdf/2009-power-of-prevention.pdf
18. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: a systematic review. Prev Chronic Dis. 2013;10:E26.
19. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162(20):2269-2276.
20. Arend J, Tsang-Quinn J, Levine C, et al. The patient-centered medical home: history, components, and review of the evidence. Mt Sinai J Med. 2012;79(4):433-450.
21. Anderson GF. Testimony before the Senate Special Committee on Aging. The Future of Medicare: Recognizing the Need for Chronic Care Coordination. Serial No. 110-7. May 9, 2007, pp 19-20.
22. World Health Organization, National Institutes of Health. Global Health and Aging. NIH Publication 11-7737. October 2011. Available at: http://www.who.int/ageing/publications/global_health.pdf.
23. United Nations. World Population Prospects. 2019 Revision. Available at: http://esa.un.org/unpd/wpp.
24. Boparai MK, Korc-Grodzicki B. Prescribing for older adults. Mt Sinai J Med. 2011;78(4):613-626.
25. Hanlon JT, Shimp LA, Semla TP. Recent advances in geriatrics: drug-related problems in the elderly. Ann Pharmacother. 2000;34(3):360-365.
26. Pasina L, Brucato AL, Falcone C, et al. Medication non-adherence among elderly patients newly discharged and receiving polypharmacy. Drugs Aging. 2014;31(4):283-289.
27. Tamura BK, Bell CL, Inaba M, et al. Outcomes of polypharmacy in nursing home residents. Clin Geriatr Med. 2012;28(2):217-236.
28. Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.
29. Kohn LT, Corrigan JM, Donaldson MS, Ed. To Err Is Human: Building a Safer Health System. Institute of Medicine: Committee on Quality of Health Care in America. Washington, D.C.: National Academy of Sciences, 2014.
30. Exploring Pharmacists' Role in a Changing Healthcare Environment. Avalere Health. May 2014. Available at: http://www.nacds.org/pdfs/comm/2014/pharmacist-role.pdf.
31. Weber ZA, Kaur P, Hundal A, et al. Effect of the pharmacist-managed cardiovascular risk reduction services on diabetic retinopathy outcome measures. Pharm Pract (Granada). 2019;17(1):1319.
32. Sharma K, Cooke CE, Howard AK, et al. Beneficiary, Caregiver, and Case Manager Perspectives on the Medication Therapy Management Program Standardized Format. J Gerontol Nurs. 2019;45(4):7-13.
33. Heaton PC, Frede S, Kordahi A, et al. Improving care transitions through medication therapy management: A community partnership to reduce readmissions in multiple health-systems. J Am Pharm Assoc (2003). 2019;59(3):319-328.
34. Brandt NJ, Cooke CE, Sharma K, et al. Findings from a National Survey of Medicare Beneficiary Perspectives on the Medicare Part D Medication Therapy Management Standardized Format. J Manag Care Spec Pharm. 2019;25(3):366-391.
35. Machado M, Bajcar J, Guzzo GC, et al. Sensitivity of patient outcomes to pharmacist interventions. Part I: systematic review and meta-analysis in diabetes management. Ann Pharmacother. 2007;41(10):1569-1582.
36. Fera T, Bluml BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc (2003). 2009;49(3):383-391.
37. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003;43(2):173-184.
38. Machado M, Bajcar J, Guzzo GC, et al. Sensitivity of patient outcomes to pharmacist interventions. Part II: Systematic review and meta-analysis in hypertension management. Ann Pharmacother. 2007;41(11):1770-1781.
39. Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc (2003). 2008;48(2):203-211; 203 p following 211.
40. Koshman SL, Charrois TL, Simpson SH, et al. Pharmacist care of patients with heart failure: a systematic review of randomized trials. Arch Intern Med. 2008;168(7):687-694.
41. Chisholm-Burns MA, Graff Zivin JS, Lee JK, et al. Economic effects of pharmacists on health outcomes in the United States: A systematic review. Am J Health Syst Pharm. 2010;67(19):1624-1634.
42. Tan EC, Stewart K, Elliott RA, et al. Pharmacist services provided in general practice clinics: a systematic review and meta-analysis. Res Social Adm Pharm. 2014;10(4):608-622.
43. Stebbins MR, Cutler TW, Parker PL. Assessment of Therapy and Medication Therapy Management. In: Alldredge BK, Corelli RL, Ernst ME, et al. Koda-Kimble and Youngs Applied Therapeutics: The Clinical Use of Drugs. 10th ed. Baltimore: Wolters Kluwer/Lippincott Williams & Wilkins; 2013.
44. Center for Medicare & Medicaid Services. Medicare Part C & D Star Ratings: Update for 2019. Available at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2019-Star-Ratings-User-Call-slides.pdf.

1. The government program that initially defined the pharmacist's role in Medication Therapy Management (MTM) was the:

1. Patient Protection and Affordable Care Act (Obamacare)
2. Medicare Prescription Drug Improvement and Modernization Act (MMA)
3. Medicaid Drug Utilization Review (DUR) Program
4. Health Insurance Portability and Accountability Act (HIPAA)

2. The rationale for instituting MTM programs is based on:

1. the high cost of medications to government payers and the public
2. the aging population of the United States
3. the high rate of medication errors and drug waste
4. all of the above

3. What is the essential difference between MTM and comprehensive medication management (CMM)?

1. MTM and CMM always refer to the same thing
2. CMM is a newer form of MTM
3. MTM and CMM overlap in many respects, but MTM specifically describes medication management services for patients receiving Medicare Part D
4. MTM refers to services delivered by pharmacists while CMM is delivered by other healthcare professionals

4. According to 2018 data provided by CMS, the healthcare professionals most likely to provide MTM services for Medicare recipients are:

1. pharmacists
2. physicians
3. nurse practitioners and pharmacists at equal proportions
4. pharmacy technicians

5. MTM opportunities for pharmacists are likely to expand in future years due to:

1. growing population base of elderly and chronically ill individuals
2. expanding healthcare coverage due to national health insurance programs
3. incentives to decrease health spending such as PQRS systems
4. all of the above

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