WHAT IS MEDICATION THERAPY MANAGEMENT (MTM)?

MTM usually refers to counseling services between a pharmacist (or nurse or other health professional) and a patient (or caregiver). In MTM, the patient's medications are evaluated to make sure they are:¹

• prescribed appropriately
• safe and effective for that person
• being taken correctly, at the correct dose and times
• able to be taken by the patient as intended
• financially viable for the patient

MTM is being promoted to help address some of the major problems of healthcare delivery. These include:

• high costs of medications
• potential for medication errors
• poor adherence and inappropriate use of medications

Pharmacists are recognized as among the most appropriate sources for MTM services. In addition, the support and participation from the technician are essential for MTM. In fact, many pharmacy educators believe that in order to carry out MTM efficiently, pharmacists need to work alongside technicians who are trained and able to take on many of the roles.

THE BASICS: HOW MEDICARE PART D HAS INFLUENCED MTM

Medicare Part D was introduced as the first outpatient prescription drug benefit for patients who have Medicare coverage. Medicare is a government program that provides health insurance for Americans aged 65 and older, and for younger people with certain disabilities. Legislation known as the "Medicare Prescription Drug Improvement and Modernization Act" (MMA)² requires that some Medicare Part D recipients who have chronic illnesses should receive MTM services to help contain costs and better manage the complex aspects of treating these conditions.^3,4 The basic goals for Medicare Part D–sponsored MTM are outlined in Table 1.³

RISING DRUG COSTS DRIVE THE NEED FOR MTM

For the Medicare program, cost savings is a major goal to be accomplished through MTM. Spending on both prescription and nonprescription drugs in the U.S. has grown exponentially over the past 50 years, from $4 billion to over $324 billion (Figure 1).⁵ Expenditures for drugs are projected to grow an additional 6.7% per year through the year 2025.⁶

People aged 65 and older (those eligible for Medicare) are the highest consumers of prescription drugs. Medicare recipients who have multiple chronic illnesses:⁷

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

Rising costs are also related to medication complications and errors. Various sources suggest that preventable inpatient medication errors cost approximately $16.4 billion annually and outpatient preventable medication errors cost approximately 4.2 billion annually.^7,8 These costs are likely to continue to increase as a larger segment of the population reaches older ages. MTM services are aimed at reducing or preventing complications, and inappropriate use of medications, which drive up costs.

DEFINING MTM

The Medicine Modernization Act defines MTM as:²

• A program of drug therapy management that may be furnished by a pharmacist;
• Designed to ensure that drugs covered under Medicare Part D drugs under the prescription drug plan are appropriately used;
• Designed to optimize therapeutic outcomes through improved medication use and reduced risk of adverse drug events.

A group of 11 pharmacy organizations determined that an optimal MTM program should include:⁹

• Individualized services provided directly by a pharmacist to the patient;
• Face-to-face interaction between the patient and the pharmacist;
• Opportunities for pharmacists to identify patients who should receive MTM services; and
• Payment for MTM services based on the time and resources involved.

WHERE DO PHARMACY TECHNICIANS FIT IN?

MTM services are well suited for a pharmacist's skill set and training, and this is where pharmacy technicians come in. A trend is occurring now in which technicians are taking on many of the traditional roles of pharmacists, while pharmacists expand their roles in patient counseling and medical decision making (Figure 2). There is a strong influence in many sectors of healthcare that encourage pharmacists to practice "at the top of their licenses."¹⁰ This means that pharmacists utilize their clinical skills and delegate or share other responsibilities with technicians. Pharmacy technicians are pursuing advanced training and many are receiving certification from the Pharmacy Technician Certification Board (PTCB) to take full advantage of their training.

Table 2 summarizes some of the roles pharmacists currently have, and suggestions of how technicians can help to support those roles.⁹

Technicians' skill sets are well suited to many of the essential steps involved in preparing for and executing MTM. Technicians who receive training in MTM can apply these skills in many responsibilities for MTM, as illustrated in Figure 3.

HOW DOES THIS AFFECT PAYMENT FOR PHARMACY SERVICES?

Changes in the laws in many states are expanding the responsibilities of pharmacists and the services for which they can receive payment. In recent years many more states have authorized expanded roles for pharmacists as healthcare providers. This varies according to how "provider" is defined, but as of 2020 at least 37 states recognize pharmacists as healthcare providers by state law.¹¹

Some of these expanded roles are tied to reimbursement. For example, in California the law allows pharmacists to administer medications and immunizations, furnish hormonal contraception and tobacco cessation agents, and order and interpret tests, among other services. As of April 2019, California’s State Medicaid program, Medi-Cal, provides payment for selected pharmacist services California Assembly Bill 1114 passed in 2016.¹² Nationally, pharmacy organizations are calling upon Congress to pass a bill amending section 1861(s)(2) of the Social Security Act, which would enable pharmacists to bill for certain services for patients who reside in medically underserved communities.¹¹

OVERALL GOALS OF MTM

A group of 11 pharmacy organizations—including the American Pharmacists Association (APhA) and the National Association of Chain Drug Stores Foundation—drafted an outline of basic steps for planning and delivering MTM.⁹

Many of these steps are also reflected in the CMS Medicare Part D guidelines for MTM.¹³ A summary of the main MTM steps is shown in Figure 4.¹³

QUESTIONS AND ANSWERS ABOUT MTM

How is MTM different from other pharmacist services?

MTM differs from other patient counseling services provided by pharmacists in that it is patient–centered, rather than product–centered, as summarized in Figure 5. With most pharmacy services, counseling happens when a patient brings in a prescription or refills a prescription, so the conversation focuses on education pertaining to the particular drug product. MTM takes a more comprehensive approach, focusing on the patient's disease state and complete healthcare. It examines what medications the patient is currently taking, as well as what treatments might have been overlooked.

How are patients selected for MTM?

Almost anyone who has problems or questions about their medications can benefit from MTM— including people who are not aware that a problem exists. However, the best targets for MTM services are usually patients who have chronic diseases and who are taking multiple medications. To get MTM services paid for through Medicare Part D, patients must meet 3 basic conditions as shown in the chart below:¹⁴

Outside of Medicare Part D, any patient may receive MTM services at the request of their physician, through their employer, at the invitation of the pharmacist, or by self–referral. Transitions of care—such as when a patient is discharged from the hospital or switches physicians—are ideal times to review the medication history and address potential problems.

Does MTM work?

MTM and similar counseling services in the pharmacy can improve many aspects of healthcare, for patients and for the system overall. Research has shown benefits including:

• Increased access for certain patient groups that lack healthcare services
• Improved patient safety, by reducing errors in prescribing, dispensing, or taking medicines
• Support for physicians in the process of health education and counseling
• Enhanced cost–effectiveness

Many studies have demonstrated health benefits for patients with chronic diseases such as heart failure, diabetes, high blood pressure, and high cholesterol.^15-17 These benefits have included better control of diabetes, more foot examinations for patients with diabetes, reduced blood pressure and cholesterol, and fewer adverse drug reactions.

As an example, a report published in 2020 looked at the impact of MTM services over a 10-year period in a large integrated health system in Minnesota:¹⁸

• Over 9,000 patient records were analyzed, with 33,706 documented encounters (mean 3.7 encounters per patient);
• 38,631 drug therapy problems were identified and addressed by MTM pharmacists. These included:
• Need for additional drug (28%)
• Subtherapeutic dose (26%)
• Approximately 13,000 medical conditions were identified by pharmacists as not being treated to the therapeutic goal when they enrolled in the program. After MTM, the majority were either improved with pharmacist intervention or remained stable;
• Cost savings to the health system over a 10-year period were nearly $3 million;
• In a patient satisfaction survey, 95% of respondents agreed or strongly agreed that their overall health and wellbeing had improved through MTM services.

How can MTM services be adapted to fit our pharmacy practice?

MTM services can apply to virtually any patient, in any practice setting.¹⁹ The way MTM services are delivered is rapidly changing. MTM services may be provided in hospital settings, community and retail pharmacies, and as part of interdisciplinary teams of doctors, pharmacists, and other healthcare professionals (such as a patient–centered medical home). Figure 6 lists questions that pharmacists, technicians, and others on the team may want to consider when planning for a new MTM service.

What does the future hold for technicians in MTM services?

With continued changes in healthcare policy we can expect many aspects of MTM to evolve. This may include more ways in which pharmacists can receive payment for MTM services. Changes in legislation may continue to expand the reimbursement options available to pharmacists for MTM services. An official statement by the American Society of Health-System Pharmacists (ASHP) about the roles of pharmacy technicians states:²⁰

"Pharmacy technicians have important roles and responsibilities in the pharmacy profession...A safe and effective medication–use process depends significantly on the [technicians'] skills, knowledge, and competence."

CONCLUSION

Now is an ideal time for pharmacy technicians who are not already involved in MTM to begin learning about the process. There is growing recognition by pharmacists that technician support is essential for successful and efficient MTM—and that appropriate technician training is needed. Pharmacy technicians who are aware of MTM principles and how they can support the MTM process will be in a good position to meet the changing needs of the pharmacy profession.

REFERENCES

1. Patient-Centered Primary Care Collaborative (PCPCC). Defining the Medical Home. Available at: https://www.pcpcc.org/about/medical-home. .
2. 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.
3. Centers for Medicare & Medicaid Services. Medicare. Medication Therapy Management (MTM). May 2020. Available at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/MTM.
4. Centers for Medicare & Medicaid Services (CMS). A Physician's Guide to Medicare Part D Medication Therapy Management (MTM) Programs. MLN Matters Number SE1229. Available at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/PhysiciansGuidetoMedicarePartDMTM110812.pdf.
5. IMS Institute for Health Informatics. The Use of Medicines in the United States: Review of 2011. April 2012.
6. 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.
7. Burton MM, Hope C, Murray MD, et al. The cost of adverse drug events in ambulatory care. AMIA Annu Symp Proc. 2007:90-93.
8. Betsy Lehman Center for Patient Safety. The Financial and Human Cost of Medical Error. June 2019. Available at: https://betsylehmancenterma.gov/assets/uploads/Cost-of-Medical-Error-Report-2019.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. Jacobson D. New could expand role of pharmacists as health care providers. Interview with Marilyn Stebbins, PharmD. UCF School of Pharmacy. Available at: https://pharmacy.ucsf.edu/news/2013/11/new-law-could-expand-role-pharmacists-health-care-providers.
11. American Pharmacists Association (APhA). What is Provider Status? Available at: https://pharmacistsprovidecare.com/.
12. California Legislative Information. AB-1114 Medi-Cal: Pharmacist services. Available at: https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB1114.
13. Centers for Medicare & Medicaid Services (CMS). Medication Therapy Management Program Guidance and Submission Instructions. May 22, 2020. Available at: https://www.cms.gov/files/document/memo-contract-year-2021-medication-therapy-management-mtm-program-submission-v-052220.pdf.
14. Center for Medicare & Medicaid Services (CMS). 2019 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Summary of 2019 MTM Programs. Available at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/CY2019-MTM-Fact-Sheet.pdf.
15. 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.
16. Smith M, Giuliano MR, Starkowski MP. In Connecticut: improving patient medication management in primary care. Health Aff (Millwood). 2011;30(4):646-654.
17. Ferreri SP, Hughes TD, Snyder ME. Medication Therapy Management: Current Challenges. Integr Pharm Res Pract. 2020;9:71-81.
18. de Oliveira DR, Brummel AR, Miller DB. Medication Therapy Management: 10 Years of Experience in a Large Integrated Health Care System. J Manag Care Spec Pharm. 2020;26(9):1057-1066.
19. 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.
20. American Society of Health-System Pharmacists. ASHP Statement on the Roles of Pharmacy Technicians. Am J Health-Syst Pharm. 2016;73:928-930.