Medication Therapy Management: Putting the 'CARE' in Health Care

The success—and challenges—of Medicare Part D's Medication Therapy Management Programs can inform the future of this collaborative practice.

Medication therapy management (MTM)—working collaboratively with patients and other health care professionals to optimize medication use while employing the best guidelines available—represents the pinnacle of pharmacy practice. Although any qualified professional can provide MTM, when pharmacists take the lead it elevates the practice from a dispensing and counseling model to a collaborative problem-solving approach that includes the patient as a member of the health care team. It shifts focus from “product” to “service,” or better yet, “care.”

With MTM, care should be patient centered, outcomes should improve, and patients should feel empowered to manage their health care problems more efficiently and effectively.^1,2 The Table^3-5 lists many expected outcomes when pharmacists provide MTM services to patients. Pharmacists have dreamed of this type of collaborative, patient-centered approach for decades.

Currently, pharmacists are compensated only for MTM provided to patients enrolled in Medicare Part D Prescription Drug Plans (PDPs; also called sponsors). All Medicare beneficiaries are automatically enrolled in MTM, and are given the opportunity to opt-out. Plans must look at their populations of Medicare beneficiaries and identify those who need MTM services most—at least quarterly based on criteria that the plan develops. Medicare asks PDPs to target Part D enrollees who have multiple chronic diseases, are taking multiple Part D drugs, and are likely to incur $3000 in annual costs for covered Part D drugs in their criteria. The Centers for Medicare & Medicaid Services (CMS) is specific in its guidelines. The CMS indicates that Part D plans:

• Should use 3 or fewer comorbid chronic diseases as the minimum for MTM services (ie, they cannot require 4 or more)
• Must target at least 4 of 7 core chronic conditions: hypertension, heart failure, diabetes, dyslipidemia, respiratory disease, bone disease/ arthritis, and mental health
• Must set the minimum threshold for “multiple medications” at a number equal to or between 2 and 8

Pharmacists, or other qualified providers, often provide a comprehensive medication review (CMR) when they identify an actual or potential medication-related problem. The CMR examines prescription and OTC medications, herbal therapies, and dietary supplements. Professionals must engage in interactive counseling (eg, face-to-face meetings, telephone conversations).⁶

How Are we Doing?

The 2011 Medicare Part D Medication Therapy Management (MTM) Programs Fact Sheet reports that all plans are offering MTM. They also report that every program offers interactive, person-toperson CMR consultation telephonically, and roughly one-fourth (27.0%) of programs also offer face-to-face consultations (up slightly from 25.8% in 2010).

Although pharmacists are the leading MTM service providers in all programs, a growing percentage of programs are using outside entities, such as prescription benefit managers that are not an integral part of their program, to provide their MTM services.⁷

The programs’ reliance on telephonic review is understandable, but disappointing. Programs use telephone counseling as a convenience measure, to improve patients’ access to care, and to optimize resource utilization in the workplace. It’s not clear that health care professionals can provide the same level of counseling over the telephone that they do in person.

One study looked at this issue among physicians and found that telephone counseling was 50% shorter, identified 30% fewer problems, and failed to gather as much data and build as much rapport as face-to-face sessions did. Patient involvement and satisfaction outcomes were similar in both consultation types.⁸

Focus group research indicates that telephone counseling may be best used when medical problems are chronic and well documented (as opposed to acute), when the health care professional knows the patient well,⁹ and when there is no language barrier.

What’s Next?

CMS requires programs to have structured, ongoing quality improvement programs and strives to improve its own programs as well. In the future, they will mandate the content and format of communications given to patients after CMR is conducted. By January 1, 2013, CMS will require 3 components:

• A Beneficiary Cover Letter that includes directions on how to contact the MTM program
• A Medication Action Plan of specific action items and practitioner activities that may affect the beneficiary’s tasks and responsibilities in the action plan, and
• A Personal Medication List

Ideally, pharmacists should strive to provide MTM services to at-risk patients other than just Medicare beneficiaries, but reimbursement (and the lack thereof) is a barrier. Many pharmacists report that they offer comprehensive counseling, but more than 50% of patients do not recall having been offered counseling.¹⁰ This is an area where the profession needs to improve.

What’s Novel?

MTM creates opportunities for pharmacists to use good communication skills and the ever-growing technology arsenal to improve outreach. Numerous MTM programs employ these available technologies.

End Note

MTM is developing a track record of success. Pharmacists who are looking for ways to increase their clinical involvement, use new communication and monitoring methods, and increase patient satisfaction can observe successful MTM programs to find a wide range of ideas.

Table 2. Noteworthy MTM Programs

· In an outpatient program, pharmacists use a remote blood glucose meter upload device to provide better care and improve outcomes for patients with diabetes. The device can upload data from multiple blood glucose meters brands. It transmits the data from a patient’s home via a telephone line connection to a centralized secure database, which the pharmacist, patient, and physician can access. Note that this program was designed for seniors and available for free. But despite the fact it was free, many seniors were skeptical or cautious about the program, probably because the technology is quite modern.

· Ten pharmacies in California participated in an MTM project aimed at HIV/AIDS patients. After special training, in some cases at an advanced level, pharmacists used an online data collection tool to report MTM services. Services most often reported included individualized counseling when overuse or underuse was detected and telephonic refill reminders. Pharmacists indicated that patient satisfaction, medication usage, therapeutics response, and patient quality of life improved.

· Pharmacists implemented MTM at 14 assisted living facilities in rural Minnesota for 130 residents who were taking an average of 13 medications each. Over 12 months, the program cost approximately $20,000. Patient satisfaction increased, and pharmacists postulated that only modest patient gains and avoidance of a few major adverse events justified the program’s expense.

· A large integrated health care system examined their 10-year MTM program between 1998 and 2008. Approximately 9000 patients received 33,706 documented encounters (translating to 3.7 encounters per patient). Pharmacists identified a need for additional drug therapy (28.1%) and subtherapeutic dosage (26.1%) most often. Estimated cost savings over the 10-year period were $2,913,850 ($86 per encounter). MTM’s total cost was $2,258,302 ($67 per encounter). Most patients (>95%) agreed or strongly agreed that MTM had improved their overall health and well-being.

Adapted from references 11-14.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.

References

• Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.
• Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Institute of Medicine; 2001.
• Institute of Medicine. Report Brief: Preventing Medication Errors. Washington, DC: Institute of Medicine; July 2006. www.iom.edu/Object.File/Master/35/943/medication%20errors%20new.pdf. Accessed September 9, 2011.
• Centers for Medicare & Medicaid Services. Medicare Prescription Drug Benefit Final Rule: 42 CFR Parts 400, 403, 411, 417, and 423 Medicare Program. Federal Register, vol 70, no. 18. January 28, 2005. http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/pdf/05-1321.pdf. Accessed September 9, 2011.
• The American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice. www.pharmacist.com/AM/Template.cfm?Section=Pharmacists&CONTENTID=19013&TEMPLATE=/CM/ContentDisplay.cfm. Accessed September 16, 2011.
• Centers for Medicare & Medicaid Services. Medication therapy management and quality improvement program. In: Prescription Drug Benefit Manual, Chapter 7. www.cms.gov/PrescriptionDrugCovContra/Downloads/Chapter7.pdf. Accessed September 16, 2011.
• Centers for Medicare & Medicaid Services. 2011 Medicare Part D Medication Therapy Management (MTM) Programs Fact Sheet. Accessed September 16, 2011.
• McKinstry B, Hammersley V, Burton C, et al. The quality, safety and content of telephone and face-to-face consultations: a comparative study. Qual Saf Health Care. 2010;19:298-303.
• McKinstry B, Watson P, Pinnock H, Heaney D, Sheikh A. Telephone consulting in primary care: a triangulated qualitative study of patients and providers. Br J Gen Pract. 2009;59:e209-e218.
• Feifer RA, Greenberg L, Rosenberg-Brandl S, Franzblau-Isaac E. Pharmacist counseling at the start of therapy: patient receptivity to offers of in-person and subsequent telephonic clinical support. Popul Health Manag. 2010;13:189-193.
• Rosenquist A, Best BM, Miller TA, Gilmer TP, Hirsch JD. Medication therapy management services in community pharmacy: a pilot programme in HIV specialty pharmacies. J Eval Clin Pract. 2010;16:1142-1146.
• Schenk RJ Jr, Schenk J. Integration of remote blood glucose meter upload technology into a clinical pharmacist medication therapy management service. J Diabetes Sci Technol. 2011;5:188-191.
• Scott DM, Dewey MW, Johnson TA, Kessler ML, Friesner DL. Preliminary evaluation of medication therapy management services in assisted living facilities in rural Minnesota. Consult Pharm. 2010;25:305-319.
• Ramalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm. 2010;16:185-195.