Download Fundamentals of Medication Therapy Management (MTM) Services

Fundamentals of Medication Therapy
Management (MTM) Services
By Bruce R. Siecker, Ph.D., R.Ph.
Bruce Siecker is president of Paradigm Research & Advisory Services,
Inc. based in Stone Ridge, Virginia. He trains, writes, consults, and
testifies on drug program, regulatory, and corporate compliance.
E.L.F. Publications, Inc. is accredited by the Accreditation
Council for Pharmacy Education as a provider of
continuing pharmaceutical education. This program has
been approved for 1.5 contact hour (0.15 CEU).
Universal Program Numbers:
406-000-09-009-H04P & 406-000-09-009-H04T
The expiration date for this program is 1/31/10.
Goals and Objectives
Pharmacists:
Goals:
Based on historical and professional developments, to provide the pharmacist with an
introduction to Medication Therapy Management (MTM) services in the contemporary
community pharmacy.
Pharmacy Technicians:
Goals:
Based on historical and professional developments, to provide the pharmacy technician with an
introduction to Medication Therapy Management (MTM) services in the contemporary
community pharmacy.
Objectives:
After completing this lesson a pharmacist should be able to:
1. Briefly describe the meaning of medication therapy management.
2. Explain how OBRA-90 is different from MTM.
3. Describe the intended patient of MTM services.
4. Explain the purpose of Medication Therapy Management (MTM) in Pharmacy Practice:
Core Elements of an MTM Service (Version 2.0).
5. Tell why public (Medicaid), state plans, and private insurers (and even the individual self-paying
public) are beginning to recognize the value of MTM services.
6. Explain why MTM services are considered a long-term patient interface.
7. Explain what these MTM components are meant to do:
a. Medication Therapy Review (MTR)
b. Medication Action Plan (MAP)
c. Personal Medication Record (PMR)
d. Intervention and/or Referral
e. Documentation and Follow-up
8. Explain how HIPAA requirements figure into planning for a MTM service.
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their medicines. Beginning in 2006 the MMA-03
requires Medicare health plans to develop Part D
plans for Medicare beneficiaries and to make
medication therapy management (MTM) services
available to “targeted” beneficiaries.
Evolving a Broader
Definition of Pharmacy
For more than 50 years pharmacy has struggled
to expand what it does for patients. Some of the
focus has been on expanded clinical services as
more pharmacists gained skills in these areas
through an expanded educational experience. This
was accomplished by the adoption of the universal
doctor of pharmacy degree. But meaningful growth
of clinical services has been limited mostly to
hospitals and larger clinics.
The idea of “targeted,” means that beneficiaries
have multiple disease states (typically chronic
conditions), use multiple Part D-covered
medications, and are expected to reach (and exceed)
the spending limit for the year.
Exactly What Is Medication
Therapy Management?
Despite minor advances, the pharmacist has
been locked into a “count and pour” environment.
Until recently—with the Omnibus Budget
Reconciliation Act of 1990 (OBRA-90)—there has
not been a major change in the definition or
payment for pharmacy services. OBRA-90 included
a requirement that patients receive (or be given the
option to receive) counseling about the prescription
medication dispensed to them.
Medication Therapy Management involves a
different way of thinking about the patient, and is
quite distinct from what is defined as pharmacy
practice. The focus is on identifying, preventing,
and solving problems to get optimum therapeutic
outcomes for each patient. MTM is distinct from the
counseling that occurs as a result of OBRA-90
requirements. Specifically, MTM—
Under OBRA-90, patients were to be told the
prescription drug name and its description, the route
of administration, dosage form, and the dosage of
the medicine, the duration of therapy, common side
effects, adverse reactions, and interactions (food
and other medications), proper storage, and
appropriate action in the event of a missed dose.
 Is patient centered,
 Involves an analysis of a patient total
medication experience, and
 Involves activities designed to improve
patient use of medication.
MTM services focus generally on patient overall
therapeutic needs, but may be focused on specific
clinical issues when necessary. They are more than
a one-time event; it is up to the pharmacist to
develop a continuous therapeutic relationship with a
patient who is enrolled in the MTM service.
The problems with OBRA-90 were fivefold.
First, it represented a single event, viz., information
is transferred only at the time of dispensing.
Second, it does not take into account the patient’s
history (drug and otherwise) and behaviors. And
thirdly, it does not provide a means of following up
with the patient to ensure changes have been made.
On a fourth related note, it does not have a follow
up with other health providers.
Services associated with MTM were to be
created in cooperation between physicians and
pharmacists, and care provided by pharmacists. The
resultant standards were by definition vague and
lacked uniform standards. As a result, early efforts
at MTM to Medicare beneficiaries varied widely.
This lack of uniformity was confusing to
pharmacists trying to implement MTM services,
and the services to Medicare beneficiaries varied a
great deal.
But the real problem with OBRA-90 is a failure
to provide a means of recouping the cost of
providing such services. Without payment for these
and similar services, pharmacists would be forced to
“borrow” time from dispensing services. Anyone
familiar with the modern pharmacy—and the queue
for simple dispensing—knows the folly of this
solution.
The 2008 American Pharmaceutical Association
(APhA) Annual Meeting provided a wealth of
material—including tools, educational offerings,
and pharmacist practices—and the long-awaited
APhA-NACDS collaboration, Medication Therapy
Management (MTM) in Pharmacy Practice: Core
The Medicare Modernization Act of 2003 was
passed to provide a comprehensive prescription
benefit to the more than 40 million senior citizens
(and disabled people) in order to help them afford
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other drugs. It is about teaching patients to become
smarter in the way they take—or do not take—
prescription and nonprescription drugs.
Elements of an MTM Service (Version 2.0). (Also
available at
www.pharamcist.com/mtm/coreelements2) Also
released was MTM Digest: Perspectives on MTM
Service Representation, which summarizes the
results of MTM survey articles.
The intended benefits to patients are numerous
and real. A dramatic decrease in untoward effects,
hospitalizations, and death await patients who
participate in MTM services. Some of the less
obvious effects, such as a decrease in trips to the
emergency rooms and fewer untoward results of not
taking prescribed medicines, add to the substantial
benefits of MTM services.
Version 2.0 refines the current definition of
MTM services, thereby helping pharmacists get the
recognition—and reimbursement—for these unique
and valuable services.
The National Community Pharmacists
Association (NCPA) is also heavily committed to
reporting MTM success stories at its annual meeting
and in its journals. NCPA sponsors “MTM Tip of
the Month” in Pharmacy Today. The number of
educational sessions at all meeting venues boldly
promotes in a meaningful way the concept of
successful MTM.
Who Is the Intended Patient?
In its core definition, the intended patient for
medication therapy management services is the
Medicare patient who suffers from multiple chronic
diseases, e.g., heart problems, high blood pressure,
diabetes, and high cholesterol. The patient also
takes several drugs covered under the Part D portion
of Medicare. And the final qualification is that the
patient is expected to exceed an annual amount of
drug costs, currently set at $4,000.
A definition of MTM standards was created by a
consensus of eleven national pharmacy
organizations in 2004. Implementation by hundreds
of pharmacists helped MTM evolve into a national
standard that is now recognized by the American
Medical Association (AMA). The Current
Procedural Terminology (CPT) codes [first
established as Category III (practice is emerging) to
Category I (established)] for MTM services have
been incorporated into the published edition of the
AMA’s CPT 2008.
But early experience suggests that the benefits
of medication therapy management apply to other
important patient segments. Public (Medicaid), state
plans, and private insurers (and even the individual
self-paying public) are beginning to recognize the
value of MTM services. Early results from those at
the far reaches of practice application report early
success in getting a majority of different payers
amenable to MTM services. It is easy from this
vantage point to see MTM services becoming
universal within 5 to 10 years.
One of the most important things that the AMA
has done is to recognize MTM services. In doing so
it has adopted a clear description of pharmacistprovided MTM services. Included in the standard
are vignettes of various MTM services, so there is
less chance of variation in definition.
What Is the Aim of MTM?
The aim of Medication Therapy Management is
to provide a valuable service to patients where none
exists today. Over time patients will require less
time and have fewer side effects and other reaction
to drug therapy. Visits to emergency rooms will be
less with patients who avail themselves of MTM
services. The same can be said for unexpected
deaths and the cost of misusing drugs.
What MTM is Not
The intention and practice of Medication
Therapy Management is not a reiteration of
standard pharmacy practices. Pharmacists have to
reorder their thinking to encompass an expansion of
services that includes things that are not being
carried out by traditional pharmacists, physicians, or
nurses.
Over time it is expected that patients will
become more sophisticated and informed about
drug therapy. Their definition of “drug” therapy will
expand to include the universe of medications they
are now using.
MTM is about educating the patient in a way
never done before. It involves the patient’s entire
belief system and the practical realities of his/her
personal environment in concert with medication
actions, side effects, and interactions with food and
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related issues, actions already taken, and any
associated actions to be taken, e.g., talking over a
medication problem with their secondary
physicians. The Medication Action Plan is
completed collaboratively by the patient and
pharmacist.
Fundamental Elements of MTM
To assist pharmacists in defining and
implementing medication therapy management, the
APhA and the National Association of Chain Drug
Stores Foundation (NACDSF) created a list of core
elements for a model MTM service and published in
the APhA-NACDS collaboration, Medication
Therapy Management (MTM) in Pharmacy
Practice: Core Elements of an MTM Service
(Version 2.0). The five elements include:
 Intervention and/or Referral. The pharmacist
provides consultative services during the MTR and
intervenes to address medication-related problems.
Interventions may include actions by the pharmacist
or other health providers. Also, patient goals should
be established for each intervention. The
intervention should be tailored to patient needs in
order to optimize outcomes. Not all problems can
be solved in a single session and are therefore
marked for follow-up. Finally, it may be necessary
to refer patients to other health care specialists, e.g.,
a physician or pharmacist with specialized training.
Elements of Medication Therapy
Management
• Medication Therapy Review (MTR)
• Personal Medication Record (PMR)
• Medication Action Plan (MAP)
• Intervention and/or Referral
• Documentation and Follow-up
 Medication Therapy Review (MTR). This is a
review that is conducted by the patient (and
caregiver) and pharmacist. It is meant to be
comprehensive. During the interview the patient
presents all prescription and non-prescription
therapy they currently use. Herbals and dietary
products are included. Any injectibles not included
in the initial survey are also identified here. The
pharmacist goes over each product to identify any
dosage related problem then works with the patient
and prescriber to resolve each problem. In
subsequent MTR meetings the pharmacist reviews
past problem and identifies new ones for attention.
 Documentation and Follow-up. Services
provided should be documented in a consistent way
that is sufficient for:
a. evaluating patient progress,
b. informing other health care providers about
care provided to the patient,
c. billing purposes, and
d. billing or question follow-up.
The patient is then scheduled for a follow-up
visit if necessary.
 Personal Medication Record (PMR). At the
conclusion of the MTR, the patient gets a
comprehensive list of all medication covered in the
session—including all prescription, injectable,
nonprescription, herbals, and dietary supplements.
The record is a simple patient-centered tool that
serves as an important information guide. Older
PMRs are updated as needed. Patients are
encouraged to share the information with other
health care providers. Some pharmacists forward a
copy of the PMR to the patient’s primary care
physician to promote continuity of care.
You must prepare for an MTM service in the
same manner as you would prepare for a new
pharmacy. There are many questions to address.
The list of excellent pointers and tips is far too long
to be addressed here. Some of the fundamental
areas of concern include:
Preparing for a Medication
Therapy Management Service
Physical Resources:
Regardless of how you define MTM services in
a pharmacy, you have certain physical
requirements. You must provide a private (or at
least semi-private) space that conforms to the
Health Insurance Portability and Accounting Act
(HIPAA) of 1996 privacy requirements. The area
should have a table and chairs sufficient for the
patient (possibly a caregiver) and pharmacist.
 Medication Action Plan (MAP). A MAP is
given to each patient at the end of the session. The
MAP is a patient-centered document that is a
comprehensive yet simple guide that helps the
patient keep track of all important information. It
includes the actions they will take to solve dosage-
A description of your MTM service, a brochure
on how to use medications safely, wellness issues,
and materials to conduct the service (educational
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materials, testing supplies, and demonstration
models) are necessary. Access to clinical
information (reference books and on-line
subscriptions) you may need during the session in
also important.
Comprehensive Documentation:
Documentation is essential to any MTM service.
It can be paper based, electronic, or a combination
of both. Information needs to be readily accessible
and retrievable.
There will also be a need for file storage and to
house program materials. Each patient needs an
individual chart. Again, you will have to store this
material in a way that conforms to HIPAA
requirements. You should also consider which
records you will want to keep in paper or in paper
and computer format.
MTM suggests several types of information that
should be included. A complete medical history
form is needed. An authorization for a medical
review and release of medical information are
essential. Finally, the system should have a means
of generating invoices and tracking payments.
Workflow and Scheduling:
You will have to schedule pharmacists’ time to
create the time necessary to provide MTM services.
You may need extra pharmacy help to do this, and
not all pharmacists are interested in, or good at,
MTM services.
A Final Note
This review is by no means a complete
discussion of MTM services. As a continuing
education lesson it is limited by definition. The
literature of medication therapy management is
voluminous, and more is being added daily. This
represents an attempt to provide a beginning for
your educational efforts. The reference cited and
many others are available in professional journals
and web sites.
The amount of time required to conduct a MTM
service is of vital concern. Obviously, the time
required is influenced by the experience of your
pharmacists and the complexity of issues raised by
new MTM patients. In general it takes 30 to 60
minutes to conduct a thorough, first-time
Medication Therapy Review. Targeted and followup MTRs usually require less time.
An MTM service also requires time to call
patients with a reminder of their appointment and
the importance of bringing all drugs to the session,
schedule patients, meet and greet them at the time
of their appointments, and to do follow-up work.
Personal and Training Needs:
A major amount of time and effort will have to
be devoted to training pharmacists and technicians
to handle MTM services.
Technicians can handle many tasks that do not
require professional judgment. For example,
technicians can make patient appointments,
complete patient charts, manage the filing system,
do data entry, and explain what to expect during a
visit to the service.
Training needs to be done to assure that
everyone understands what they will be doing and
how to go about doing it. Everyone needs to
understand the documentation system and how to
use it.
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