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. 1
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. 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. 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. 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. 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 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 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. 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? 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 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. 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. 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 2
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. 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. 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. 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 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. 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 3 other drugs. It is about teaching patients to become smarter in the way they take or do not take prescription and nonprescription drugs. 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. 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. 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. 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. 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.
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: 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 4 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. 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. 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 dosagerelated 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. 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. 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. Preparing for a Medication Therapy Management Service 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: 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. A description of your MTM service, a brochure on how to use medications safely, wellness issues, and materials to conduct the service (educational
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. 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. 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. 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. 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. 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. 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. 5