As the healthcare landscape continues to move toward team-based care, pharmacists are playing a significant role in improving patient outcomes. One of the most important ways pharmacists can take an active role is by providing Medication Therapy Management (MTM).
Uncovering the benefits
For patients, a Comprehensive Medication Review (CMR) conducted during an MTM consultation provides a better understanding of the medications they take and ensures they’re taking them correctly, to limit adverse effects. Patients also receive a Medication Action Plan that highlights recommended changes to their medication regimen and a Personalized Medication List, which makes it easier for those with chronic conditions to bring a coordinated prescription list to multiple physicians. The ultimate result is improved care and outcomes for patients.
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For pharmacists, MTM provides an opportunity to provide more than just a filled prescription — it’s an opportunity to fulfill their role as a trusted care provider. If patients aren’t on the right medications and properly adhering to their medications, their health will likely decline and increase healthcare costs. In fact, studies show that up to $3.6 trillion could be saved in the next ten years by improving medication use1. By successfully completing MTM cases, pharmacists provide better quality of care to patients and prevent unnecessary costs caused by suboptimal use and medication noncompliance.
For payers, industry pressure on quality measurement and managing costs and reimbursements is growing, so payers are taking a closer look at pharmacy performance and a more active role in their members’ medication use. The Centers for Medicare & Medicaid Services (CMS) internal studies indicate real benefits from MTM programs, and CMS is expecting more robust solutions for patients moving forward. In fact, five of the measures within Star Ratings are specific to medication use, with a sixth Star Ratings measure expected for 2016 specific to receiving MTM services with ratings based on 2014 performance.
Identifying the barriers
If MTM services offer so many benefits to players in the healthcare system, why are so few MTM cases completed?
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The first issue is the standards of eligibility. Right now, CMS allows health plans to set their own criteria for eligibility within certain parameters. In order to qualify, a patient must have 2-3 medical conditions, be on 3-8 medications annually (both of the health plan’s choosing) and have a projected annual drug spend of $3,100. You can see how the number of eligible patients can shrink quickly.
The second issue is a problem with actual case completion. One of the biggest barriers to MTM case completion is that pharmacy services haven’t been set up in traditional medical billing formats. CMS pays the health plans out of their administrative fees, not their medical fees. As a result, these services can be offered directly from health plans, through pharmacy benefit managers, or MTM vendors who may or may not push the opportunities to the community pharmacies, resulting in a fragmented delivery model. While billing codes to enable pharmacists to fill these services have been established, no dollar value has been assigned to the codes so they haven’t been picked up by the health plans for use. Subsequently, there’s no way to integrate MTM into the traditional medical billing cycle. Plus, when Medicare was created, pharmacists were not listed as “providers” in the Social Security Act.
As a result, pharmacists simply have limited reimbursement opportunities available to them, which throws the return on investment for offering the MTM service into question. The lack of standardization for qualifying patients makes it difficult to locate who is eligible, and with few opportunities to complete MTM, there isn’t a chance to apply workflow processes and scale the programs. While a typical CMR should only take about 35 minutes, in truth, it often takes longer to deliver the service as a result of these barriers.
Working toward a solution
As the case for the benefits and need for MTM grows, changes are beginning to take place throughout the healthcare industry that will enable pharmacists to overcome barriers to MTM. CMS is gradually beginning to push the eligibility criteria measures toward a more standardized framework and raise expectations for payers in terms of medication adherence and quality measures for members.
In terms of case completion, a key driver for change will be pharmacist status as providers in the Social Security Act. There’s currently a bill before Congress to amend Title XVIII of the Social Security Act to provide for coverage of pharmacists’ patient care services and grant pharmacists provider status recognition. Once this is in place, pharmacists will be more integrated into the medical benefit, making payment to pharmacists for providing MTM will be more mainstream.
As demand and awareness for MTM grows, so will the opportunities for pharmacists to implement best practices and standardize documentation and billing.
In summary, Medication Therapy Management is a win for patients, pharmacists, payers and the broader healthcare system. It helps improve patient outcomes, reduces unnecessary healthcare costs, and strengthens the important relationship between pharmacies and their patients.
1Kelly, B., Fabius, R. (2010). A path to eliminating $3.6 trillion in wasteful healthcare spending. Thomason Reuters.
