Medication Therapy Management: Pharmaceutical Safety and Savings

Updated: 10/1/2016

This report now includes recent developments and state details not published elsewhere. It was created as a supplement to NCSL's LegisBrief on
Medication Therapy Management, Catching Errors, Saving Lives and Money,  distributed electronically,  publication date January 2010 - available online in PDF format. 

Related Resource:
LegisBrief on "Taking Medications As Prescribed: Programs That Help" - An overview of Medication Adherence, June/July , 2010 -

 
Medications save or improve lives, but taken incorrectly or in excess they can make patients worse.  With thousands of prescription drugs on the market, increasingly powerful and popular over-the-counter products and an array of less-regulated herbs and supplements, frequently no one prescriber or manufacturer knows the total picture for each patient.

Most often the local pharmacy is the like place to spot a problem and identify a solution. The patient submits a prescription order (handwritten, computer printed or totally electronic) across a counter and picks up a bag at the other end. A pharmacy technician checks for product accuracy, insurance copayment pricing and completes the sale. Ideally the patient, voluntarily and accurately, mentions all other conditions and  medications and any dangerous or unintended medical results are avoided.

 Yet, the Institute of Medicine's 2004 report on health literacy says 90 million people have difficulty understanding, using, and acting on health information.i  The problem is compounded by the fact that most patients hide their confusion from their doctors because they are too ashamed and intimidated to ask for help.

 To catch and resolve the more at-risk patients, pharmacists have designed a formal but consumer-friendly program called Medication Therapy Management  (MTM) or Review. Usually MTM is used when a patient is taking many (eight plus) separate drugs. It is typically delivered as a face-to-face visit between the pharmacist and patient. The MTM consultation can be defined in statute or in a Medicaid, state or private contract, and is added as a reimbursed professional service. 

MTM Grahic of features

 The Core Elements of MTM 

An alliance of 10 organizations representing the pharmacy and pharmacist professions designed a uniform definition of acceptable practice:

  1. Review all current medications including nonprescription and herbal agents,

  2. Assess medication-related problems

  3. Provide a personal medication record (PMR) - a comprehensive, reconciled list of all of the patient's medications  to the patient and other clinicians for self-management, care coordination and continuity.

  4. Compile a medication-related action plan (MAP) for tracking progress in self-management.

  5. Identify cases needing intervention including collaborating with other clinicians

*NEW*  2016: Eligibility For And Enrollment In Medicare Part D Medication Therapy Management Programs Varies By Plan Sponsor. - 

Medicare Part D prescription drug plans must offer medication therapy management to beneficiaries with multiple chronic conditions and high drug expenditures. Bruce Stuart and colleagues analyze newly available data and find that plans with more restrictions had lower enrollment rates, suggesting missed opportunities for interventions that might improve outcomes and reduce spending. Published by Health Affairs, September 2016.

STATE M .T. M. PROGRAMS AND LAWS

The following are examples of MTM programs in 18 states; other states may have similar projects or payments.
State
Type
Description and Notes
California Medicaid HIV/AIDS MTM program for Medi-Cal.
Study Results:  report online.   This program was reported to have been cut in 2010.

Colorado

Medicaid

The MTM program was expanded statewide in 2008.

Florida

Medicaid

An MTM program is operational.
Georgia

Institutional
patients

HB 361 of 2010: Enacts the Safe Medications Practice Act; provides for collaboration between hospital pharmacists and members of the medical staff on drug management therapy for a patient in an institutional setting. (Signed into law by governor as Act 392, 5/20/10)

Iowa

Medicaid

Iowa Medicaid reported that 31% of 3,037 eligible patients met with pharmacists; reporting 2.6 medication-related problems per patient, 52% recommended new medication and 31% recommended discontinuing a medication.  Medicaid pays $75 for initial assessments, $40 for follow up problems and $25 for preventive follow-up.
State Employees

Iowa Launches New Medication Therapy Management Program: helps State employees use medications safely and effectively. Sponsors anticipate over 64,000 patients will be enrolled.    (Launched July 2010)  http://www.jeffdanielson.org/primaryNews/article.asp?ID=2335

Minnesota

Medicaid

Minnesota implemented MTM services for low-income patients with complex medical and drug-related needs. Pharmacists received an average of $92.50 per patient visit, based on the complexity of care for the given patient. They resolved an average of 3.1 drug therapy problems per patient, usually issues of inadequate therapy. Patients averaged six medical conditions and 14 drugs each. Bills to create MTM were introduced over 12 years and finally enacted in 2005 [1]
2009 rates: a first-time, face-to-face encounter up to 15 minutes is $52, repeat visit is $34. Additional 15 minutes are billed at $24. 
Study Results:  MTM services resulted in a 31% reduction in total health expenditures per patient, from $11,965 to $8,197, and a 14% increase in meeting patient’s goals. The savings exceeded the cost of MTM services by more than 12 to 1. i

Signed into law as Minn. Stat. §256B.0625, subd. 13h in 2005.

[i] Source: Isetts BJ, Schondelmeyer SW. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. J Am Pharm Assoc. 2008;48:203-11

Mississippi

Medicaid

Mississippi was first to offer MTM, in 2003; Medicaid pays $20 for initial visits, with a 12-visit annual cap.

Missouri

Medicaid

Started January 2008, focusing on diabetes and asthma education. Subsequent phases will integrate chronic obstructive pulmonary disease, cardio-vascular disease, depression, gastro-intestinal disease, migraine, osteoporosis, and various other conditions.  Reimbursement:
> Initial 15 min., new patient            = $50
> Initial 15 min., established patient = $10
> Additional 15 minutes, all patients  = $5

Montana

Medicaid

An MTM program is reported operational.**

New Mexico

Medicaid

 An MTM program is operational.

New York

Medicaid

New York’s 2008-2009 Budget authorized implementation of a pilot Medicaid MTM program to improve therapeutic outcomes.  The program pays $35 for an initial new patient and $25 for a follow-up consultation, limited to six per year. 

North Carolina

Medicaid;
State employee plan

Medicaid has named the MTM program Focused Risk Management Program (FORM); it requires a limit of eight Rx per patient per month unless the patient enrolls in FORM.
North Carolina's ChecKmeds program is available to all 650,000 Medicare Part D patients, paid for by a state operated trust fund. The MTM  Program is scheduled to terminate July 1, 2011 due to state budget shortfalls. [Description of budget changes for FY 2012]
Study: NC State Employee MTM  link

Ohio

Medicaid

  An MTM program is operational.

Oregon

 

Medication Therapy Management (MTM) Pharmacists must enroll with DMAP as a professional provider to bill for MTM services. Services must be provided based on referral from a physician, licensed provider, or a Prepaid Health Plan (PHP).

Description

DMAP rate

Code

Initial 15 minutes, new patient

 $28.22

99605

Initial 15 minutes, established patient

 $26.34

99606

Each additional 15 minutes.

 $13.17

99607

For Oregon documentation requirements, refer to Guideline Note 64 of the Prioritized List of Health Services.  http://www.dhs.state.or.us/policy/healthplan/guides/pharmacy/rxsupp1009.pdf

Utah

Medicaid

 
Vermont Medicaid

An MTM program is reported operational.**

Virginia

Medicaid

An MTM program is reported operational.**

Washington

State, public employees

Washington State Health Care Authority now administers an MTM program for eligible public employee enrollees of the Uniform Medical Plan (UMP) and the Aetna Public Employees Plan of Washington.

Wisconsin

Medicaid

Medicaid pays $40.11 per encounter.
Public employee pilot.

Wyoming

Medicaid

An MTM program is reported operational.

** MTM program reported by NACDS, 1/09

Other State Actions

Idaho's legislature in 2008 considered, but did not pass, a resolution (HCR 40) "encouraging the Department of Health and Welfare to proceed with the development of a Medicaid Medication Therapy Management Program."  It was not reconsidered in 2009.

Wisconsin's Pharmacy Society plans to pilot an MTM initiative with about 50 pharmacies during 2007 and evaluate the impact of the program before expanding it to third-party payers (health plans, employers, and state agencies, including public employees in ETF and DHFS). ETF is working with its PBM, Navitus, to determine areas of duplication, as well as efficiency and quality enhancement opportunities.

In Connecticut: Improving Patient Medication Management in Primary Care – published 2011 in Health Affairs. online at http://www.ctpharmacists.org/files/public/Health%20Affairs%20Article.pdf

Medicare Part D and MTM Requirements

Under federal statutes 423.153(d), each Medicare Part D sponsor must have established a MTM program that:

  • Ensures optimum therapeutic outcomes for targeted beneficiaries through improved medication use. 

  • Targets beneficiaries who have multiple chronic diseases and cannot require more than 3 chronic diseases as the minimum number of multiple chronic diseases and must target at least four of the following seven core chronic conditions: 

    • Hypertension;

    • Heart Failure;

    • Diabetes;

    • Dyslipidemia;

    • Respiratory Disease (such as Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung disorders);

    • Bone Disease-Arthritis (such as Osteoporosis, Osteoarthritis, or Rheumatoid Arthritis);

    • Mental Health (such as Depression, Schizophrenia, Bipolar Disorder, or Chronic and disabling disorders). 

  • Reduces the risk of adverse events

  • Is developed in cooperation with licensed and practicing pharmacists and physicians

  • Describes the resources and time required to implement the program if using outside personnel and establishes the fees for pharmacists or others

  • May be furnished by pharmacists or other qualified providers

  • May distinguish between services in ambulatory and institutional settings

  • Is coordinated with any care management plan established for a targeted individual under a chronic care improvement program (CCIP)

Each Part D Sponsor is required to incorporate a Medication Therapy Management Program (MTMP) into their plans' benefit structure.  A CMS-approved MTMP is one of several required elements in the development of Sponsor' bids for the upcoming contract year.  CMS requirements online. [Updated 12/09]

*NEW*  2016: Eligibility For And Enrollment In Medicare Part D Medication Therapy Management Programs Varies By Plan Sponsor. - 

Medicare Part D prescription drug plans must offer medication therapy management to beneficiaries with multiple chronic conditions and high drug expenditures. Bruce Stuart and colleagues analyze newly available data and find that plans with more restrictions had lower enrollment rates, suggesting missed opportunities for interventions that might improve outcomes and reduce spending. Published by Health Affairs, September 2016.

Archive: Review of 2009 Medicare MTM Programs

There were 736 active Part D contracts with an approved MTMP in calendar year 2009, including 640 Medicare Advantage prescription drug plans (MA-PDs) and 96 prescription drug plans (PDPs). Employer MTM programs have been included in the statistics for PDPs. This analysis includes characteristics of 2009 MTMP applications approved during the Annual Review and changes approved during the March and June update windows as of July 21, 2009.

Additional Resources

Recent MTM Articles of Interest

The Emerging Role of the Pharmacist in the Healthcare Ecosystem -Infographic June 7, 2014 posted by © 2014 Eye on Infographics by Healthcare Intelligence Network

Pharmacists Reduced Drug Problems, Costs Through Primary Care MTM, Study Shows. -  published by the American Society of Health-System Pharmacists, online: http://www.ashp.org/DocLibrary/Advocacy/PolicyAlert/PrimaryCareMTM.aspx

Clinical Pharmacist Improves Diabetes Patients' HbA1c Levels andLowers Blood Pressure, Hospitalizations, ER Visits, Study Finds -  published by the American Society of Health-System Pharmacists, online: http://onlinewww.ashp.org/DocLibrary/Advocacy/PolicyAlert/PharmacistInterventionDiabetes2-25-2010.aspx

Pharmacists Improve Clinical, Economic Outcomes, Review Shows. -  published by the American Society of Health-System Pharmacists, online: http://onlinewww.ashp.org/DocLibrary/Advocacy/PolicyAlert/Pharmacists-Improve-Clinical-Economic-Outcomes-Review-Shows.aspx

Pharmacists Reduce Hospitalizations, Length of Stay for Dialysis Patients, Study Finds. -  published by the American Society of Health-System Pharmacists, online: http://onlinewww.ashp.org/DocLibrary/Advocacy/PolicyAlert/Dialysis-Patient-Medication-Reviews.pdf 

Pharmacists Reduced Drug Problems, Costs Through Primary Care MTM - 
May 9, 2011

Pharmacists identified 917 drug therapy problems (10.4 per patient) that saved an estimated annual $1,595 per patient during a Medicaid demonstration project at federally qualified health centers, according to a study in the April 2011, Health Affairs.1

 Pharmacists, working with primary care providers, saved an estimated annual $1,123 per patient in medication claims and $472 per patient in medical, hospital, and emergency department costs.  The study authors "recommend that the Center for Medicare and Medicaid Innovation support the evaluation of pharmacist-provided medication management services in primary care medical homes, accountable care organizations, and community health care transition teams, as well as research to explore how to enhance team-based care."

 An abstract of the study is available here.

1.       Smith M, Giuliano MR, Starkowski MP. In Connecticut: Improving patient medication management in primary care. Health Aff. 2011; 30:646-54.

 

Florida: Clinical Pharmacist Improves Diabetes Patients' HbA1c Levels and Lowers Blood Pressure, Hospitalizations, ER Visits, Study Finds
 

A clinical pharmacist counseling type 2 diabetes patients improved patients' HbA1c levels, lowered patients' blood pressure, and reduced hospitalizations and emergency room visits, according to a case study published in the February 15, 2010.

The Polk County Pharmacist Intervention Model, over one year, led to a 9% relative improvement in patients' HbA1c levels, a 30% reduction in all-cause hospitalizations, and a 24% reduction in all-cause emergency room visits, the study found. The model, implemented in February 2005, provided medication and disease counseling by a clinical pharmacist to diabetes patients in Polk County, Fla., who were employees, dependents, and retirees of the county government.

 Program participants had six, 30-minute visits with the clinical pharmacist. Patients also received copayment waivers for disease-related medications, supplies, and nonprescription products. Patients were required to sign an agreement to comply with program rules and were terminated from the program if they did not. There were 564 patients enrolled in the program, with 477 patients who remained enrolled at the end of the program's first year.

 The study is available at: 
Iyer R, Coderre P, McKelvey T et al. An employer-based, pharmacist intervention model for patients with type 2 diabetes. Am J Health-Syst Pharm. 2010; 67:312-15.

Pharmacists Improve Clinical, Economic Outcomes, Review Shows

Twenty studies found pharmacists improved economic and clinical outcomes through direct patient care, according to a systemic review in the October 1, 2010, American Journal of Health-System Pharmacy.1  These studies showed that a pharmacist's care reduced and avoided costs by "reducing drug expenditures, hospital admissions, lengths of hospital stay, and emergency department visits."

Pharmacists improved outcomes for patients with a variety of health conditions, from patients with multiple diseases to those with asthma, infections, or patients in need of anticoagulation management. Patients with diseases such as dyslipidemia, diabetes, heart failure, hypertension, epilepsy, and HIV/AIDS experienced improvements in their conditions as well.

The study is available online   Chisholm-Burns MA, Zivin JSG, Lee JK et al. Economic effects of pharmacists on health outcomes in the United States: a systematic review. AJHP. 2010; 67:1624-34.ext

 Health Plans Demand More ROI Data as CMS Toughens its Regs on Medication Therapy Management 

Featured Story, Oct. 19, 2010 Reprinted from DRUG BENEFIT NEWS, biweekly news, data and business strategies for health plans, PBMs and pharmaceutical companies.

By Renée Frojo, Editor (rfrojo@aispub.com)

Complying with the growing number of CMS requirements for medication therapy management (MTM) programs is becoming tougher as the number of Medicare Part D beneficiaries eligible to enroll in such pro-grams also expands. While the agency is convinced of MTM’s effectiveness, some payers — including an in-creasing number considering MTM programs for their commercial populations — are demanding more specifics on such programs’ return on investment (ROI), according to several pharmacy benefit experts who participated in a Sept. 28 webinar sponsored by AIS.

At the beginning of this year, CMS estimated that 25% of Part D beneficiaries were eligible for MTM services, compared with 10% to 12% in previous years. At the same time, CMS began requiring Part D plans to expand their current MTM programs to include an annual comprehensive review of medications, a process to assess the medication use of individuals who are at risk, and automatic enrollment of targeted beneficiaries who qualify on a quarterly basis.

As a result of increased reporting requirements, many plans have had to invest more money and hire additional staff to meet CMS standards, according to Marissa Schlaifer, the Academy of Managed Care Pharmacy’s (AMCP) director of pharmacy affairs.

“Previously, all Part D plans were required to report the number of beneficiaries eligible for their MTM program and the number who opted out,” she said during the webinar. beginning this year, plans had to report at the beneficiary level the receipt of a comprehensive medication review, the number of targeted medication reviews, the number of prescriber interventions and changes in therapy from MTM requirements.”

In interviews with several plans to see how they are complying with the 2010 requirements, Schlaifer found that one plan had to hire more staff and provide additional training for its internal call center staff. Other plans either contracted with an outside call center or an MTM pharmacy network to provide person-to-person comprehensive medication reviews and other services.

What they all had in common was “the need for updated and improved information technology systems to provide integrated data and reporting capabilities,” Schlaifer said. “Some of that was to provide MTM services, but to a greater extent it was to comply with increased reporting requirements.”

Taking note of the increased work and investment necessary on behalf of plans, many payers often question how these MTM providers determine ROI. The problem is that “it’s very hard to isolate ROI with your MTM program,” Schlaifer maintained. “Pretty much any plan that is offering MTM services is also offering other services — whether it’s the standard PBM utilization management or disease management programs — and it’s very hard to isolate ROI and just quantify it as being due to MTM services.”

MTM Company Estimates $4.73 per dollar ROI

However, some providers say they can provide solid numbers. Over the past two years, “we’ve seen a lot of expansion of MTM programs to non-Medicare Part D populations,” Brand Newland, vice president of MTM services provider Outcomes Pharmaceutical Health Care, said during the webinar. “And many other plans are considering doing such.”

According to Newland, this is because plans are seeing an ROI of $4.73 for every $1 spent for overall estimated cost avoidance. “And when we just looked at drug product costs, we were seeing $1.87 to $1 for our en-tire book of business — a number that has increased over the past year,” he added.

ROI can be calculated by assessing improved quality of care, drug product costs, number of physician visits, hospital admissions and emergency room visits, among other things.

WellPoint, Inc. is one health plan that has been experimenting with MTM programs in the commercial space for the past couple of years. “There just hasn't’t been a lot of education for patients about medication compliance,” Laurie Amirpoor, staff vice president of clinical program policy at WellPoint, Inc., said during the webinar.

As a result, WellPoint rolled out an “innovative” employer-based MTM program in Cincinnati aimed at improving diabetic and hypertensive members’ knowledge of their disease, medication adherence, self-management behavior and clinical outcomes. This “Pharmacy Coaching” program encouraged eligible patients to go to large pharmacy chains to get one-on-one consultations with a pharmacist.

While it’s too early to disclose the final results of the study, Amirpoor revealed that WellPoint did see improved outcomes for patients in the form of lower hemoglobin A1c, blood pressure and lipid levels, and a significant ROI for the plan. WellPoint is planning to launch a similar program in California later this year.

Trends in Pharmacist Reimbursement

SUMMARY: Many healthcare organizations reported a strong effort to improve medication adherence levels, with a serious focus on patient education and primary responsibility assigned to either the PCP or pharmacist. We wanted to see which medication adherence-related tasks were reimbursable for pharmacists.

The January 2010 Medication Adherence e-survey by the Healthcare Intelligence Network captured the industry's efforts to improve medication adherence. Sixty-nine percent of responding healthcare organizations include a pharmacist on their medication adherence team. According to responding organizations, pharmacists are reimbursed for the following medication adherence-related tasks:

  • Medication reconciliation/review (26.5 percent);
  • Patient education (17.6 percent);
  • Resolving drug therapy problems (14.7 percent);
  • Converting regimens to generic drugs or preferred formulary medications (8.8 percent); and
  • Not currently reimbursing (70.6 percent).

For additional research data and insights on this topic:

Download the executive summary of 2010 Benchmarks in Medication Adherence and Management. 

Pharmacists Reduce Hospitalizations, Length of Stay for Dialysis Patients, Study Finds
December 18, 2009 - American Society of Health-System Pharmacists

Patients with end-stage renal disease who received in-depth medication reviews by clinical pharmacists had 42% fewer hospitalizations and a 21% decline in length of hospital stay, according to a study in the December 2009 Pharmacotherapy.1 Pharmacists identified 530 drug-related problems among 57 patients while reviewing patients’ medications every three weeks during the two-year pilot study at a dialysis clinic in New Mexico. The pharmacists also joined weekly patient rounds and monthly patient reviews with the patients’ health care team. One of the pharmacists was a nephrology-trained clinical pharmacist, while the other two were completing nephrology pharmacotherapy postdoctoral training. The 47 patients in the control group received “periodic drug profile updates by dialysis nursing staff,” which is standard care. “This demonstrates that consistent care by a nephrology-trained clinical pharmacist can translate into cost avoidance for third-party payers (e.g., Medicare) and improved financial profiles for ambulatory hemodialysis centers that avoid lost revenue secondary to missed treatments while the patient is hospitalized,” the study’s authors stated. As a result of these findings, the study’s authors suggest health care policy makers consider adding pharmacists to a multidisciplinary care team for hemodialysis patients. An abstract of the article is available at http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.29.12.1433 
Source: 1.  Pai A B, Boyd A, Depczynski J et al. Reduced drug use and hospitalization rates in patients undergoing hemodialysis who received pharmaceutical care: a 2-year, randomized, controlled study. Pharmacotherapy. 2009; 1433-40.

 

Pharmacists Improve Care of Diabetics While Cutting Costs

Source: University at Buffalo, December 28, 2009 - http://www.buffalo.edu/news/10781

The role of pharmacists hasn't received much attention in the debate on the cost of healthcare. But national and regional studies show that when pharmacists directly participate in patient care, they significantly reduce treatment costs and improve outcomes. A study on diabetic patients by the University at Buffalo (UB) School of Pharmacy and Pharmaceutical Sciences identified cost savings with improvements in a key indicator of glucose control in diabetes patients, the hemoglobin A1C measurement. The A1C provides a three-month average of the amount of excess glucose in the blood. Higher A1Cs indicate that a patient is at higher risk for developing long-term complications associated with diabetes, such as kidney disease or vision problems.

The study found that:

  • In just six months, clinical pharmacists, in collaboration with primary care providers, were able to significantly reduce patients' A1C levels.

  • Patients' A1C levels were reduced by an average of 1.1 percent, from an average of 8.5 percent to 7.4 percent, one year after being enrolled in the program, while also improving the overall metabolic profile.

  • Enhancing the patient's access to care through collaborative physician-pharmacist relationships can yield lower blood glucose levels, improve the overall metabolic profile and reduce costs to the payor. These clinical improvements occurred while monthly costs per patient went down by approximately $212, around $2,500 per year, even though there were nominal increases in the cost of medications prescribed.

The key to success is that patients had unlimited access to pharmacists throughout the year, says Erin Slazak, PharmD, UB clinical assistant professor of pharmacy practice and board certified pharmacotherapy specialist. The UB pharmacists spent an initial one-hour appointment with each patient, where they worked up detailed health records covering dietary information and all medications and disease conditions, and then reviewed them with each patient. After that, patients could call or make appointments with pharmacists at will. For patients in the initial stages of administering insulin, Slazak says it was common to be contacted once every few days. The pharmacists then made suggestions to physicians about changes in medications, dosages or lifestyle that might be beneficial to their patients. That kind of individualized attention is far from the norm for diabetic patients. "Nationwide, the standard of care is that the primary care provider manages diabetes alone," says Slazak. "Pharmacists typically do not have direct involvement." That is partly because some states, including New York, have not yet approved collaborative practice agreements between physicians and pharmacists. 
As Medication Therapy Management Programs Become More Robust, Plans Need to Compare Cost to Health Status                 
Reprinted from MEDICARE PART D NEWS

The health reform law has codified CMS medication therapy management program (MTMP) requirements, aiming to make the program more robust and providing incentives for some plans to provide programs that go beyond CMS requirement. Some industry insiders would like to see plans do more with their MTMPs but acknowledge a conflict between cost and beneficiary health status. Read Full Story- may require user password

 

Notes:

[i] Institute of Medicine. (2004, April 8). Health literacy: A prescription to end confusion. Accessed December 5, 2009, at www.iom.edu/report.asp?id=19723