Community Pharmacists and Medication Therapy Management
Medication therapy management (MTM) is a distinct service or group of services provided by health care providers, including pharmacists, to ensure the best therapeutic outcomes for patients. MTM includes five core elements: medication therapy review, a personal medication record, a medication-related action plan, intervention or referral, and documentation and follow-up.
Within the context of cardiovascular disease (CVD) prevention, MTM can include a broad range of services, often centering on the following:
- Identifying uncontrolled hypertension
- Educating patients on CVD and medication therapies
- Advising patients on health behaviors and lifestyle modifications for better health outcomes
MTM is especially effective for patients with multiple chronic conditions, complex medication therapies, high prescription costs, and multiple prescribers. MTM can be performed by pharmacists with or without a collaborative practice agreement (CPA), and it is a strategy that can be considered to straddle Domain 3 (health care system interventions) and Domain 4 (community-clinical links).
Strong evidence exists that the use of MTM by pharmacists is effective. Although the exact combination of MTM activities tends to vary between settings, studies examining MTM have generally found it to be effective and to have strong internal and external validity. MTM trials have been replicated in many different contexts with positive results. Implementation guidance on MTM is available from several sources, including the guidance provided under Medicare Part D.
In 2015, the Agency for Healthcare Research and Quality (AHRQ) found the evidence behind MTM to be insufficient because of inconsistency in the operationalization of MTM across studies, but concluded that MTM can improve medication adherence.1 MTM has been shown to be effective for lowering systolic and diastolic blood pressure; lowering LDL cholesterol and other health indicators (e.g., glycosylated A1C, HbA1c); increasing patient knowledge; improving patient quality of life and medication adherence; and improving the safe and effective use of medications, including reducing therapeutic duplication, decreasing total medications prescribed, and increasing adherence for therapeutic care.2–8
Health Disparity Impact
Expanding the pharmacist’s role through MTM is likely to increase access to health care for populations facing the most barriers to care. However, few studies have examined the ability of MTM to reduce health disparities in CVD outcomes. Although some evidence exists that MTM can achieve positive outcomes among minority and low-income populations, the extent of this evidence is limited and inconsistent.4,5 More research is needed to directly examine the effect of MTM on different populations.
Studies have indicated that MTM can produce health care cost savings and a positive return on investment (ROI) for health care systems.9–11 A study that examined the effect of providing MTM in a large health system for over 10 years found that the cost to providing MTM services was $76 per patient encounter, and the ROI that resulted from health care cost savings was $1.29 per $1 spent on MTM services over this period.10
Another study that evaluated the use of MTM by a self-insured employer reported an intervention cost of $145.61 per patient and an ROI to the payer of $1.67 per $1 of MTM costs over a 6-month period.11 Despite early findings of potential economic benefits, recent meta-analyses and systematic reviews have identified a need for better cost-effectiveness data on expanded pharmacist care.7,8
MTM has been implemented in several settings, including Federally Qualified Health Centers (FQHCs), patient-centered medical homes, managed care health systems, community pharmacies, hospital pharmacies, and primary care clinics.
- Policy and Law-Related Considerations
MTM is currently supported under the Centers for Medicare & Medicaid Services (CMS), as a service available to selected Medicare beneficiaries. As a part of Medicare Part D regulations, enrollees with multiple chronic diseases who are taking multiple Part D drugs are eligible for MTM programsexternal icon.12 Outside of the CMS guidelines, reimbursement for time and services is a key issue for pharmacists performing MTM. Regional variations in training and scope of practice can limit pharmacists when they attempt to provide MTM services. For MTM to work most effectively, pharmacists and prescribers can develop CPAs with shared blood pressure management protocols. Other policy considerations that need attention are determining the inclusion criteria for patients to receive MTM and encouraging payers to make the service available and offer reimbursement for pharmacists.
- Implementation Guidance
Implementation guidance has been developed by various organizations, including the following:
- Centers for Medicare & Medicaid Services pdf icon[PDF-323 KB]external icon12
- American Pharmacists Association’s MTM Centralexternal icon,13 which includes implementation guidance, an MTM resource library, and information about the added value of MTM.
Several federal agencies are working on initiatives that focus on greater involvement of pharmacists in CVD prevention and MTM. They include the following:
- Centers for Medicare & Medicaid Servicesexternal icon12
- AHRQ, which provides the National Guideline Clearinghouse14external icon and a list of resources related to innovations in MTMexternal icon.15
- CDC’s 6|18 Initiative16
- CDC’s Million Hearts Initiative pdf icon[PDF-188 KB]external icon17
MTM at Ohio Department of Health
In 2014, the Ohio Department of Health (ODH) teamed up with three FQHC sites to assess the effect of MTM counseling sessions on patients with hypertension. This effort involved collaboration among the Ohio State University College of Pharmacy, Ohio Pharmacists Association, Ohio Association of Community Health Centers, and the Health Services Advisory Group. These partners helped plan and develop the assessment. Pharmacists administered MTM to 500 patients with hypertension who were receiving care at one of the three FQHC sites. After 6 months, assessments found that hypertension control had increased to 68.6% among these patients. There were key components related to the project’s achievement, which included maintaining relevant partnerships, implementing the pilot in one type of pharmacy setting, allowing FQHC sites to develop their own protocols for patient enrollment, using effective dissemination processes, and selecting data points that align with current pharmacy practices. Challenges included finding champions for the MTM model.
- Viswanathan M, Kahwati L, Golin C, et al. Medication therapy management interventions in outpatient settings. JAMA Intern Med. 2015;175(1):76–87.
- Theising KM, Fritschle TL, Scholfield AM, Hicks EL, Schymik ML. Implementation and clinical outcomes of an employer-sponsored, pharmacist-provided medication therapy management program. Pharmacotherapy. 2015;35(11):e159–e163.
- Tsuyuki RT, Johnson JA, Teo KK, et al. A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP). Arch Intern Med. 2002;162(10):1149–1155.
- Carter BL, Barnette DJ, Chrischilles E, Mazzotti GJ, Asali ZJ. Evaluation of hypertensive patients after care provided by community pharmacists in a rural setting. 1997;17(6):1274–1285.
- Chabot I, Moisan J, Grégoire J-P, Milot A. Pharmacist intervention program for control of hypertension. Ann Pharmacother. 2003;37(9):1186–1193.
- Cheema E, Sutcliffe P, Singer DRJ. The impact of interventions by pharmacists in community pharmacies on control of hypertension: a systematic review and meta-analysis of randomized controlled trials. Br J Clin Pharmacol. 2014;78(6):1238–1247.
- Santschi V, Chiolero A, Colosimo AL, et al. Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials. J Am Heart Ass. 2014;3(2).
- Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev. 2014(4):CD007768.
- Isetts B, Schondelmeyer S, Artz M, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc. 2008;48:203–211.
- Ramalho de Oliveira D, Brummel A, Miller D. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm. 2010;16(3):185–195.
- Wittayanukorn S, Westrick S, Hansen R, et al. Evaluation of medication therapy management services for patients with cardiovascular disease in a self-insured employer health plan. J Manag Care Pharm. 2013;19(5):385–395.
- Centers for Medicare & Medicaid Services. Medication Therapy Management. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/MTM.htmlexternal icon. Accessed February 21, 2017.
- American Pharmacists Association. APhA MTM Central. Implementing MTM in Your Practice. https://www.pharmacist.com/implementing-mtm-your-practice. Accessed February 21, 2017.
- Agency of Healthcare Research and Quality. Improving Medication Management for Older Adult Clients. https://www.guideline.gov/ summaries/summary/37826/improving-medication-management-for-older-adult-clients?q=assisted+livingexternal icon. Accessed August 18, 2017.
- Agency of Healthcare Research and Quality. Innovations in Medication Therapy Management. https://innovations.ahrq.gov/issues/2015/02/18/innovations-medication-therapy-managementexternal icon. Accessed February 21, 2017.
- Centers for Disease Control and Prevention. The 6|18 Initiative: Accelerating Evidence into Action. https://www.cdc.gov/sixeighteen. Accessed February 1, 2017.
- Million Hearts. Cardiovascular Health Medication Adherence: Action Steps for Public Health Practitioners. Atlanta, GA: Centers for Disease Control and Prevention and Centers for Medicare & Medicaid Services; 2016.