Medication therapy management at a community pharmacy

Medication Therapy Management (MTM) programs were first introduced as part of the Medicare Modernization Act of 2003. The goal of MTM is to improve patient outcomes and reduce healthcare costs. Patients with at least two chronic disease states, two Medicare Part D prescription drugs, and an annual medication cost above $4,000 could participate. The guidelines and methods for improving patient outcomes and reducing healthcare costs were largely left undefined.

My MTM population is predominately elderly and/or immigrant. Most patients take at least 10 prescriptions, often from multiple providers. The typical patient has some combination of diabetes, arrhythmia, congestive heart failure, hypertension, hyperlipidemia, and asthma.

Since 2006, I have conducted more than 350 MTM encounters. In these encounters, 70% of my patients required at least one medication change for drug-drug, drug-disease, and drug-gender interactions; drug duplications and drug-class duplications; and formulary requirements. Adherence failure was found in 80% of these patients. Face-to-face MTM intervention, combined with personalized education counseling, has led to significant adherence improvements and reductions in medication interactions at follow-up visits. Both patients and physicians find MTM encounters beneficial.

Surmountable hurdles

Multiple problems must be addressed before more community pharmacies provide MTM. Medicare must clearly define MTM eligibility and delivery. Reimbursement must be streamlined, preferably from Medicare with pharmacists as recognized providers. Pharmacists and physicians must be actively encouraged and incentivized to provide and promote MTM.

There are initial costs in starting MTM. A private or semi-private consultation room is needed, with space for an elderly patient and family for 30 to 60 minutes. My own MTM space doubles as an educational, diagnostic testing, and immunization center. The financial benefit can make the investment worthwhile.

Like many independent pharmacists, I rely almost exclusively on dispensing and distribution fees. Cutbacks in dispensing fees and average wholesale price reimbursement have drastically reduced profits. Wholesale acquisition cost reimbursement has increased margin pressure, closing more than 1,000 independent pharmacies since 2006. With healthcare reforms encouraging generic prescriptions, our financial challenges will continue.

MTM programs can help combat these challenges. Typical reimbursement is $60 to $80 per encounter. The initial face-to-face MTM encounter takes approximately 40 minutes; follow-ups take 20 minutes. By scheduling MTM encounters during off-peak hours, I can maintain my standard dispensing patterns and volumes. MTM services also help market my pharmacy to physicians. Consultative MTM has increased referrals both for MTM and traditional dispensing.

The future is bright for MTM. Changes in 2010 increase the number of eligible patients. The annual medication cost threshold is now $3,000. Medicare-eligible patients must opt out of MTM as opposed to opting in. Medicare mandates quarterly MTM reviews with annual interactive consultation. MTM programs provide patient benefit, reduce health-system costs, and provide new pharmacy revenue. My own success in improving patient outcomes shows that face-to-face MTM in a community pharmacy provides superior outcomes compared to current PBM practices.

Medicare needs data, not anecdotes, to shape future MTM guidelines. We are conducting a prospective longitudinal MTM pilot study. We will provide Medicare with clinical data and financial outcomes from face-to-face MTM at the community pharmacy level. Our goal is to show that community pharmacies can have a favorable impact on patient outcomes and costs using consultative face-to-face MTM compared to the current PBM approach of no MTM or MTM by telephone or mail.