What Is Medication Therapy Management, And Why Does Only One Type of Pharmacy Actually Do It?

What Medication Therapy Management Actually Is

Medication Therapy Management is a clinical service, not a prescription transaction, in which a pharmacist conducts a comprehensive review of everything a patient is taking: all prescription medications, all OTC products, all vitamins, and all supplements.

The goals of an MTM review are:

Identify drug therapy problems. Unnecessary medications, medications for which there is no current clinical indication, medications dosed too high or too low, medications causing adverse effects, drug interactions, duplications in therapy, and medications the patient needs but is not receiving.

Create a personal medication record. A complete, up to date list of everything the patient takes, in a format the patient can carry, share with other providers, and refer to in an emergency.

Develop a medication action plan. A prioritized list of specific recommendations for the patient and their prescribers, medications to reconsider, doses to adjust, interactions to address, monitoring to add.

Provide patient education. Ensuring the patient understands what each medication is for, how to take it correctly, what side effects to watch for, and how to manage their medication regimen effectively.

Coordinate care. Communication with the prescribing physicians to implement the recommendations that require prescriber action.

A comprehensive MTM review typically takes 45 to 60 minutes for a complex patient on multiple medications. It is a clinical consultation, not a counter transaction.

Who Qualifies for MTM Under Medicare Part D

Medicare Part D plans are required by CMS to offer Comprehensive Medication Reviews to beneficiaries who meet all three of the following criteria:

Multiple chronic conditions. The patient has two or more chronic conditions from a defined list that typically includes diabetes, heart failure, dyslipidemia, hypertension, respiratory disease, bone disease, mental health conditions, and others.

Multiple Part D medications. The patient is taking multiple Part D covered medications, typically defined as three or more, though the threshold varies by plan.

At risk for high medication costs. The patient is likely to incur annual Part D drug costs above a threshold established by CMS.

Patients who qualify are entitled to a free comprehensive MTM review at least once per year, typically conducted by a pharmacist, and covered by their Medicare Part D plan.

Many patients who qualify are never informed that they qualify. Many who are informed never actually receive the service because the chain pharmacy where they fill their prescriptions has not established the staffing, time, or operational infrastructure to consistently deliver 45 to 60 minute clinical consultations.

Why Chain Pharmacies Underdeliver MTM

The business model of a chain pharmacy is built around prescription volume, the number of prescriptions filled per hour, per day, per pharmacist. Performance metrics, staffing ratios, and operational systems in large chain pharmacies are calibrated around throughput.

A 45 to 60 minute MTM consultation with a single patient represents the time that could be used to fill 15 to 20 prescriptions. In a volume based business model, that is a significant productivity trade off, regardless of the clinical and reimbursement value the MTM consultation provides.

Chain pharmacies do bill for MTM services and do employ programs and systems designed to deliver them. But the structural tension between volume based metrics and time intensive clinical services consistently results in MTM delivery that is less thorough, less comprehensive, and less clinically meaningful than what the service is designed to provide.

Independent pharmacies with a clinical service orientation do not face the same structural tension to the same degree. A clinical consultation that takes an hour is a normal part of the practice model, not a productivity exception that requires justification.

What a Real MTM Review Looks Like at Fairview

At Fairview a Medication Therapy Management review begins before the appointment, with a review of the patient’s complete medication profile and preparation of a preliminary drug therapy problem identification.

The consultation itself covers every medication on the patient’s list, the clinical indication for each one, the appropriateness of the dose, the timing and administration, any interactions with other medications or supplements, and any side effects the patient may be experiencing and attributing to other causes.

The outcome is a written personal medication record the patient leaves with, a written medication action plan with specific prioritized recommendations, and a summary communication to the patient’s prescribing physicians for any recommendations that require prescriber action.

The entire process is covered by Medicare Part D for qualifying patients and is available for a clinical fee for patients who want it outside the Medicare MTM structure.

The Clinical Impact of a Genuine MTM Review

Across decades of pharmacy practice I have conducted comprehensive medication reviews that found:

Patients taking duplicate medications prescribed by different specialists who were unaware of each other’s prescribing. Patients with documented drug allergies receiving medications in the same class as their allergen because the allergy was in one medical record but not another. Patients whose neuropathy symptoms resolved when B12 deficiency from long term metformin use was identified and treated. Patients on eleven medications whose prescribing cascade was traced back to a single NSAID side effect that had been treated as a new condition four times over. Patients on doses calibrated for normal kidney function whose kidney function had declined significantly without dose adjustment.

None of these findings required extraordinary clinical skill. They required time, a complete medication list, and a pharmacist who was doing a clinical review rather than processing a transaction.

This article is for general information only and is not a substitute for personalized medical advice. Before starting or changing any medication, including over the counter products and supplements, talk with your pharmacist or physician about your specific situation.