As oral drug therapies become more commonplace in specialty medicine, many practices are adding physician in-office dispensing programs, which not only provide a comprehensive approach to medication use improvement, risk-reduction for adverse events and medication adherence, but also present a potential revenue opportunity. In this two-part series, we will explain the core elements and key benefits of medication therapy management and discuss how to measure outcomes and overcome common challenges associated with medication therapy management programs.
Why medication therapy management (MTM) programs?
The number of oral drug therapies for specialty care is rapidly increasing. As these new agents are incorporated into care plans or treatment protocols that ensure optimal use of outcomes in a timely manner, the responsibility of administering the medication is shifting to the patient, which presents medication adherence challenges.
This, coupled with the evolution in healthcare from fee-for-service to value-based payments, is persuading practices to dispense medication through their practice by establishing a physician dispensing program or a retail pharmacy. Both types of programs provide valuable services to patients, including patient education, monitoring to ensure appropriate use of specialty medications and early intervention for management of adverse effects.1-2
As a result, many practices are increasingly seeking accreditation for their dispensing programs from respected organizations or agencies to demonstrate that they comply with the highest standards. For example, specialty pharmacies, including those in physician offices, may apply for accreditation through an independent organization such as URAC, formerly the Utilization Review Accreditation Commission. Additionally, the Accreditation Commission for Health Care (ACHC) recently developed accreditation standards, including those for physician dispensing programs. Regardless of the type of accreditation (URAC vs ACHC) chosen, practices must demonstrate that they provide comprehensive medication therapy management (MTM) services.3-4
MTM programs are designed to ensure high-quality, cost-effective, evidence-based and coordinated health care to patients or beneficiaries. These programs employ a comprehensive approach to medication use improvement, risk-reduction for adverse events and medication adherence in patient care plans.2
Purpose of MTM programs
MTM programs target patients receiving multiple medications or those with chronic diseases who are at higher risk of medication-related problems.2 MTM services provide continuity of care from one provider to another and serve as a valuable resource to improve patient quality of care by ensuring adherence to prescribed medication regimens. The results of a study published by the Centers for Medicare and Medicaid Services (CMS) in 2013 stated that MTM programs reduce health care costs and improve outcomes in Medicare beneficiaries with complex therapies.5
Core elements of MTM programs
MTM programs consist of 5 core elements:
- Medication Therapy Review (MTR)
- Personal Medication Record (PMR)
- Medication Action Plan (MAP)
- Referrals or interventions
- Follow-up and documentation
The MTR includes a complete assessment of a patient’s medications, including over-the-counter and herbal medications, and is generally conducted by a pharmacist. During an MTR, pharmacists identify and evaluate potential medication-related problems and share their findings with the patient’s provider. This information is used to create a PMR, which patients can share with other healthcare providers who can revise or update the patient care plan as needed. Finally, the MAP, an interactive document designed to help patients keep track of their medications and document drug-related concerns or adverse events, is provided. Interventions or referrals to other healthcare providers or services aimed at solving medication-related problems identified during the MTM visit are made as needed. The process concludes with the creation of a good “paper trail” via documentation of key findings/interventions and patient follow-up with regard to compliance and therapy outcomes that will help ensure patients achieve the best possible care.6
CMS requirements for MTM programs
MTM services have become more widely recognized and used since their introduction in the 2003 Medicare Prescription Drug, Improvement, and Modernization Act (MMA).7 Within the MMA, MTM services fall under the Medicare Part D prescription drug plan for beneficiaries. Part D sponsors are required to build MTM programs that focus on improving medication use, avoiding medication misadventures and improving overall medication adherence into their patients’ benefit plans. CMS requires minimum MTM services for its beneficiaries, which include:
- Interventions for beneficiaries and prescribers to resolve medication-related problems and improve medication adherence.
- An annual comprehensive medical review (CMR) or MTR performed by a pharmacist or other qualified provider with a summary written in a standardized format.
- Quarterly Targeted Medication Reviews (TMRs) with follow-up interventions as needed.2
Although CMS permits Part D sponsors to set their own minimum number of chronic conditions and Part D drugs a patient must have or be taking to be eligible for MTM services, the CMS requires a minimum threshold of two or three chronic diseases and between two and eight medications. The type of chronic disease is not currently regulated by CMS. However, CMS evaluates each Part D sponsor’s MTM program description to ensure that it meets these minimum requirements. In addition, sponsors are encouraged to offer additional services, such as referrals to specialists for disease management, patient education and medication guides and refill reminders, that add value to one’s healthcare.2,7
Accreditation standards for MTM programs
Although currently not required for physician-dispensing pharmacies, two organizations – URAC, and the Accreditation Commission for Health Care (ACHC) – are recognized nationally by state and federal regulators, including CMS, as qualified to accredit various healthcare organizations, including but not limited to retail or physician-dispensing pharmacies and, by way of association, their MTM programs. For example, URAC’s accreditation of retail pharmacies includes a drug therapy management (DTM) accreditation, which ensures existing MTM programs provide, at a minimum, CMRs, medication treatment plan development and cost-effective, evidence-based medicine that aligns with national standards. Historically, regulators, employers, consumers and health plans have considered URAC accreditation as the gold standard for MTM practices.3 The ACHC has introduced the Distinction in Oncology program, the first oncology pharmacy accreditation program that provides distinction in oncology services to organizations who dispense oncology drugs. This program recognition incorporates a review of medication delivery methods for cancer therapy, cost containment and copay programs, manufacturer assistance programs, patient/clinical outcomes and collaboration between provider, pharmacist and patient in the optimization of a patient’s care plan.
ACHC’s efforts are also being supported by the Community Oncology Pharmacy Association (COPA), a subsidiary of the Community Oncology Alliance (COA), which shares their mission of ensuring that patients receive high-quality drug therapy management services. For a physician dispensing pharmacy to earn the ACHC/COPA Distinction in Oncology accreditation, providers must have ACHC Specialty Pharmacy Accreditation. In anticipation of the need for accreditation, physician-based dispensing programs should develop MTM services that meet the minimum accreditation standards defined by these organizations that demonstrate their validated commitment to quality, accountability and excellence.3,4,8
As the use of oral specialty medications continues to grow and administering these treatments becomes more complex, the need for medication adherence programs has increased and physician dispensing programs have become more relevant. Whether a practice has a new program or has been providing dispensing services for some time, they should consider formalizing their MTM programs to align with the highest standards as promoted by URAC and ACHC accreditation.
- Kliethermes MA, Parrott AM, Sachdev G, Singh RF, Weber ZA. ASHP Section of Ambulatory Care Practitioners: Pharmacist Billing for Ambulatory Pharmacy Patient Care Services Based Clinic and Other Non-Hospital-Based Environments – FAQ. May 2014. https://www.ashp.org/doclibrary/policy/ambulatory-care/pharmacist-billing-in-physician-based-clinic-faq.pdf. August 5, 2016.
- CY 2016 Medication Therapy Management Program Guidance and Submission Instructions. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Memo-Contract-Year-2016-Medication-Therapy-Management-MTM-Program-Submission-v-040715.pdf. Accessed June 16, 2016.
- URAC Accreditation and Measurement: Accreditation Programs: Drug Therapy Management.https://www.urac.org/accreditation-and-measurement/accreditation-programs/all-programs/drug-therapy-management.
https://www.urac.org/about-urac/frequently-asked-questions/. Accessed August 7, 2016.
- Introducing ACHC’s Distinction in Oncology. http://www.achc.org/go/oncology. Accessed August 7, 2016.
- Acumen LLC. Medication Therapy Management in Chronical Ill Populations: Final Report August 2013. https://innovation.cms.gov/files/reports/mtm_final_report.pdf. Accessed June 23, 2016.
- McGivney M, Simenson S. Medication Therapy Management Services: Creating a Patient Care Process for MTM in Your Practice. American Pharmacists Association. 2007.
- Bluml B. Definition of Medication Therapy Management: Development of Professionwide Consensus. J Am Pharm Assoc. 2005;45: 566-572.
- Community Oncology Pharmacy Association: ACHC Accreditation.http://www.coapharmacy.com/achc-accreditation. Accessed August 7, 2016.