1. Medication Therapy Management
LT Scott Raisor, PharmD
Indian Health Service, Phoenix Area,
Colorado River Service Unit
Medication Therapy Management

2. Legacy of Innovation in IHS
1962: Shift from distribution to clinical services
1969: Pharmacists provide direct patient care as primary care providers

3. Legacy of Innovation in IHS
1996: RADM Michael Trujillo codifies Pharmacists as Primary Care Providers (PCPs) with prescriptive authority
1997: National Clinical Pharmacy Specialist (NCPS) certification established
2011: PHS Pharmacy Report to the Surgeon General and the Surgeon General’s Support Letter

4. Justification for Expanding Services
“Advance beyond discussion of the value of expanded roles of pharmacists and move towards health system support and implementation of these roles.”
1.5 billion preventable medication related problems occur each year
The United States health care system spends over $177 billion dollars annually on medication related problems

5. What is Medication Therapy Management?
Medication Therapy Management services are patient centered assessment and evaluation of the patient’s full medication regimen and not only individual medications
Goals:
Optimize medication use
Improve collaboration
Enhance communication
Empower patients

6. What is Medication Therapy Management?
MTM is separate and distinct from pharmacist managed disease state clinics
Pharmacist managed clinics require and provide a higher level of care

7. What is Medication Therapy Management?
Medicare Part D sponsors are required to provide MTM services to their patients
42 CFR (d)

8. 42 CFR (d)
(d)Medication therapy management program (MTMP)— (1) General rule. A Part D sponsor must have established a MTMP that—
(i) Is designed to ensure that covered Part D drugs prescribed to targeted beneficiaries described in paragraph (d)(2) of this section are appropriately used to optimize therapeutic outcomes through improved medication use;
(ii) Is designed to reduce the risk of adverse events, including adverse drug interactions, for targeted beneficiaries described in paragraph (d)(2) of this section;
(iii) May be furnished by a pharmacist or other qualified provider; and
(iv) May distinguish between services in ambulatory and institutional settings.
(v) Must enroll targeted beneficiaries using an opt-out method of enrollment only.
(vi) Must target beneficiaries for enrollment in the MTMP at least quarterly during each plan year.
(vii) Must offer a minimum level of medication therapy management services for each beneficiary enrolled in the MTMP that includes all of the following:
(A) Interventions for both beneficiaries and prescribers.
(B) Annual comprehensive medication review with written summaries. The comprehensive medication review must include an interactive, person-to-person, or telehealth consultation performed by a pharmacist or other qualified provider unless the beneficiary is in a long-term care setting and may result in a recommended medication action plan.
(C) Quarterly targeted medication reviews with follow-up interventions when necessary.
(D) Standardized action plans and summaries that comply with requirements as specified by CMS for the standardized format.

9. Who is Eligible? Medicare criteria Medicaid Private plans Employers
Multiple chronic disease states
Multiple medications
High drug costs
Medicaid
Florida, Iowa, Maryland, Minnesota, Missouri, Mississippi, Ohio, Virginia
Private plans
Employers
Self-pay

10. Medicare Eligibility Chronic disease states
CMS requires 3 or less
Sponsors must include the 7 core chronic diseases
Diabetes
Hypertension
Dyslipidemia
Heart failure
Respiratory disease
Bone disease
Mental health disorder
2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at Accessed on May 16th, 2012

11. Medicare Eligibility Multiple medications High drug costs
CMS requires 8 or less
High drug costs
$3,000 or higher in annual medication costs
Average $250 per month
2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at Accessed on May 16th, 2012

12. MTM Best Practices
CMS regulations established a general framework that allows for best practices
10 pharmacy organizations collaborated to develop the core elements of an MTM visit
APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

13. Five Key Elements Medication Therapy Review (MTR)
“is a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them”
Personal Medication Record (PMR)
“is a comprehensive record of the patient’s medications”
Medication-Related Action Plan (MAP)
“is a patient-centric document containing a list of actions for the patient to use in tracking progress for self-management”
Interventions or Referrals
“The pharmacist provides consultative services and intervenes to address medication-related problems; when necessary, the pharmacist refers the patient to a physician or other healthcare professional”
Documentation and Follow Up
“MTM services are documented in a consistent manner, and a follow-up MTM visit is scheduled based on the patient’s medication-related needs, or the patient is transitioned from one care setting to another”
APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

14. Best Practice Flow Chart
APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

15. MTM Services
Medicare sponsors must provide a minimum level of MTM services
Comprehensive Medication Review (CMR)
Annually
Targeted Medication Review (TMR)
Quarterly

16. Comprehensive Medication Review (CMR)
Comprehensive annual review of all medications
Interactive person to person
Phone call
Pharmacy visit
Affordable Care Act standardizes the content and format of the CMR starting January 1, 2013
Components
Cover Letter
Medication Action Plan
Personal Medication List

17. Targeted Medication Review (TMR)
TMR must be provided at least quarterly
TMR is meant to address specific or potential medication-related problems
Does not have to be face-to-face

18. Who can provide MTM services?
Pharmacists
Only provider specifically mentioned
Registered Nurses
Physicians
Non-physician providers
2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at Accessed on May 16th, 2012

19. IHS Pharmacy Electronic Health Record (EHR) IHS mode of counseling
Allows for comprehensive reviews
Physician notes, lab work, and medication lists
IHS mode of counseling
New
Three prime questions
Refill
Show and tell
Open dialogue about disease not just medicine

20. 10 Steps to Your Medications: Why the Wait?
Five Key Elements to an MTM visit:
Medication Therapy Review (MTR)
Personal Medication Record (PMR)
Medication-related Action Plan (MAP)
Intervention or referral
Documentation and Follow Up
1. After your appointment, the doctor enters your prescription into the computer
2. The pharmacy receives the order signed by the doctor
3. The pharmacist checks the prescription for errors
4. The pharmacist looks at your lab results
5. The pharmacist reviews your chart for drug interactions and allergies
6. The pharmacist may call your doctor for questions
7. The medications are counted and packaged
8. The pharmacist does a final check for safety and accuracy
9. The pharmacist counsels you on your medications
10. You receive your medications and can ask any questions you have
Document
MTR
Review EHR
Document
MAP
Intervention
Document
PMR
Medication List

21. Best Practice Flow Chart
IHS Prescription Processing Chart
Meds ordered in EHR
Meds dispensed and patient counseled
APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.

22. IHS is Leading Again
Our legacy of innovation has allowed PHS pharmacists to lead the profession
Providing clinical services since 1962
We are already providing MTM for our patients
Potential reimbursement opportunities?

23. Reimbursement Process

24. Part D Prescriptions Filled in 3 months
Number of Prescriptions
Medicare Part D Plans

25. Part D Reimbursement
The largest Part D provider does not allow for reimbursement to community pharmacists for MTM services
The second largest provider only has four patients who qualify for MTM reimbursable services

26. Part D reimbursement
Part D sponsors determine payments for MTM services
Considered administrative costs
80% allow external personnel
31% use vendors
25% use community pharmacists
Plans require contracts with pharmacies
Separate from medication dispensing
There is not much published on reimbursement 
Limited to vendor’s published numbers

27. MTM Vendors MirixaPro® MirixaEdge® Outcomes® Others: Mirixa.com
No cost for participation
MirixaEdge®
Pay
Provides documentation to submit to non-contracted part D plans or for out of pocket billing
Outcomes®
Getoutcomes.com
No cost for participation
Others:
PharmMD®
Pharmmd.com
Employ pharmacists
Can make $2,000/month

28. Reimbursement Rates MirixaPro® Comprehensive medication review $60
Welcome review $40
Medication adherence
15 minute initial $30
10 minute follow up (2) $20
Cardiovascular risk
45 minute initial $90
Follow up $30

29. Reimbursement Rates Outcomes®
Comprehensive Medication Review $50 to $75
Prescriber Consultation
Cost Efficacy Management $20
Drug Therapy Problem $20
Patient Compliance Consultation $20
Patient Education/Monitoring $10
Prescriber Refusal $2
Patient Refusal $2

30. Is MTM the future of pharmacy?
Providing MTM services improves outcomes
Reimbursement for pharmacist-delivered patient care is a step forward, BUT:
Part D pays the pharmacy not the pharmacist
Pharmacists are not the only providers
Right now, MTM does not look to prevention
Eligible patients are already a burden on health system

31. Pharmacists are Patient Care Providers
“Pharmacist-delivered patient care services fit most definitions of “primary care” services (with the exception of diagnosis) as defined by major medical and health organizations”
“Compensation … should reflect the level of care provided”
Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.

32. MTM Conclusion
Potential reimbursement for actions that PHS pharmacists engage in currently
Create time to make appointments, proper documentation, and provide opportunities for reimbursement and reporting
Work with Tribes
Provide presentations on correct medication habits
MTM should not prevent PHS pharmacists from continually leading with new and innovative patient care practices

33. Citations
APhA/NACDS Foundation: Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2.0. March 2008.
Lee MP, Giberson S. Implementation of the Indian Health Service National Clinical Pharmacy Specialists (NCPS) Program. Available at Accesses May 16th, 2012.
2011 Medicare Part D Medication Therapy Management (MTM) Programs. Fact Sheet. Available at Accessed on May 16th, 2012.
Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.
Schupbach R. Insights from the bizarre perspective and mind of Ryan Schupbach. Presented at the Oklahoma Area IHS Pharmacy Chief’s Meeting, February 17th, 2012.

34. Questions
LT Scott Raisor Colorado River Service Unit Agency Road Parker, AZ