Analysis of Pharmacist-Provided Medication Therapy Management (MTM) Services in Community Pharmacies Over 7 Years
Barnett MJ, Frank J, Wehring H, et al.
J Manag Care Pharm. 2009;15:18-31
Barnett and colleagues performed a study with 2 objectives: (1) to describe trends over a 7-year period in the primary types of medication therapy management (MTM) services provided by community pharmacies that have used MTM administrative services to contract with drug plan sponsors, and (2) to quantify potential MTM-related cost savings based on pharmacists' self-assessments of the likely impact of their interventions on medical care utilization.
The authors analyzed MTM claims from a multistate MTM administrative services company from January 1, 2000, through December 31, 2006. During this process, they extracted data from each MTM claim that included patient demographics, the drug and type that triggered the intervention (eg, drug therapeutic class, drug therapy type), and specific information about the service provided (eg, Reason, Action, Result, and Estimated Cost Avoidance [ECA] values). The ECA values are derived from average national healthcare utilization costs, which are applied to pharmacist self-assessment of the outcome of the intervention and are updated yearly for healthcare inflation.
A convenience sample of 50 plan sponsors was selected from a database of nearly 100,000 MTM claims. Claims with missing or potentially duplicate data were excluded. Results were reported on 76,148 claims for 23,798 patients from community pharmacy MTM providers in 47 states. Over the time period analyzed, the average pharmacy reimbursement was $8.44 per MTM service, and the average ECA was $93.78. MTM interventions changed from mostly education and monitoring for new or changed prescription therapies to prescriber consultations regarding cost-efficacy management.
Services moved from acute medication claims (eg, penicillin antibiotics, macrolide antibiotics, narcotic analgesics) to services regarding chronic medications (eg, antihyperlipidemics, angiotensin-converting enzyme inhibitors, beta blockers). These results demonstrated significant changes in the therapeutic classes associated with MTM claims and an increase in the proportion of older patients served. In addition, these trends resulted in higher pharmacy reimbursements and greater ECAs per claim over time. Specific trends related to drug therapy problems included an increase in services related to suboptimal drug selection, unnecessary therapy, and compliance underuse.
Historically, community pharmacists have been paid primarily for drug distribution and dispensing services. In the 1990s, pharmacists and other providers began offering MTM services to assist physicians and patients in managing clinical, service, and cost outcomes of drug therapy. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA 2003) provided for prescription drug coverage through Medicare Part D, beginning in January 2006. The new law also required MTM services to be provided by pharmacists or other providers to targeted Medicare beneficiaries who have multiple chronic diseases, are taking multiple covered Part D drugs, and are identified as likely to incur annual costs that exceed $4000 for all Part D drugs.
A subset of Medicare beneficiaries (more than 20 million) with high drug costs were enrolled in MTM services through Part D. Although the MTM services were limited to a subset of Medicare Part D patients, the provision of MTM under the MMA 2003 has provided a new opportunity that recognizes the value of pharmacist-provided MTM services in the healthcare system. Publications that document changes in the provision of pharmacist-provided MTM services are important to inform service providers, payers, and patients about the effect of this policy over time, although only a few articles have been published on this topic.
This is one of the first descriptive studies to report changing trends of community pharmacy MTM over a long period. Because the study data represented claims from community pharmacy MTM providers in 47 states over a period of 7 years, the findings can be expected to be generalizable to US community pharmacy MTM providers. The study also showed that on average, for every $8.44 reimbursed to community pharmacists for providing MTM, the average estimated cost avoided by the healthcare system was $93.78.
Study limitations, as the authors mention, are related to the pharmacist MTM provider self-reported estimates of cost avoidance without follow-up assessment of the actual avoidance of healthcare utilization events, such as office visits and hospitalizations. Further, caution is recommended in using projected costs-saving estimates that could overstate actual cost savings. Another limitation is lack of a comparator group, which limits the study's ability to attribute the outcomes to pharmacist interventions.
The authors demonstrated that MTM service interventions over a 7-year period evolved from primarily the provision of patient education involving acute medications toward prescriber consultation-type services for chronic medications. These changes were associated with increases in reimbursement amounts and pharmacist-estimated cost savings.
The authors proposed that the shift of service type may be a result of clinical need, documentation requirements, or reimbursement opportunities. However, the changes appeared to be directly related to the Medicare Part D legislation. Continuing research should address clinical need, documentation requirements, and reimbursement opportunities for pharmacy MTM services in other health system settings and in specific disease management programs.
Opportunities beyond Medicare Part D may expand for employers and other government-sponsored programs. Considering the study limitations and other stakeholder perspectives, future research can inform service providers, payers, and patients about shaping future health policy by expanding the scope of pharmacy practice to promote cost-effective access to and quality of care.