MTM: Adoption still pending

December 12, 2005

The Medicare Modernization Act (MMA) sets a precedent for the design of prescription drug plans (PDPs) by requiring that medication therapy management (MTM) services be offered to certain enrollees. The MMA targets beneficiaries for MTM if they take multiple medications, have multiple chronic diseases, and expect to have total drug costs in excess of $4,000 per year.

The Medicare Modernization Act (MMA) sets a precedent for the design of prescription drug plans (PDPs) by requiring that medication therapy management (MTM) services be offered to certain enrollees. The MMA targets beneficiaries for MTM if they take multiple medications, have multiple chronic diseases, and expect to have total drug costs in excess of $4,000 per year.

MTM under Medicare is a program of drug therapy management that may be provided by a pharmacist. It is designed to ensure that covered Part D drugs under the PDP are appropriately used by targeted beneficiaries to optimize therapeutic outcomes through improved medication use and to reduce the risk of adverse events, including adverse drug interactions.

Although plans are required to offer MTM services, the individual PDPs have the latitude to design their program. There are widely different strategies for the operation of MTM programs. Some will provide only telephone call centers; others will cover a face-to-face meeting with a pharmacist or other healthcare provider who will work with patients and their physicians to establish a drug regimen that best meets their needs.

MTM in Community Pharmacy Practice: Core Elements of an MTM Service is a model document developed jointly by APhA and the NACDS Foundation. On-line copies are available at http://www.aphanet.org/medicare/

Basic MTM services include, but are not limited to, providing education and training, medication compliance advice, medication administration, and recommendations for disease prevention to patients and their caregivers; and formulating solutions, treatment plans, and monitoring strategies to address medication-related problems. According to a review of state practice acts, all pharmacists have the authority and ability to provide the core MTM services.

A consensus definition of MTM developed jointly by 11 pharmacy organizations goes beyond the core elements to include collaborative practice agreements that are covered under applicable state practice acts. The consensus definition also can be found at http://www.aphanet.org/medicare/.

MTM services are provided at no cost to the beneficiaries who meet the criteria, but individual PDPs define the criteria and reimbursement rates that they will cover. Pharmacists who want to provide MTM services must have an agreement with each PDP or Medicare Advantage plan in order to bill for the designated services. Pharmacists may offer MTM services to beneficiaries and others if the patients agree to pay the fee. Giving MTM services free to non-Medicare customers while billing Medicare or an affiliated plan for the same services could be viewed as an act of Medicare fraud.

The most widely used set of codes for reporting and billing healthcare services is Current Procedural Terminology (CPT). Three CPT codes for MTM services were recently added to the compendium. The codes can be used by pharmacists to bill Medicare and other third-party payers for services performed in a face-to-face encounter. Although there is no assurance that a given third party will cover the services, CPT codes give pharmacists a billing method that is comparable to that of other healthcare providers.

The new CPT codes come into use on Jan. 1, 2006. They are broad enough for all settings and all types of MTM services. Providers should have a mechanism to record their specific activities in support of a claim for service. Relevant documents include a record of current medical history obtained from the patient, the prescription and nonprescription medication profile, interventions and recommendations for optimizing therapy, referrals to other healthcare professionals, and a summary of communications with other professionals.

MTM Services in Community Pharmacy: Planning for Successful Implementation, another collaborative project of APhA and NACDS, is now available for purchase on-line ( http://www.pharmacist.com/). The manual covers staff education and training, marketing to patients and other health providers, legal and contracting considerations, quality assurance, billing, documentation, and business planning. It is likely that administrative issues surrounding Part D implementation will overshadow the introduction of MTM services. It may be months before plans identify those eligible, but reports from those who are first to experience MTM services will likely shape the nature of the benefit structure and its adoption as a standard of practice.

The Author is associate professor, Department of Pharmacy Health Care Administration, University of Florida College of Pharmacy.