Getting Involved in MTM and Medication Reviews

Full update May 2023 

Medication Therapy Management (MTM) services in the US can involve a broad range of professional activities, including performing Comprehensive Medication Reviews (CMR), identifying and resolving drug-related problems, and providing patient education and training. MTM allows pharmacists to optimize a patient’s drug therapy. It also can give pharmacy staff more meaningful patient interactions. In Canada, a similar service is provided and is referred to as a “medication review” or “medication therapy review (MTR).”

These services have traditionally been thought of as a pharmacist-only task. However, pharmacy technicians can get involved in many ways. Your pharmacist will appreciate your proactive involvement in helping efficiently deliver MTM services and medication reviews to patients.

What exactly do MTM or medication review services refer to?
There are several different definitions of MTM in the industry. Simply put, MTM services are focused on the identification, prevention, and resolution of medication-related problems. Medication-related problems can include dosing issues, drug interactions, duplicate therapy, missing therapy, adherence problems, etc. MTM services may be reimbursable by payers or patients can pay out-of-pocket for them.

Experts typically refer to five core elements of MTM:

1. Medication therapy review (e.g., Comprehensive Medication Review or CMR)
2. Personal medication record or list (PMR or PML)
3. Medication action plan (MAP) or Recommended To-Do List (TDL)
4. Intervention and referral
5. Documentation and follow-up

The personal medication list and medication action plan are patient-centered documents intended to be provided directly to a patient after a CMR. The personal medication list is a document that includes all medications (including Rx, over-the-counter [OTC] meds, vitamins, and supplements), indications, directions, and prescriber information. The patient can show this document to their healthcare providers and update it as changes are made. The medication action plan is a simple guide with a list of actions addressing medication and/or health concerns. The medication action plan includes the pharmacist’s suggestions for the patient to address these concerns, and a space for the patient to fill in progress made. Many payers (health insurance companies, employer groups, state or federal government, etc) who cover CMRs may require that these documents be provided to a patient within a certain period of time, such as within 14 days of the CMR completion date, in order for the pharmacy to get reimbursed for the service.

Each core element is not required in order for a service to be considered MTM. A CMR will typically include all five core elements. However, there are other shorter interventions, typically referred to as a “Targeted Medication Review” (TMR), or targeted interventions, which may require intervention/referral and documentation/follow-up. For example, let’s say you alert the pharmacist to a patient who appears to be nonadherent to their oral diabetes med based on an erratic fill history. The pharmacist may intervene by reaching out to the patient to resolve this issue. This intervention would be documented, and the pharmacist will likely want to follow-up with the patient in a couple of weeks. But this targeted intervention would not necessarily result in the generation of a personal med list or medication action plan. Certain targeted interventions may be reimbursable by some payers.

Although requirements vary among provincial programs, medication reviews in Canada generally involve patient assessment, identification of medication therapy problems, creation and implementation of a care plan, and documentation.

What is the difference between a CMR and TMR?
The terms CMR and TMR come from the Centers of Medicare and Medicaid Services (CMS) Medicare Part D MTM program, but are widely accepted in the industry. CMRs are only one type of MTM service, but it is the service that takes the most time, so it usually gets the most attention. It’s also what people typically think of when they hear “MTM.”

A CMR is a systematic process used to collect and analyze information about a patient’s medications (including OTC meds, vitamins, and supplements) and medical conditions. The pharmacist then uses the information collected to identify medication-related problems. CMRs are usually completed once a year. You can think of these as a “medication check-up.” A TMR is a targeted review of a specific medication-related problem. These are problems or potential issues that can come up in between CMRs. Think of these as similar to the visits you make to your physician in between your annual check-ups for problems that come up (e.g., bacterial infection, flu, back pain). Examples of TMRs could be identifying an issue with adherence, noticing that a patient should be on a med they aren’t on, or intervening to prevent a drug interaction. While CMRs usually involve communication with both the patient and prescriber, TMRs may only require communication with the patient or the prescriber (it can include both too). CMRs usually take anywhere from 30 to 60 minutes, while TMRs take just a few minutes. Depending on the payer, CMRs may have to be completed face-to-face with the patient. Other payers allow for CMRs to be completed over the phone. TMRs usually don’t have specific requirements on whether they need to involve face-to-face or over-the-phone interactions.

Who needs MTM or medication review services?
In a perfect world, patients would get MTM or medication review services when they experience any of the following:

• start a new medication.
• don’t understand why they are taking a medication or how to take a medication.
• are nonadherent.
• get admitted to or discharged from a hospital or other healthcare facility.
• are diagnosed with a new chronic condition (diabetes, asthma, etc).
• have difficulty meeting targets for good control of their conditions (e.g., blood pressure, blood sugar).
• feel they would benefit from additional education, regardless of the number of chronic conditions or number of medications they are taking.

However, realistically, payers usually limit MTM reimbursement to patients they think would benefit most from MTM services. In Canada, provinces determine medication review program eligibility and funding.

Let’s take the US Medicare Part D MTM program as an example. CMS sets parameters within which each Part D plan should develop their criteria for MTM program eligibility. These criteria include that the patient should be on multiple drugs, have multiple chronic conditions, and be likely to incur above a certain amount of prescription drug costs per year. The specific details outlined by CMS, such as the number of drugs and chronic conditions and the minimum drug costs, can change from year to year.

Commercial plans that pay for MTM services (not all do) also develop their own criteria for MTM program eligibility. Usually, the common theme is that in order for a patient to be eligible, they need to have multiple chronic conditions and take multiple meds. However, there’s no standardized number of either that is used across all payers. Canada is also lacking in standardization of medication review program eligibility.

In the US, there are companies that offer MTM software, or an “MTM platform,” which can help participating pharmacies identify patients who are eligible for a payable MTM service. These MTM software companies may work with both the payers and pharmacies to pass information on patient eligibility from the payer to local pharmacies. Documentation and billing of the MTM services can often be completed within the MTM software itself.

Why is MTM or medication review important?
MTM or medication review is important for a variety of reasons. Let’s start with the benefits to the patient. The intended outcome is optimization of a patients’ medication regimens, increase in medication adherence, and reduction in the risk for adverse drug events and drug interactions. Here are some actual examples based on published data of benefits observed in different patient populations:

• asthma: MTM services have been found to decrease asthma-related emergency room visits and hospitalizations, decrease direct and indirect healthcare costs, and decrease the number of missed workdays per year.
• diabetes: Patients who have multiple MTM visits annually have been found to have significant improvements in blood sugar levels.
• high cholesterol: Participation in MTM programs has helped patients meet treatment goals and reduce drug costs compared to patients who do not participate in MTM programs.
• human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS): MTM services, such as patient counseling about overuse or underuse of meds, management of side effects, and telephone refill reminders, have been found to increase medication adherence rates, help patients stay on the same HIV regimen for longer periods, and reduce the risk of using contraindicated drugs.

Keep in mind, it is generally accepted that similar benefits can be seen in more conditions than those listed above. In addition to benefits for the patient, the pharmacy also benefits from an additional revenue source. Payment for MTM or medication review services can help some pharmacies offset the increasingly slim margins on drug reimbursement. MTM and medication reviews also help pharmacy staff develop stronger relationships with patients and providers, improve the overall patient experience, and identify additional services that patients can benefit from (e.g., immunizations, med sync).

Over the years, the importance of community pharmacy involvement in MTM services has gained more attention and traction in the US. In 2016, CMS began including CMR completion rate in the Medicare Star Rating program. CMR completion rate is a measurement that looks at the percentage of patients enrolled in a MTM program who received a CMR during the year.

The Medicare Star Rating program was created in 2006 as a way to report on plan quality and reward Medicare plans with high quality. The program assesses Medicare plans on a variety of measurements, including adherence- and medication safety-related measurements. Based on a plan’s performance, the plan will get a rating anywhere between 1 through 5, with 5 being the best and 1 being the worst. Plans with higher ratings can get rewarded by CMS with bonus payments and/or marketing advantages. When the CMR completion rate started counting towards the Star Rating score, Medicare plans began focusing on MTM more than they had before. Since local pharmacies often have a trusted relationship with patients, they can play a huge role in helping plans achieve high CMR completion rates.

But what does all this mean for pharmacies? Pharmacies that can help Medicare plans achieve high Star Ratings could get financial bonuses from the plan and/or be included in “preferred” pharmacy networks. For example, plans can select specific groups of pharmacies to be included in their preferred network. These preferred pharmacies will likely be able to offer lower copays to patients, compared to non-preferred pharmacies. This could mean more patients and more business for the pharmacy. To learn more about the Star Rating program, refer to our CE, Quality Measures in Pharmacy Practice.

How can technicians help with MTM or medication review services?
There are many ways pharmacy technicians can get involved in MTM services and medication reviews. Since pharmacies differ in how they approach these services and how they incorporate them into workflow, talk to your pharmacist about how to best assist. Use the suggestions below to offer up ideas for how you can get involved.

Identify eligible patients. Find out how your pharmacy identifies patients who are eligible for MTM services or medication reviews. In some cases, this may involve going into another system (e.g., MTM software) to get this information. Take the time to add MTM/medication review eligibility information into the patient’s profile. Since eligibility can change as time goes on, it’s important to do this eligibility check on a regular basis. For example, each week you can print a list of eligible patients from the system and compare it with last week’s list. Then you can focus on additions and deletions and make the appropriate changes within the patient profiles.

In other cases, your pharmacy may have specific criteria for determining patient eligibility. For example, some pharmacies may work directly with payers to offer MTM services. The eligibility criteria may include patients with a certain disease state (e.g., diabetes, high blood pressure), patients who are on a certain number of drugs, etc. Be familiar with reports that your dispensing system can generate. You may be able to print a report with a list of patients who could be eligible for MTM based on the specific criteria.

Once you have identified patients who are candidates for the service, take steps to notify the patient. This could include giving them a call or talking to them about it in person. If you are filling a prescription for a patient and see a message in their profile regarding program eligibility, put a note on the Rx. When the patient comes to pick up the Rx, whoever is helping the patient will know to offer the service. Or, as part of your review of patient eligibility, you can call the patient at that time. Either way, make sure to clearly explain the benefits and what the patient can expect. Here is an example of a 30-second “pitch” for offering MTM to a patient:

“Did you know your pharmacist can provide a ‘medication check-up’ to look at all the medicines you take, including prescriptions, over-the-counter products, vitamins, and supplements? We’ll work as a partner with you and your prescriber to make sure you’re getting the most benefit from your medicines. We can also help identify less expensive alternatives to save you money, make sure you’re taking the right meds in the right way and at the right doses, and answer any questions you may have about your medicines. You’ll get a complete medication list after the visit and a list of suggested actions to help improve your health. Would you like to schedule an appointment?”

Manage appointments. You can help schedule appointments and make appointment reminder calls. Schedule appointments for CMRs during pharmacist overlap or off-peak times, if possible. Call the patient a couple of days before the appointment, especially if it’s for a face-to-face session. Remind the patient to bring all of the medications that they’re taking, including OTCs, vitamins, and supplements. Also ask the patient to bring an updated medication list, recent lab results, their immunization card, and a list of questions or concerns. Encourage the patient to bring a friend or family member if that person helps the patient manage their meds. You can also explain what the patient should expect from the meeting.

Prepare for appointments. Help pharmacists prepare for an appointment by gathering paperwork, equipment (e.g., vaccination or health screening supplies), a printed list of all the meds the patient gets filled at your pharmacy, and any other relevant health-related information your pharmacy has access to.

Interact with the patient. When a patient arrives for a face-to-face appointment, you can meet with the patient first and gather vital signs, such as weight and blood pressure (if your pharmacy has the equipment). For both phone and face-to-face meetings, you can help out by becoming proficient in documenting medication lists and drug allergy histories. Ask the patient about smoking status and their vaccine history, and document their lab results if they provided a copy. Also ask the patient if they have any specific issues or concerns they want to discuss with the pharmacist. Gather all of this information from the patient, document it, and then pass it on to the pharmacist.

Document and bill. At the conclusion of a CMR or medication review, there may be a good amount of information to document. Depending on the payer, this documentation may need to follow a specific format. It might also need to be entered into an electronic system. Some pharmacists may be able to complete the documentation in the format it’s needed while talking to the patient. But others may want to jot down notes, and then transfer these notes into the appropriate format. You may be able to help pharmacists transfer their notes, but the pharmacist should still double check any information you have transferred before the documentation can be finalized. Know your company’s policy on document retention, such as where MTM- or medication review-related documentation needs to be stored and for how long.

Get trained on how to bill for MTM or medication review services. This can save pharmacists a lot of time. Billing may take place either through an electronic system, or by filling out a form and faxing or mailing it. Either way, develop an organized process that ensures prompt and accurate billing, so the pharmacy gets paid on time. Make sure to track payments requested and payments received on a regular basis (e.g., monthly) to identify any issues. If you are billing for services within an electronic system, get familiar with reports that can be generated. You may be able to run a report that shows you what was billed and what was paid during a certain timeframe.

Follow-up. Help the pharmacist with follow-up after an MTM service or medication review. The pharmacist may need to follow up with the patient, prescriber, or a specialist to resolve issues. Work with the pharmacist to develop a system for executing and tracking follow-up. For example, you could use paper trays to help develop a process for following up with prescribers. One paper tray could be labeled “Contact prescriber” and another could be labeled, “Prescriber contacted – waiting for response.” You could arrange the documentation by date and review it a couple times a week to determine if additional follow-up is needed. You can also use a binder sorted by day of the month to assist with follow-up.

Cite this document as follows: Technician Tutorial, Getting Involved in MTM and Medication Reviews. Pharmacist’s Letter/Pharmacy Technician’s Letter. May 2023. [390580]

 

“Cheat Sheet” for Getting Involved in MTM and Medication Reviews

What is the definition of MTM/med review?
MTM (US terminology) and med reviews (Canadian terminology) are enhanced patient care services focused on the identification and resolution of drug-related issues (e.g., adherence, drug interactions, unneeded therapy). These services involve spending time with a patient to review all their meds and identify problems a patient may be having. Based on the drug-related issues, pharmacists create a plan of action for the patient. Pharmacists also follow up with prescribers and specialists as appropriate to help get these issues resolved.

How is patient eligibility determined for MTM/med reviews?

Many patients can benefit from these services. However, because they can take a lot of time on the part of the entire pharmacy team, it’s best to focus on patients who would benefit the most. Pharmacies may choose to focus on patients who are taking a certain number of meds, have a certain number of conditions, are nonadherent, have recently been discharged from a hospital, etc. If a pharmacy receives reimbursement from a payer (e.g., insurance companies, employer groups, state or provincial government, federal government) for these services, the payer will usually outline specific patient eligibility criteria.

What are the benefits of MTM/med reviews?

• Ability to help payers achieve high scores on quality measures (which can mean additional payments for pharmacies and inclusion in preferred pharmacy networks).
• Additional source of revenue for pharmacy.
• Improved patient care and patient satisfaction with their pharmacy.
• Opportunity to offer patients additional services (e.g., immunizations, med sync).

How can technicians get involved in MTM/med reviews?

• Identify eligible patients by completing eligibility checks on an on-going basis (e.g., once or twice a week) and adding eligibility info to patient profiles; use the 30-second “pitch” below to introduce MTM/med reviews to eligible patients.
• Manage appointments by scheduling them during pharmacist overlap or off-peak times and calling the patient a couple of days before the appointment to remind them to bring all their meds (Rxs, OTCs, vitamins, and supplements), recent lab results, immunization card, etc.
• Help pharmacists prepare for appointments by gathering required paperwork, equipment, and relevant health-related information your pharmacy has access to.
• Assist with the appointment by interacting with the patient to gather med lists, drug allergy histories, and other important info.
• Document and bill for services by being familiar with what needs to be documented and where, and by getting trained in billing practices.
• Create a timely follow-up system by working with the pharmacist to develop a process for executing and tracking patient or prescriber outreach.

What is a 30-second “pitch” that can be used to offer MTM/med review services to patients?
“Did you know your pharmacist can provide a ‘medication check-up’ to look at all the medicines you take, including prescriptions, over-the-counter products, vitamins, and supplements? We’ll work as a partner with you and your prescriber to make sure you’re getting the most benefit from your medicines. We can also help identify less expensive alternatives to save you money, make sure you’re taking the right meds in the right way and at the right doses, and answer any questions you may have about your medicines. You’ll get a complete medication list after the visit and a list of suggested actions to help improve your health. Would you like to schedule an appointment?”

[May 2023; 390580]