Rusty Hailey, PharmD, DPh, MBA, FAMCP

Mr. DePue is corporate clinicalpharmacy director for Medicare atCoventry Health Care Inc in GlenAllen, Virginia. Dr. Hailey is chiefpharmacy officer and senior vicepresident of Pharmacy Services atCoventry Health Care Inc.

The Medicare Prescription Drug,Improvement, and ModernizationAct of 2003 provided thelegislative framework for the programwe all know as Medicare Part D. One ofthe requirements for all Medicare Part Dprogram sponsors is that they offermedication therapy management (MTM)services to qualified plan members. Thequalifying criteria for MTM services areset forth by the Centers for Medicare &Medicaid Services. To qualify, membersmust have a projected annual drugexpenditure of $4000 or more, havemultiple chronic disease states, andtake multiple Part D medications.

Prescription drug plan sponsors havethe flexibility to design their MTM serviceswithin these guidelines.

In 2007, it is estimated that morethan 26% of plan sponsors used outsidesources to provide MTM services,and another 24% used a combinationof internal staff and outside sources.

This additional opportunity for face-to-faceconsultation with patients helpsto strengthen the patient?pharmacistrelationship and promotes loyalty to aparticular store or chain. It also has thepotential to improve health outcomesand quality of care.

Although MTM is recognized by mostas an excellent opportunity for thepharmacy profession, it is not withoutchallenges. With multiple Part D plansponsors in the marketplace, a host ofunique MTM programs exist, each withits own program requirements, methodsfor identifying qualifying patients,and documentation procedures.

Once providers of MTM servicesbecome familiar with the specific planrequirements and are supplied withqualifying patients, they will need tocontact patients to set up an MTMcounseling session. When the sessionis scheduled, pharmacist overlap willbe necessary to ensure that normalpharmacy operations continue whilethe counseling session takes place. Inaddition, a private area will need to beset up in the pharmacy to protect privacyand allow the focus to be on thepatient.

Each pharmacist performing MTMservices will have his or her own counselingstyle. This may be based on personalpreference, chain software fordocumentation of counseling services,or MTM software provided by the plansponsor. Regardless of the flow ofquestions and documentation, it isimportant that providers ask patientsto bring to the session all medicationsthey currently take or plan to take, prescriptionor other. This brown-bagcounseling session will allow the pharmacistto see the patient's entire medicationregimen.

Although the ideal situation wouldbe that patients have all of their prescriptionsfilled at 1 pharmacy andpharmacists have a full online historyof medication use, this is not alwaysthe case. In addition, OTC products aretypically not included in a patient'scomputer-based drug history. Often,many patients do not consider OTCmedications or herbal supplements asmedications when asked what they aretaking. For these reasons, a brown-bagcounseling session will give the pharmacistthe most complete picture.

During the session, the pharmacistshould make sure that the patientunderstands the purpose of all themedications, the frequency with whichthey should be taken, whether or notthey should be taken with food or onan empty stomach, and the optimaltime of day to take them. Because thepharmacist will have the completemedication picture, drug-to-drug interactions,therapy duplications, high-dose/low-dose considerations, patientadherence issues, and polypharmacyare some of the many areas that canbe addressed. To promote consistency,pharmacies anticipating that they willbe performing these services on a regularbasis should use a software programor develop a form to documenttopics discussed, recommendations,and an action plan. If a form is developed,it should be created in a formatthat allows patients to take it withthem after the session. This informationalso would serve as a record forthe pharmacy and as documentationto transmit to prescriber(s) with anyrecommendations for the patient andphysician.

Pharmacists providing this servicewill not always have time to prepare inadvance for the session, nor will theyknow ahead of time all of the medicationsthe patients will bring with them.For these reasons, the pharmacistshould have easily accessible referencematerials. Patients understandthat pharmacists have not memorizedevery possible drug interaction anddrug dose for every condition. Apatient will not think less of a pharmacistfor taking a moment to verify thatan obscure herbal supplement doesnot interfere with warfarin levels. Ifanything, the patient will appreciatethe extra effort by the pharmacist toensure the most accurate informationis used for the medication review.

Patient education materials are anintegral component of MTM programsas well. Although the session will begeared toward medication adherence,disease state information provided astake-home reading is well received bypatients. This material helps providebackground information that the pharmacistwill most likely not have time toexplain in person. It would be impossibleto have information prepared onevery disease state, but there are commonconditions seen in the senior populationthat cover the majority ofpatients. Pharmacists also can directpatients to reputable Web sites, suchas those of the American Heart Associationor American Diabetes Association,so that they may learn moreabout their condition(s).

With their extensive medicationknowledge, pharmacists are long overdueto be reimbursed for cognitiveservices. Patients are likely to come incontact with their pharmacist moreoften than any other health care professional;thus, pharmacists are in theperfect position to influence patientsand improve outcomes.

Although Medicare created a formalMTM program, these services do nothave to be limited to the Medicare population.MTM can be made available forand promoted to all patients. For thosewho do not have MTM insurance coverage,the pharmacy can determine areasonable rate to charge and whatspecific services will be provided.These one-on-one counseling sessionswill help to strengthen the patient?pharmacist relationship and reinforcethe role of the pharmacist as an integralpart of the patient's health careteam.

US Department of Health and Human Services. Medicare Part D: Contract Year 2007 Medication Therapy Management (MTM) Programs Fact Sheet. 

US Department of Health and Human Services. Contract Year 2008 Medication Therapy Management Program (MTMP) Submission. 

www.cms.hhs.gov/.../MTMPSubAnnouncement.pdf

Articles

Pharmacists are in the perfect position to influence patients and improve outcomes with medication therapy management.