Pharmacist-led MTM services can deliver measurable clinical and financial value while advancing patient-centered care.
Medication therapy management (MTM) services continue to expand throughout all pharmacy subspecialties and increasingly align with reimbursement opportunities. These services enable pharmacists to identify and resolve medication-related problems for patients receiving care across the health system.1
Hospital-integrated pharmacies with access to electronic medical records (EMRs) enable efficient identification and resolution of MTM opportunities within the health care team. Integrated EMR interventions promote transparency and visibility across disciplines.2,3
MTM services improve patient outcomes by reducing rates of hospitalization and emergency department visits, improving identification of medication-related problems, and reducing overall health care expenditures. Pharmacists are well positioned to manage chronic conditions, particularly in patients with polypharmacy, and to optimize medication outcomes.2,3
Medicare Part D sponsors are required to support MTM services for beneficiaries. Medicare Part D Star Ratings assess plans on specific measures used to determine plan performance.4 MTM services are a large component of these measures. Pharmacy benefit managers (PBMs) use electronic platforms claims data to help pharmacies identify patients who may benefit from MTM services. PBMs have a fiscal interest in ensuring MTM services are offered and completed for Medicare Part D enrollees.5
In 2023, the integrated health system specialty pharmacy, Outpatient Pharmacy Services, implemented a pilot workflow to capture Medicare Part D–assigned interventions across 2 electronic MTM platforms. The MTM team comprised 2 pharmacists and 2 interns working in the pharmacy call center who used a specialty case management tool within the EMR.2,3 Clinical services included identification of PDC (proportion of days covered) gaps, completion of comprehensive medication reviews (CMRs), identification of cost-effective alternatives, and recommendation of clinically preferred therapy alternatives. PDC gaps are used to evaluate adherence in the management of hypertension, diabetes, and hyperlipidemia. The team managed clinical interventions for the specialty pharmacy and 2 integrated retail locations within the health system.2,3
The MTM team communicated directly with providers within the health system via a workgroup inbox. Additionally, a dedicated collaboration channel and work queue were created to facilitate communication.
At the pilot initiation in June 2023, the specialty pharmacy had a 0% completion rate for both CMRs and targeted intervention programs (TIPs). In November 2023, CMR and TIP completion rates reached 88% and 65%, respectively.3 By the end of 2024, CMR and TIP completion rates were 91% and 56%, respectively.3 Each successfully completed TIP and CMR service generated reimbursements through quarterly payment.
Historically, community pharmacies have led MTM program implementation in the retail setting. Specialty pharmacies overseen by the Accreditation Commission for Health Care and the Utilization Review Accreditation Commission have high standards of clinical consultation, medication review, and patient follow-up. However, both retail and specialty pharmacies face challenges in demonstrating transparency and quantifying the economic impact of MTM services.6
Several barriers were identified during the pilot implementation of the MTM program. Financial constraints, particularly profitability ratios, remain a significant obstacle to broader MTM adoption. Reimbursement for services provided through either of the 2 commercially available MTM platforms is often determined by the payor. Neither platform currently allows pharmacists to bill for their services using MTM Current Procedural Terminology codes. Compounding this challenge, pharmacists do not currently have provider status under the Centers for Medicare & Medicaid Services, further restricting reimbursement opportunities.7
Delays in payment were a significant operational challenge. The team did not fully reconcile Performance Network Program revenue generated in 2023 until July 2024, hindering the team’s ability to evaluate the true financial impact of MTM services in real time. Clinical and quality measurement challenges were also identified. Glucagon-like peptide-1 (GLP-1) receptor agonists prescribed for metabolic indications (rather than diabetes) were incorrectly included in diabetes-related quality metrics. This resulted in inappropriate flagging of patients for add-on statin therapy for metabolic indications and reduced adherence scores. Furthermore, manufacturer supply shortages of GLP-1 agents contributed to decreased adherence rates, further impacting diabetes performance metrics.2,3
Athena Peterson, PharmD, MBA, CSP, is a specialty clinical pharmacist II at Outpatient Pharmacy Services, a specialty pharmacy integrated within Yale New Haven Health System in Connecticut. Her work focuses on optimizing specialty medication management, improving health outcomes, and reducing costs.
From a technological perspective, embedding MTM opportunities directly into the EMR could significantly improve workflow efficiency and intervention capture. Pharmacy interns can make significant contributions to MTM services.2 Under pharmacist supervision, interns can conduct comprehensive patient reviews, identify medication misuse and therapeutic duplication, and provide patient education. This approach extends pharmacist capacity without requiring additional staff.
Overall, the MTM pilot demonstrates that pharmacist-led MTM services can deliver measurable clinical and financial value while advancing patient-centered care within an integrated health system specialty pharmacy.
