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 empower pharmacists to mitigate medication issues 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 room visits, improving identification of medication-related problems, and reducing overall health care expenditures. Pharmacists are uniquely trained to manage chronic conditions, particularly in patients with polypharmacy, and to optimize pharmacotherapy-related outcomes.2,3
Medicare Part D sponsors are required to support MTM services for beneficiaries. Medicare Part D Star Ratings measure plans on specific measures used to determine plan performance.4 MTM services are a large component of said measures. Pharmacy benefit managers (PBMs) have leveraged electronic platforms using claims data to guide pharmacies in identifying patient interventions. 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 (HSSP) Outpatient Pharmacy Services implemented a pilot workflow to capture Medicare Part D–assigned interventions within 2 electronic MTM platforms. The MTM team comprised 2 pharmacists and 2 interns working in the pharmacy call center who utilized a specialty case management tool within the EMR.2,3 Clinical services included proportion of days covered (PDC) gaps, comprehensive medication reviews (CMRs) completed, identification of cost-effective alternatives, and recommendations of superior 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 through a work group inbox. Additionally, a dedicated collaboration channel and work queue were created for ease of communication.
At the pilot initiation in June 2023, the specialty pharmacy had a 0% completion rate for both CMRs and targeted intervention programs (TIPs), and no completed interventions. In November 2023, CMR and TIP completion rates of 88% and 65%, respectively, were achieved.3 By the end of 2024, CMR and TIP completion rates of 91% and 56%, respectively, were achieved.3 Each successfully completed TIP and CMR service generated reimbursements through quarterly payment.
MTM service success continues to be relevant to key stakeholders. 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 assessments. 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 rendered through either of the 2 commercially available MTM platforms is often determined by the payor. Neither platform currently offers the capacity for 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 and 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 led to inappropriate identification for add-on statin therapy for metabolic indications and negatively impacted adherence scoring. 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. 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 play an integral role in supporting MTM services.2 Under pharmacist supervision, interns can conduct comprehensive patient reviews, identify medication misuse, therapeutic duplication, and provide patient education. This approach enhances operational efficiency by extending pharmacist capacity within existing resources.
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.
