July 2009 FEATURE ARTICLES
Medication Management
MTM Services Standards Improve Patient Safety
Medication therapy management safeguards, systems and services can reduce the total number of medication-related complications.
By John S. Klimek, R.Ph.
Medication-related problems (MRP) continue to
be a leading healthcare challenge. The realities of an aging
population heightens the need for additional tools, technology
and collaboration to eliminate this potential danger to patient
safety. The first Baby Boomers to be eligible for Medicare will
reach that milestone in 2011, with an estimated doubling of the
Medicare population by 2030. This growing senior population is
expected to take more medications and suffer the highest
proportion of MRPs of any group.
Seniors often manage as many as five different medications for a variety of chronic ailments. The expanding use of ePrescribing will help reinforce the circle of care between the primary physician, care environment, pharmacy and the patient. This can only do so much, however, in addressing the primary challenges that contribute to the growth of MRPs.
The two primary contributions to MRP acceleration for older adults are non-adherence to medication regimens (improper dosage, order or time intervals between medications) and non-compliance (not taking the medications regularly or at all). ePrescribing can make filling out prescriptions and obtaining the necessary directions and notes regarding use easier for patients. The problem is that older patients often need greater follow-up than current approaches can provide.
According to a 2006 Institute of Medicine report titled "Preventing Medication Errors," adverse drug events account for more than 1.5 million preventable medication-related incidents each year. The Centers for Medicare and Medicaid Services (CMS) has attempted to provide a greater atmosphere of collaboration in order to create safeguards, systems and services that can reduce the total number of medication-related complications. The most recent step was the establishment of guidelines for the creation of medication therapy management (MTM) services.
The stage for MTM service providers was set by the Medicare Modernization Act of 2003, which requires that all Medicare Part D plan sponsors provide MTM programs as part of a senior drug benefit. These programs, which are provided at no cost to the patient, are intended to improve medication use and reduce adverse drug events, thereby improving therapeutic outcomes.
Definition of MTM Services
Eleven national pharmacists organizations, including ASCP, AMCP, ACCP and APhA, have developed a consensus definition of MTM services that includes patient assessment with review of pertinent laboratory data; calculation of liver and kidney function; comprehensive medication review; formulation of a medication treatment plan; a recommendation process for additions and modifications to medication therapy; monitoring drug therapy outcomes; detection of adverse drug events; patient education and empowerment; documenting treatment plans; and, communicating treatment plans to other providers.
While MTM services may reduce adverse drug events and improve patient adherence, their effectiveness depends on the participation of pharmacists, pharmacies and all of the members of the patient’s healthcare team — with the patient taking a defined role. The first step in ensuring superior care and patient safety is the secure and proper sharing of pertinent health information among all of these stakeholders.
For more information
on the NCPDP
CMS has established eligibility criteria for MTM programs that signal when a beneficiary must receive MTM services. The result has been a plethora of programs that have opened up opportunities for implementation, innovation and creativity.
The National Association of Chain Drug Stores and the American Pharmacists Association developed a framework for implementing effective MTM services in community pharmacies. The framework is known as "Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 1.0," which was updated to version 2.0 in 2008.
The latest version broadens the applicability across pharmacy practice settings by placing an increased emphasis on the patient’s role in medication self-management, care transitioning and collaborative healthcare team partnerships. Version 2.0 can be found at www.nacdsfoundation.org.
When MTM services engage and educate patients on the nature of their chronic conditions and the medications used to manage their healthcare, studies indicate that patient adherence and outcomes improve. This outcomes improvement and reduction in medication error requires that MTM services include all of the attributes as laid out in the consensus definition. Even as MTM service providers include these attributes, the lack of standards for information exchange between health plans, pharmacists/pharmacies, prescribers and long-term-care facilities can hamper progress for the patient population.
The Need for Standards
In most Medicare Part D beneficiary cases, MTM service providers receive information from the Part D plan on specific patients meeting the plan criteria for services. While MTM providers report back to the payer via proprietary paper or electronic billing documentation and the patient receives a document summary of medication history and MTM services performed, there is currently no standard of communication between all stakeholders in the patient’s health.
Pharmacy organizational intervention is taking form through the National Council for Prescription Drug Programs (NCPDP) MTM task force. NCPDP is an ANSI-accredited standards development organization supporting the pharmacy services sector of healthcare. The task group is composed of representatives of professional pharmacy and trade associations that are working to identify the data that pharmacists need for compulsory two-way communication. The group is focused on enhancing existing standards, developing new needed standards and laying out a plan for adoption of electronic communications between payers, providers and patients that will enhance medication therapy management and clinical pharmacy services.
The details of the communication aspects of the group’s mission is currently attempting to identify all necessary bilateral communication streams between patients, providers, pharmacists and all other healthcare stakeholders that impact the patient. The communication streams include all necessary service and billing information, as well as a process of checks and balances for adherence and follow-up. The next step will be additional information sharing, such as outcomes reporting and referrals.
When MTM services engage and educate patients on the nature of their chronic conditions and the medications used to manage their healthcare, studies indicate that patient adherence and outcomes improve.
These are only the first steps in a continuing process that deals with privacy and security. These attributes should be independent of the care setting, while remaining transparent to the MTM service provider. The standards of communication should also fit seamlessly into the provider’s normal MTM workflow and integrate with other elements of a pharmacy practice-management system or electronic health record.
Earlier this year, CMS posted a draft call letter on its Web site that addressed new proposed minimum standards for MTM programs. The revision allowed prescription drug plans to meet the requirement by providing each eligible enrollee with a medication review conducted behind-the-scenes by a qualified provider and/or use of computer-assisted algorithms. Although the letter was withdrawn due to the new administration’s desire to review beneficiary protections, a revised letter is expected in the near future.
The goal is to identify the data and formats needed for interoperability between systems and aid pharmacy system vendors with MTM tool integration. This will ultimately allow medication therapy-management services and pharmacists to live up to their full potential in keeping patients safe as they regain or maintain their health.
John Klimek, R.Ph., is senior vice president, industry information technology, of the National Council for Prescription Drug Programs, Scottsdale, Ariz.