Medication Therapy Management and Collaborative Drug Therapy Management

■■ Medication Therapy Management and Collaborative Drug Therapy Management With the current push for health care reform, many are asking how ongoing government programs like Medicare Part D are performing. The Medicare Modernization Act of 2003 established the requirement that Medicare Part D prescription drug plans (PDPs) and Medicare Advantage prescription drug plans (MA-PDs) provide medication therapy management programs (MTMP) using pharmacists or other qualified health care providers as part of their benefits.1 In general, medication management services encompass care beyond traditional medication counseling. MTM services are designed to maximize the benefits of prescribed medication regimens, increase medication adherence, and reduce the risk of adverse drug events and drug interactions.2 In an article by Spooner (2007), he suggested that at the 1-year mark, it was time to start evaluating MTMP services.3 Spooner recommended that evaluations focus on the following 2 questions: “are we correctly identifying patients who would benefit the most and has the MTMP been successful in achieving established goals.”3 According to the Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0, MTM programs should also be designed “to improve collaboration among pharmacists, physicians, and other health care professionals, enhance communication between patients and their health care team; and optimize medication use for improved patient outcomes.”4 In a recently published article in JMCP, Cook and MburiaMwalili discussed Medicare Part D policy changes that have affected pharmacists working in MTMP. They described how the availability of the National Provider Identification (NPI) numbers and pharmacy-specific Current Procedural Terminology (CPT) codes have facilitated the implementation of MTMP by allowing pharmacists to seek reimbursement for their services.5 The authors suggest that with a wide range of services being provided including mailed information, telephone consultations, as well as in-person appointments, large chain community pharmacies may be the best settings for the provision of MTM because of previously developed billing infrastructure and in-store clinics with prior trained clinical staff. However, Cook and Mburia-Mwalili acknowledge that even with a collaborative approach of pharmacist and prescriber, community pharmacy chains would not likely manage more serious chronic conditions. We foresee collaborative drug therapy management programs as a way to gather data for outcomes of improvements of these chronic conditions.


■■ Medication Therapy Management and Collaborative Drug Therapy Management
With the current push for health care reform, many are asking how ongoing government programs like Medicare Part D are performing. The Medicare Modernization Act of 2003 established the requirement that Medicare Part D prescription drug plans (PDPs) and Medicare Advantage prescription drug plans (MA-PDs) provide medication therapy management programs (MTMP) using pharmacists or other qualified health care providers as part of their benefits. 1 In general, medication management services encompass care beyond traditional medication counseling. MTM services are designed to maximize the benefits of prescribed medication regimens, increase medication adherence, and reduce the risk of adverse drug events and drug interactions. 2 In an article by Spooner (2007), he suggested that at the 1-year mark, it was time to start evaluating MTMP services. 3 Spooner recommended that evaluations focus on the following 2 questions: "are we correctly identifying patients who would benefit the most and has the MTMP been successful in achieving established goals." 3 According to the Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0, MTM programs should also be designed "to improve collaboration among pharmacists, physicians, and other health care professionals, enhance communication between patients and their health care team; and optimize medication use for improved patient outcomes." 4 In a recently published article in JMCP, Cook and Mburia-Mwalili discussed Medicare Part D policy changes that have affected pharmacists working in MTMP. They described how the availability of the National Provider Identification (NPI) numbers and pharmacy-specific Current Procedural Terminology (CPT) codes have facilitated the implementation of MTMP by allowing pharmacists to seek reimbursement for their services. 5 The authors suggest that with a wide range of services being provided including mailed information, telephone consultations, as well as in-person appointments, large chain community pharmacies may be the best settings for the provision of MTM because of previously developed billing infrastructure and in-store clinics with prior trained clinical staff. However, Cook and Mburia-Mwalili acknowledge that even with a collaborative approach of pharmacist and prescriber, community pharmacy chains would not likely manage more serious chronic conditions. We foresee collaborative drug therapy management programs as a way to gather data for outcomes of improvements of these chronic conditions.

Collaborative Drug Therapy Management
CDTM refers to collaborative practice agreements between pharmacists and prescribers in which pharmacists are enabled to initiate, modify, or continue drug therapy for specific patients as defined in a written guideline or protocol. 6 CDTM is being used in the following areas: immunizations, asthma therapy, dyslipidemia therapy, warfarin anticoagulation therapy, diabetic therapy, smoking cessation therapy, and flu/antiviral therapy. Currently, 46 states in the U.S. have authorized CDTM agreements between pharmacists and physicians, 7 including most recently Massachusetts 8 and Rhode Island. 9 Of the 4 states that do not have CDTM programs (Alabama, Oklahoma, Maine, and New York), pharmacists in New York are lobbying to implement a CDTM bill (S.3292/A.6448). 10 Kaiser Permanente of Georgia (KPGA) health plan is a nonprofit health maintenance organization that provides integrated health care services to more than 250,000 members at 15 medical offices in the Atlanta metropolitan area. At KPGA, clinical pharmacists are part of a collaborative team that provides CDTM and MTM for patients diagnosed with dyslipidemia, diabetes, hypertension, or coronary artery disease as defined in protocols developed by clinical pharmacists and primary care physicians (PCPs). A patient-specific protocol is valid for 2 years unless the patient changes physicians or disenrolls from the KPGA health plan. The CDTM protocols include algorithms for specific drug therapy modifications, dosing ranges, and monitoring information for insulin management, hypertension management, diabetes management, lipid management, lab monitoring, and aspirin therapy initiation.
Patients are enrolled into these programs through direct referral by PCPs or via administrative queries of a Web-based electronic database. When a protocol is signed by a PCP, all current patients of that PCP are authorized to be managed under the protocol as well as future patients that are individually referred to clinical pharmacists by that PCP. The collaborative protocols with KPGA PCPs allow the clinical pharmacists to confer with patients and other members of the health care team to initiate medications, order laboratory tests, and adjust dosages on the basis of lab results or reported side effects, as well as make formulary conversions.
In addition to the use of collaborative protocols, KPGA providers, patients, and staff also rely heavily upon electronic medical records (EMRs). The database used for referrals is integrated with the KPGA EMR and the collective data are used to identify patients who are due for laboratory tests, those who are diagnosed with specific chronic diseases and have not met their goals, have not seen their PCPs in more than 1 year and Medicare Part D patients eligible for enrollment in the MTMP. EMRs offer access to a complete patient history, including, but not limited to procedures, medication recommendations, and existing medical conditions. At KPGA, the clinical pharmacists and the health care team use EMRs to coordinate patient care at each point of service, including office visits, laboratory services, prescription services, hospitalizations, phone consultations, and online services. Patients enrolled in the KPGA health plan have access to view online portions of their medical record and information about their office visits. The Web-based portal also allows patients to safely and securely send messages to their providers, view lab results, schedule appointments, and order medications for pick-up or delivery. The use of this innovative information technology may potentially reduce fragmentation of medical care as it increases collaboration among providers.

MTMP at KPGA
In 2009, the Centers for Medicare and Medicaid Services (CMS) reported that in 2008 there were 712 active Part D approved MTM programs, 609 MA-PD and 103 PDP. 11 Criteria for these programs vary, however, targeted beneficiaries must have multiple chronic diseases to be enrolled. The top 4 chronic conditions frequently targeted by MTMPs in 2008 were diabetes, heart failure, hypertension, and dyslipidemia. Enrollees must also be taking multiple Medicare Part D drugs which are likely to incur annual costs of $4,000 or greater. 11 The minimum number of covered Medicare Part D drugs to determine MTMP eligibility varied among MTMPs in 2008, ranging from as few as 2 to as many as 15; most programs required a minimum of 5 to 8 medications (62.4%) per beneficiary for MTMP eligibility. 11 In the second quarter of 2009, the clinical pharmacists at KPGA began monitoring MTM patients under the collaborative protocol. The KPGA MTMP identifies and invites patients that are likely to incur annual drug costs greater than or equal to $4000, are taking at least 5 chronic or maintenance medications covered by Medicare Part D, and have at least 2 of the 5 following chronic conditions: asthma, diabetes, chronic kidney disease, hypertension, and coronary artery disease. Patient participation in the KPGA MTMP is voluntary, and MTM clinical pharmacists attempt to provide services to all MTMP-eligible members. Initially, welcome letters are mailed, and patients are later contacted by telephone and invited to participate in the MTMP. If a patient is unable to be reached by telephone after 3 attempts, a letter is mailed requesting his/her response by a specified date to become enrolled in the program. Failure of the patient to respond by the specified date will indicate the member's decision not to participate in the MTMP. Eligible members may opt After enrollment, MTM clinical pharmacists perform an initial assessment to validate the complete medication profile and the following target areas: patient compliance, drug therapy duplication, potential drug interactions, potential cost-effective alternatives, and drug therapy appropriateness. Next, MTM patients have their individualized therapeutic goals defined. After the initial patient assessment, the MTM pharmacist will conduct follow-up telephone encounters with the patient at least quarterly or more frequently if necessary, to assess progress toward treatment goals. Patient-specific education and Letter instruction regarding medication use is provided, as appropriate, during each encounter.
Going forward, CDTM protocols may be used to define outcome measures such as low-density lipoprotein (LDL) goals and hemoglobin A1c goals, and identify the patients who are due for laboratory monitoring. Currently, preliminary outcomes data are being collected on the use of high-risk medications in the elderly to monitor for safety.

■■ Conclusion
Pharmacists play a central role in management of medication therapy, particularly for patients with chronic conditions, and CDTM can enhance that role. [12][13][14] The EMR in our health system allows for seamless collaboration and the sharing of information among providers and their patients. With the use of a Web portal for access to the electronic database and the list of patients enrolled in CDTM protocols, we are able to identify Medicare patients who are monitored by clinical pharmacists at KPGA. The CDTM protocols and agreements between clinical pharmacists and PCPs facilitate the delivery of MTMP services in our health system.