Twenty Years of Experience and Counting: Strategies for Growing Medication Therapy Management Services

DISCLOSURES
No funding supported the writing of this commentary. Brummel has consulted, presented, or was engaged in an advisory board for UCB, Boerhinger Ingelheim, Pfizer, and Lilly. Sorenson has nothing to disclose.

to take on risk, they looked to other local ACOs and noted that pharmacists were a part of those teams and the effect they had on Triple Aim results. 5 Health plans also began to include these services as a part of the ACO contracts, as well. In 2019, these health systems employed 146 pharmacists (106.6 FTEs) and 13 PGY1 pharmacy residents (10.1 FTEs) in ambulatory carefocused experiences. These practitioners provided services in 181 clinic locations, generating over 84,000 encounters with over 44,000 unique patients.
The influence of Fairview's MTM program on adoption and growth in other systems is difficult to quantify but clear when looking back over time. However, reflection identifies other facilitators of successful growth. One is the development of a multisite PGY1 residency program managed by the University of Minnesota College of Pharmacy in partnership with health care organizations across the state. This program, with a focus on comprehensive medication management delivery in outpatient settings, leverages an administrative structure that reduces the overall investment required for individual health systems to host residents. This design has facilitated ambulatory care-focused residency training expansion to the point where the program now manages affiliations with 15 organizations and graduates more than 20 residents annually. The growth of residency training helped fuel MTM program expansion, creating "win-win" opportunities for residents to expand services as part of their training that ultimately sustained past their residency. In many instances, these residency-based "pilots" created new employment opportunities for residency graduates.
Another initiative that has supported MTM program success in the state is the creation of the Health-Systems Alliance for Integrated Medication Management (HAIMM). HAIMM is composed of the MTM leaders from each of the state's health systems that offers MTM services. Its mission is to advance a culture that values pharmacist contributions within team-based care models to ensure safe and effective use of medications. The Alliance has collaborated on various initiatives, including creating a patient satisfaction survey, 6 sharing program operational and clinical metrics, and weighing in on state and federal policy issues related to medication management services. "Communities of practice," such as HAIMM, are an established strategy to support success of individuals and organizations focused on a common cause. 7 Ultimately, the expansion of MTM providers in the state and the organizational collaboration supporting this growth has allowed health plans to expand coverage for MTM services. Regional health plan administrators know that they can expect a standard service definition, reliable service delivery, and, most importantly, consistent programmatic outcomes from practitioners across the state. required to ensure fidelity to this care model, as the number of pharmacists practicing in the system expanded several-fold, is a foundation for the program's success. Program leaders can confidently state that every patient and every medical provider with whom M Health Fairview's pharmacists work experience the same model, regardless of which pharmacist they encounter. This consistency has produced tremendous loyalty and expectations, making these stakeholders advocates for the role of pharmacists on the team.
Fairview was an early adopter of performance-based payment strategies, and these types of contracts account for about 60% of patients seen within the system, with 30% being covered by at-risk accountable care organization (ACO) models. This shift has played a key role in affirming the role of pharmacists on outpatient care teams, now serving as key contributors to how M Health Fairview manages high-risk populations. Another foundation of the program's success is that the majority of pharmacist patient care effort is directed toward medically complex patients, a population for which pharmacists' contributions are distinctive and effect is measurable. To support this change, the program has enhanced how it identifies high-risk patients and has built referral pathways/ tools to better automate referrals to pharmacists.
The commitment to evaluating the program's operational, clinical, economic, and humanistic effect made the article 10 years ago possible. That commitment remains today, more than 20 years after the program's inception. Evaluations have established positive effect on optimal care in complex patients with diabetes, demonstrating that the percentage of patients optimally managed was significantly higher for the MTM program patients (21.49% vs. 45.45%, P < 0.01). 3 The program demonstrated that patients who had an MTM visit after discharge from Fairview had a 33% lower rate of 30-day readmissions than patients who did not. 4 The program continues to administer annual medical provider and patient satisfaction surveys. In 2019, 87% of medical providers strongly agreed that they feel confident in the medication recommendations given by M Health Fairview's MTM pharmacists, and 95% of patients rated their pharmacists as a 9 or 10 (top box score). From a financial perspective, the MTM program still does not cover its costs from revenues from pharmacist service claims; however, the program's contributions to overall organizational, operational, clinical, and financial performance are well established and have underpinned growth and sustainability.

■■ Growth of MTM in Minnesota
While M Health Fairview was a pioneer with respect to MTM service delivery, others have integrated this model within their organizations over the past 10 years. At least 12 integrated health systems in the state now have MTM pharmacists embedded into their care teams. As more systems in the region began the health systems in Minnesota has served as a critical factor in demonstrating value and growing payment opportunities for the community as a whole, as opposed to a single system.
When it is understood that success for pharmacists in one entity is dependent on building opportunities for success for all, the value of communities of practice (e.g., HAIMM) and learning and action collaboratives (pharmacy example: A3 Collaborative) are a tremendous asset in growing MTM programs. 11,12 Implementation support structures such as these are designed to create inspiration, share best practices, expose organizations to practice standards and measurement tools, and provide mentoring and coaching to convene communities and drive change at a pace that will not likely occur otherwise.
Finally, it is essential that pharmacy programs commit to constant measurement of MTM program value across the dimensions of the Quadruple Aim. 13 While well-designed outcomes studies published in peer-reviewed journals are important, it is our experience that these types of evaluations will not drive transformative decision making within health systems or payer organizations. They might pave the way for initial investment and implementation, but for decision makers to make long-term financial commitments to MTM services, they must see the evidence of value in their own data. Therefore, it is critical that pharmacy leaders commit to longitudinal evaluation strategies which ensure that the value proposition for MTM services is clear within the context of their own organization and its partners.

■■ Conclusions
Our hope is that when we look back in another 10 years, the national adoption of MTM will mirror the expansion we have seen in Minnesota. It is time for our profession to act boldly, to use the key elements and strategies that have been outlined, and to leap into advancing the integration of pharmacists into the care team. It is through these actions that we can realize the potential that exists in the profession to improve patient health and make meaningful contributions to the goals of the U.S. health care system.

■■ Strategies for National Growth
Unfortunately, the trends in MTM service integration in medical clinics nationally has not mirrored that observed in M Health Fairview or the state of Minnesota. While there are examples of adoption, these remain somewhat isolated and do not represent a consistent pattern of growth across defined regions. A recent study notes that only 25.8% of family physicians indicate working collaboratively with pharmacists in their practice setting, a percentage that has only increased a net of 4% since 2014. 8 In reflecting on what has supported and accelerated success in MTM integration in Minnesota over the past 10 years, we can identify several strategies that have proved successful in stimulating and accelerating the incorporation of pharmacists into care teams in ambulatory care settings.
First, success depends on bold commitments from provider groups/care systems and payers to invest in this service. While this investment is necessary from both sides of the equation, our experience suggests that it is the health care provider organizations that need to commit first. Leadership within health system pharmacy departments to articulate the value proposition for MTM and position this in the context of overall organizational priorities is key. Until we reach a tipping point on the diffusion of this innovation-theorized to be 16% penetration of the service within a sector-sustainability will be illusive. 9 Provider organizations investing in the service and demonstrating the value through provider-payer partnerships will eventually lead to new fiscal opportunities.
Success in the future is tied to ACO-type contracts or other forms of systems-level performance-based agreements. Given that Medicare Part D and some state Medicaid programs have existed for well over a decade, it is clear that current government programs will not drive standardization and growth of MTM services across the United States. Value-based arrangements rooted in total cost of care metrics have led health care organizations to view their service delivery models differently and consider the care team composition that will drive performance on these metrics. Pharmacy leaders must be engaged with all parts of their organization that are defining a response to the shifting compensation programs in health care.
Success in the 2 strategies above requires a commitment to a defined practice model executed consistently. It is imperative that we recognize that the unit of measure of this innovation is not "the pharmacist" but is "the service provided by a pharmacist." To produce consistent value to a health plan, the intervention must be consistent across the experience of all of their beneficiaries, not only those that receive services from pharmacists in a single provider organization in the health plan's network. It is essential that pharmacy as a profession and its leaders understand and apply principles of implementation science in order to successfully replicate and sustain MTM services. 10 The consistency of the practice model adopted by