US Pharm. 2022;47(2):44-46.
Medication therapy management (MTM), a set of services that optimize therapeutic outcomes for individual patients, focuses on medication usefulness, effectiveness, safety, and adherence with the goal of improving patient treatment outcomes.1 MTM gives pharmacists an opportunity to use their knowledge and expertise to resolve potential medication issues. Uncovering the challenges that affect MTM services in pharmacy practice is necessary in order to improve outcomes. The current challenges pharmacists face with MTM delivery are many.
MTM serves as an instrument for pharmacists and other providers to improve patients’ therapeutic outcomes and reduce healthcare costs. In the United Kingdom, pharmacists are contracted to conduct medicines use reviews; this free service is available to all patients to help with medicine adherence, particularly among those with chronic conditions, and to reduce medicine waste.1 In Canada, pharmacists provide medication management, which is a detailed pharmacy service that helps optimize health and medication outcomes; this service is available to residents taking at least one medication. Similarly, Australia has the home medicines review, wherein a pharmacist in a community setting performs government-funded medication reviews.
In the United States, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 furnished a Medicare Part D benefit that included delivery of MTM services to eligible beneficiaries. A new facet of this legislation was that healthcare professionals—community pharmacists included—could provide these services and be compensated.1,2 Since then, little has been accomplished in terms of standardizing implementation of the service. To address this, the American Pharmacists Association and the National Association of Chain Drug Stores Foundation developed a framework on MTM in community pharmacy practice.1,2
Although Medicare Part D MTM delivery has increased to approximately 65% of plans that use community pharmacists through MTM vendor contracts, it remains necessary to focus on associated challenges. A considerable number of Part D providers do not employ community pharmacists as the primary provider for their MTM services.1,2
Challenges in MTM that have been identified to date involve pharmacy workflow, the healthcare team, new technology, pharmacist reimbursement, and patient participation.
MTM and Pharmacy Workflow: Although the benefits that MTM confers have generated much excitement, the presence of formal systems and staffing structures supporting MTM is limited in community pharmacies.1-3 Pharmacies have tried to determine whether MTM should be part of their regular dispensing workflow or a service separate from dispensing. Irrespective of whether they receive payment for it, many U.S. community pharmacists have encountered difficulties in incorporating MTM into their current workflow. Specifically, these challenges include lack of time, paucity of trained support personnel, excessive workload or absence of management’s support, and space limitations. Pharmacists who have been willing to adapt to change have been successful at incorporating clinical services into their workflow. The relationship between pharmacist perspectives and the provisions of patient-care services continues to warrant further exploration; moreover, pharmacist job descriptions generally lack details about pharmacists’ growing role in MTM.1-3
Both pharmacists and patients have noted similar concerns regarding time limitations. Limitations are typically related to insufficient pharmacy staff and staffing inconsistencies. Pharmacies that have support from residents have been able to more easily implement MTM programs compared with pharmacies lacking such support.1-3
An increase in pharmacy technician hours is associated with a greater likelihood of successful MTM implementation; however, some pharmacists think that technicians’ training is insufficient for involvement in MTM. Adequate training in MTM integration is crucial for the assignment of technical and clinical roles, but inconsistency in training creates resistance to assigning MTM responsibilities to nonpharmacist staff, and these barriers often discourage technicians from supporting MTM. Technician turnover also complicates the involvement of pharmacy technicians in MTM. Frustration ensues when pharmacists who train technicians to support MTM must shoulder the MTM workload because of technician turnover.1-3
Another challenge is the absence of pharmacy management support. Lack of managerial support from pharmacy owners, corporate entities, and pharmacy benefit managers has led to difficulties in implementing MTM delivery.1-3
The delivery of MTM services has also been affected by lack of adequate space. The need for appropriate physical space for medication and disease-state management services in community pharmacies is obvious. Some pharmacies stop providing medication management service because of the absence of private space.1-3
MTM and the Healthcare Team: The absence of community-pharmacist involvement with the rest of the healthcare team has posed difficulties that affect MTM provision globally and is a source of frustration for pharmacists.1,2,4 Community pharmacists in the U.S. generally work in a location that is separate from healthcare centers, and most MTM services are provided without complete integration of the pharmacist into the healthcare team. Additionally, communication between community pharmacists, community nurses, and general practitioners is hard to achieve in a hectic environment. The absence of a standard procedure for pharmacists to make recommendations to prescribers and report findings is also a problem.
The integration of the pharmacist into the healthcare team is challenging because other team members do not understand the community pharmacist’s responsibilities other than dispensing. Resistance by physicians or state medical associations is another barrier to pharmacist provision of clinical services. Some physicians view the expansion of pharmacist roles as a threat to their practice’s autonomy. Older physicians have stated a preference for continuing to use their own system of evaluating things, and concerns about pharmacists’ clinical skills were not known.1,2,4
MTM and New Technology: Technology poses challenges to MTM delivery in the community pharmacy as well as across the healthcare system.1,4,5 Access to medical records is considered an important factor in successful MTM, but it has not been easy to integrate the community pharmacist into the health information technology framework. Accordingly, the adoption of electronic health records systems has been minimal in community pharmacies.
Some companies have implemented policies prohibiting the provision of MTM services via Web-based vendors, but this security concern results in a technology-related challenge. MTM vendors generally require that a contracted community pharmacist use their Web-based software applications for billing and documentation. The use of MTM automated Web-based software creates other problems, such as the absence of standardization across MTM vendor systems and, frequently, a lack of information-sharing with the pharmacy’s management system. In addition, pharmacy management systems may require pharmacists to document specific services in different management systems, and it may be difficult for pharmacists to have to operate numerous billing and documentation systems.1,4,5
To simplify this task, pharmacists have created automated software applications capable of maintaining and updating medication claims, sending and receiving faxes to and from physicians and pharmacies, and permitting documentation with patient-specific freeform text. Each profile is extensive and allows the pharmacist to obtain all necessary information from a single source.1,4,5
MTM and Pharmacist Reimbursement: In the U.S., extensive coverage of MTM services by payers beyond Part D does not exist.1,5,6 From a payer perspective, there are numerous barriers to pharmacist-delivered MTM. Although Medicaid programs have discerned the benefits of MTM, many private payers have yet to see the value and compensate for these services. Several concerns were cited by healthcare executives that limit reimbursement to pharmacies, including pharmacist qualifications; physicians’ lack of knowledge about pharmacist training and their reluctance to partner with pharmacists; poorly developed population-health models; and the absence of standardized fee structures.
Even when services are covered by payers, low financial compensation is a significant barrier to MTM delivery. More commonly the pharmacy, not the individual pharmacist, receives the reimbursement. Ambiguity and unease among shareholders surrounding the legality of billing for pharmacist services also exist. Collectively, low volume and low reimbursement render it difficult for many community pharmacies to make a business case for MTM delivery.1,5,6
MTM and Patient Participation: Patients pose an additional barrier to MTM delivery because, like physicians, they do not understand the community pharmacist’s expanding role in healthcare.1,6-8 A lack of familiarity with MTM services, not being referred for MTM by a physician, and cost concerns have been cited as common patient-related barriers. Many consumers consider pharmacists to be simply dispensers of medications, not healthcare professionals who collaborate with their physician. Accordingly, they find the pharmacist’s traditional role of dispensing and brief counseling to be sufficient.
Pharmacists have indicated that some patients believe that pharmacists are infiltrating their protected patient-provider relationship and counteracting or complicating their initial therapeutic plan. This gap between pharmacist services and patient expectations is a significant reason that patients are not interested in pharmacist MTM services.1,6-8
Finally, most patients are unaware that the pharmacist collaborates with their physician to make medication recommendations. Patients also are concerned about the cost of MTM service, and their willingness to pay for the service varies. Because patients’ reluctance to pay does not offset the cost of providing MTM, this service generally is not financially sustainable for pharmacies.1,6-8
1. Ferreri SP, Hughes DT, Snyder EM. Medication therapy management: current challenges. Integr Pharm Res Pract. 2020;9:71-81.
2. Gray C, Cooke CE, Brandt N. Evolution of the Medicare Part D medication therapy management program from inception in 2006 to the present. Am Health Drug Benefits. 2019;12(5):243-251.
3. Burnside TPT, Scott NJ, Smith MG. Implementation of technician-driven medication therapy management program in community pharmacies. J Am Pharm Assoc (2003). 2019;59(4S):S156-S160.
4. Snyder ME, Zillich AJ, Primack BA, et al. Exploring successful community pharmacist-physician collaborative working relationships using mixed methods. Res Social Adm Pharm. 2010;6(4):307-323.
5. Turner K, Renfro C, Ferreri S, et al. Supporting community pharmacies with implementation of a Web-based medication management application. Appl Clin Inform. 2018;9(2):391-402.
6. Bacci JL, Bigham KA, Dillon-Sumner L, et al. Community pharmacist patient care services: a systematic review of approaches used for implementation and evaluation. J Am Coll Clin Pharm. 2019;2(4):423-432.
7. Lounsbery JL, Green CG, Bennett MS, Pedersen CA. Evaluation of pharmacists’ barriers to the implementation of medication therapy management services. J Am Pharm Assoc (2003). 2009;49(1):51-58.
8. Renfro CP, Turner K, Desai R, et al. Implementation process for comprehensive medication review in the community pharmacy setting. J Am Pharm Assoc (2003). 2019;59(6):836-841.
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