Targeted interventions: The MTM continuum
As I have written in my past two columns, this year is a challenging one for my practice due to decreased reimbursement from a large pharmacy benefit manager (PBM) that administers the drug benefit for the largest insurer in our state. This has required us to make some difficult decisions to help our practice survive—including closing down one of our practice sites and laying off some of our pharmacists working part-time.
These times can be uncertain, scary, and frustrating for pharmacists. We work hard to provide a variety of patient care services, but these services do not provide enough revenue by themselves to support our practice. We rely on dispensing and a fair professional fee to provide the foundation for our practice, but that fee has been drastically reduced.
Despite these challenges, we continue to make important interventions for our patients daily with little or no reimbursement. At my practice, our most frequent type of intervention is targeted medication therapy management (MTM). Some of our recent targeted interventions included the following:
- Consulted with a primary care provider about treatment for a patient newly diagnosed with cancer suffering from shortness of breath due to pleural effusions.
- Identified a patient taking both Vytorin (ezetimibe/simvastatin—Merck) and atorvastatin and consulted with the patient’s physician to discontinue Vytorin.
- Identified a patient taking more than 7,000 mg of acetaminophen per day and consulted with the patient and physician about the maximum dose.
- Consulted with several patients and prescribers regarding discontinued medications and recommended appropriate substitutes.
These are just a few cases representative of the interventions we make routinely—many at the time of dispensing. I know that pharmacists in community and other settings make countless similar interventions every day. I recently encountered an article about pharmacist interventions in a community pharmacy that supports this belief.1
The practice was a federally qualified health center with a pharmacy that filled approximately 160 prescriptions per day.
The goal of the study was to determine the number of interventions performed by dispensing pharmacists during the final month of each quarter in 2004.
Interventions were classified in 14 different categories ranging from cost-saving interventions to drug therapy problems. Two categories tracked interventions that involved “extensive use of resources” (e.g., completing a current medication list) and “other recommendations” (e.g., recommending labs).
During the 4 months of data collection, the pharmacists performed 1,151 interventions. The three most frequent interventions were dispensing patient assistance program prescriptions, clarifying medication orders, and performing therapeutic substitutions. Responding to drug information questions was the fourth most frequent intervention.
About 10% of the interventions were categorized as extensive use of resources, other interventions, and resolving drug therapy problems.
In this study, pharmacists routinely provided interventions that helped save money for patients and the system and improve patient care. The health care industry still questions the value of these interventions and appropriate reimbursement, however. I cannot think of another professional who is not paid to provide a professional service, but pharmacists continue to see our reimbursement rates declining with little to no recognition of a professional fee.
I hope that someday, all payers will see the value of pharmacists’ targeted interventions that improve the safety and effectiveness of drug therapy and health outcomes. I have been vocal over the years that MTM is a continuum, occurring when we perform dispensing functions, value-added services, and comprehensive medication reviews. We must not commoditize community pharmacists as only “dispensing a product” and not providing patient care. But community pharmacists must also do a better job of documenting patient care activities. “You didn’t do it if you didn’t document it” is true in this case.
We will have to fight for provider status. The most effective way that we can help our leaders and associations is to continue to provide—and to document—clinically meaningful interventions through our daily interactions with patients and other providers.
- Klubitz-Klingel C, Reeg-Dhingra M, Oehlert A, Liddell E. Clinical and cost-saving interventions performed by pharmacists in a community health clinic pharmacy. J Am Pharm Assoc. 2007;47:188–90