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INTRODUCTION

The role of the pharmacy technician is changing. Pharmacy technicians are now required by many employers to become certified by passing a national exam that tests certain key skills that are important to maintaining a workplace in which patient health is a priority. In the future, with increased education and training, pharmacy technicians may participate in more direct patient care and assist with the provision of medication therapy management (MTM) services. This module will introduce pharmacy technicians to the process of MTM and the usefulness of a complete medication review (CMR).

MTM DEFINED

Over time, pharmacies have evolved from simply places to have prescriptions filled to facilities where medication and health care services are provided. These services are provided at various points in the pharmacy workflow and involve many pharmacy personnel; the overarching goal of all of the services is to improve patient health. Programs that benefit patient well-being and health include, but are not limited to, vaccination programs, smoking cessation programs, and MTM. Broadly, MTM is a service that is intended to optimize health outcomes by helping patients receive the most benefits possible from their medications while minimizing medication-related problems.¹

Impact of the Affordable Care Act on pharmacy services

Today, patient care is routinely integrated into the pharmacy setting, and pharmacies are collaborating with other health practices such as hospitals and physician offices to provide comprehensive patient care. This is a direct result of the Affordable Care Act (ACA)—legislation that was signed into law by President Obama in March 2010. Simply, the ACA makes health coverage available to all Americans and encourages collaboration among all health care professionals involved in a patient's care. The ACA is designed to ensure that patients are offered essential health benefits, including emergency services, mental health services, and preventive and wellness services.²

The ACA gave rise to what are known as Accountable Care Organizations (ACOs). An ACO is essentially a group of providers and health care entities that join together to provide health care to different populations. The goals of ACOs include enhancing patient experiences within the health care system, improving patient health, and reducing overall health care costs. Medicare has imposed regulations on ACOs to ensure that quality health care is being provided to Medicare beneficiaries. Standards of care that must be provided include MTM services and annual wellness visits.³ These standards must be measurable so that the Centers for Medicare and Medicaid Services (CMS) can oversee the quality of care provided by each ACO. (CMS instituted this policy to protect patients from policies and practices that only benefit insurance companies, such as previous policies that did not allow coverage for pre-existing conditions like diabetes.⁴) For example, glycosylated hemoglobin levels (also known as hemoglobin A_1c) may be used as a metric for assessing care provided to a patient with diabetes. If a patient achieves targets based on these levels, the risks of complications and future hospitalizations are reduced and, therefore, health care costs for the ACO's plan are lowered.⁵ Pharmacists are among the most accessible health care professionals and, as medication experts, have a wealth of pharmacotherapeutic knowledge, and ACOs are in the process of directly integrating pharmacist-provided services into their health plans.⁶

Core elements of MTM

MTM is one way that pharmacists collaborate with other health care team members to provide patient care. Quality, comprehensive, collaborative care is especially important for patients who suffer from chronic diseases such as diabetes, since patients with chronic diseases are generally on multiple medications.⁶ Additionally, 1 in 5 Americans takes 5 or more prescription medications. The more medications a patient is taking, the greater the chance for medication misuse, including, but not limited to, medication overuse and underuse.⁷ MTM services are increasingly being included in health coverage plans, and they are becoming an key component of patient care; MTM services are often provided in community pharmacy settings. The expansion in MTM services is partly due to a new initiative encouraged by the ACA legislation to help patients with chronic diseases have access to MTM services. The end goals of MTM services are improved quality of patient care and reduced treatment expenditures.¹

There are 5 core elements of MTM services:⁶

1. Medication therapy review. A medication therapy review is a review of all medications that a patient is taking, including any supplements and/or over-the-counter medications. The pharmacist can complete a medication therapy review by completing a CMR form and submitting it to a patient's insurance company, if a patient is eligible to receive a CMR; many insurance companies pay pharmacists for conducting a CMR. A CMR is a complete review of medications by a pharmacist, and it usually requires 30 to 60 minutes or more of the pharmacist's time, depending on the complexities of a patient's medication regimen and health history. This service involves a pharmacist-patient consultation, which can be conducted in person or over the phone. In-depth discussions with patients help pharmacists uncover potential drug interactions and adherence issues. Potential adverse effects from medications are also documented as part of the medication therapy review. The results of the consultation and pharmacist review are sent to the patient's prescribers and care providers, along with any recommendations from the pharmacist for therapy changes.

2. Personal medication record. A personal medication record is a list of a patient's medications that is provided to the patient for his or her own records. This helps patients keep track of their own medications and facilitates patients noting how the medications are working for them and what questions they might have about their therapies.

3. Medication-related action plan. A medication-related action plan is a plan of action that a pharmacist outlines for a patient after providing MTM services. The plan includes recommendations on how therapy may be improved, including, but not limited to, potential additions and/or deletions of medications, detailed instructions on how to use medications properly, and explanations about the indications for the medications. The action plan should be shared with the entire health care team so that all members of the team can evaluate and agree on a final plan that meets the needs of the patient.

4. Intervention and/or referral. If a patient needs additional assistance, support, or education to optimize medication therapy, he or she may be referred to a specialist or another program that can provide specialized interventions and support. For example, if a patient with diabetes has questions or concerns about a diet plan, they may be referred to a dietitian.

5. Documentation and follow-up. All medication reviews should include a plan for a follow-up consultation to assess how a patient has incorporated the recommendations of the health care team. All MTM actions should be documented for future reference.

INCORPORATING MTM PRACTICES INTO THE PHARMACY SETTING

Pharmacy practice sites are changing to allow more opportunities for patient care, increased collaboration with other members of the health care team, and enhanced monitoring and reporting of medication use. All of these changes contribute to improved quality of and access to patient care.

Medication adherence support

At the pharmacy level, health care team members can monitor patient adherence to therapies. This is especially important for patients with chronic diseases, such as diabetes. The World Health Organization defines medication adherence as "the extent to which a person's behavior...corresponds with agreed recommendations from a health care provider." Essentially, adherence means that patients are taking their medications as they should.⁸

A recent national study found that, on average, fewer than 40% of patients are fully adhering to diabetes therapies, leaving at least 60% of patients with non-adherence issues.⁹ There are many reasons why patients may not adhere to their medication regimens, and non-adherence can take on many forms. One type of non-adherence, known as primary non-adherence, is when a patient receives a prescription from a prescriber but never gets it filled. This can be directly observed in a pharmacy when a patient asks for the price of a medication and then chooses not to fill a prescription if the cost is too high.

Another type of non-adherence includes patients who stop medications abruptly. A patient may feel a medication is not working or they misunderstand the instructions from the health care provider. Another type of non-adherence seen at the pharmacy includes patients who refill their prescriptions later or less frequently than they should. This may happen when an elderly person simply forgots that he or she needs medication, or a patient may decrease doses of medications on their own because he or she is overwhelmed by complex medication regimens or by taking too many medications.

Adherence can be improved at the pharmacy level by calling patients to remind them to refill prescriptions that are overdue for refill or to pick up prescriptions that are filled and waiting to be picked up in the pharmacy. Patients can suffer serious consequences without proper adherence to medication therapy, and pharmacy technicians can greatly impact patient health by educating patients about why they need to take their medications as prescribed.

Another technique that pharmacy staff can use to improve adherence in patients who take multiple medications is called medication synchronization.¹⁰ This is a process in which monthly medications are coordinated to be filled at the same time. This can be simply accomplished by helping patients fill their prescriptions at the same time each month. In order to schedule the prescriptions for coordinated refills, it may be necessary to have a patient pay cash for a few days or weeks of some medications, so that, going forward, the monthly refills will be payable by the insurance company at the same time. To support the medication synchronization process, some states have called for insurance plans to provide "early refills" to allow patients to coordinate medications to be refilled simultaneously.¹⁰

Pharmacy as a point of care

Changes to patient care models are greatly needed: a 2003 study showed that patients received only 55% of the acute, chronic, and preventive care recommended to keep them healthy.¹¹ Pharmacies are being integrated into health care systems in a variety of new and innovative ways, with the hope of offering improved access to and quality of patient care. One change is the partnering of pharmacies with physician offices in collaborative practice agreements. These agreements allow pharmacists, under certain conditions, to order lab tests and perform other patient care services not typically seen in the pharmacy environment.

A new Medicare mandate called the Medicare Access and CHIP Reauthorization Act will also change the landscape of patient care. This federal plan emphasizes that physicians will soon have a payment structure through Medicare that compensates them on the basis of keeping patients with chronic diseases healthy. Medicare laws are changing rapidly to provide a pay-for-performance model, as opposed to the fee-for-service model that has been in place for many years. In simple terms, a patient previously visited a doctor's office and paid for a check-up; there was no follow-up or monitoring by insurance providers or health coverage plans. Under the new model, a patient visits a doctor, but the doctor gets "rated" by how healthy the patient stays. Patient health can be measured by how frequently a patient is hospitalized or how often a patient visits a doctor's office for "sick" visits. The ratings that Medicare uses to measure performance are known as "Star Ratings."¹² Medication adherence and completion of CMRs directly impact Star Ratings, and these factors are used by Medicare to measure the quality of patient care. Medicare provides ongoing incentives to the health plans to keep patients healthy, and, under a pay-for-performance model, the better the ratings, the more incentives physicians receive. The incentives involve allowing plans to stay in the Medicare system, providing patient choice, and distributing cash incentives. Pharmacies that are in partnerships with physician offices can improve the ratings received by the physicians by working to help patients stay well through collaborative care efforts. Pharmacies generally receive payment for MTM interventions and CMR completions by health plans.

CMR DEFINED

In 2011, the Pharmacy Quality Alliance endorsed CMR as a performance measure of MTM.¹³ Medicare Part D plans pay for or allow an annual CMR for its beneficiaries.¹⁴ Health plans that complete a certain number of CMRs for their patients will get high Medicare Star Ratings. CMRs are often completed through a portal in the pharmacy computer system, and the review process includes recommendations by the pharmacist for non-adherence issues, drug interactions, and therapy changes. Payers examine CMR completion rates and evaluate the direct impacts on patient health.

Pharmacy technicians can assist with identifying patients who are eligible for MTM services, scheduling CMRs, and educating patients about the importance of CMRs.

A CMR generally includes several features:

1. A collection of patient information and clinical data to verify the appropriateness of therapy and dosing
2. A review of all prescription and over-the-counter products, including supplements
3. The identification and resolution of adverse drug effects and potential drug interactions
4. The identification of adherence issues
5. Training in the use of devices, such as insulin pens and blood glucose monitors
6. Recommendations for potential cost savings, such as coupons or alternative medications, if cost is a barrier to adherence
7. A plan of action that is created in partnership with the patient, which includes a date for follow-up on the action plan
8. Communication of the findings and recommendations with other health care team members

Reaching out to eligible patients

The ACA specifies that an annual CMR will be a covered service as part of all Medicare Part D programs. Technicians can help keep patients healthy by taking an active role in this important process. CMRs and medication reviews are especially important for patients with chronic diseases like diabetes. Diabetes is associated with high morbidity and mortality and it was the 7^th leading cause of death in the United States in 2010.¹⁵ Pharmacist interventions improve the overall health of patients with diabetes,¹⁶ and pharmacy technicians are in a key position to help facilitate consultations between the patient and the pharmacist.

Technicians can complete the following actions to assist with MTM services:

1. Create a schedule of consultations with the pharmacist for patients who are eligible for MTM services. The pharmacist can help determine when and where appointments are most convenient, such as on days when more than 1 pharmacist is on duty.
2. Collect data from patient profiles and provide it to the pharmacist for the initial patient consultation.
3. Ask patients to bring all over-the-counter medications, including supplements, to the consultation.
4. Encourage patients to bring copies of recent lab work, which will contain data such as glycosylated hemoglobin level and other pertinent markers of health outcomes.
5. Request that patients bring immunization records to the consultation. In addition to MTM services, most pharmacies provide vaccination services and can provide patients with immunizations that may be necessary.

References

1. Bluml BM. Definition of medication therapy management: development of professionwide consensus. J Am Pharm Assoc. 2005;45(5):566-572.
2. Brummell A, Lustig A, Westrich K, et al. Best practices: improving patient outcomes and costs in an ACO through comprehensive medication therapy management. J Manage Care Spec Pharm. 2014;20(12):1152-1158.
3. Lawmaker R. Are you in compliance with Medicare's annual wellness visit? WellTrackOne. https://www.welltrackone.co/compliance-medicares-annual-wellness-visit. Published March 24, 2015. Accessed September 2, 2016.
4. Key features of the Affordable Care Act. U.S. Department of Health and Human Services. http://www.hhs.gov/healthcare/facts-and-features/key-features-of-aca/index.html. Published November 18, 2014. Accessed December 8, 2016.
5. Lower costs, better care: reforming our health care delivery system. Centers for Medicare & Medicaid Services. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-01-30-03.html. Published January 30, 2014. Accessed December 8, 2016.
6. Medication therapy management in pharmacy practice: core elements of an MTM service model. Version 2.0. American Pharmacist Association. https://www.pharmacist.com/sites/default/files/core_elements_of_an_mtm_practice.pdf. Published March 2008. Accessed October 8, 2016.
7. Patterson SM, Cadogan CA, Kerse N, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2014;10:CD008165.
8. World Health Organization. Adherence to long-term therapies: evidence for action. http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf. Published 2003. Accessed December 8, 2016.
9. IMS health study: low levels of adherence and persistence remain barriers to reducing the costs of diabetes complications [press release]. Parsippany, NJ: IMS Health; July 12, 2016.
10. Norton J. States take the lead in making med synchronization easier. http://www.ncpanet.org/newsroom/ncpa's-blog---the-dose/2015/06/18/states-take-the-lead-in-making-med-synchronization-easier. Published June 18, 2015. Accessed December 8, 2016.
11. Newhouse JP and the Insurance Experiment Group. Free for All? Lessons from the RAND Health Experiment. Cambridge, MA: Harvard University Press, 1993.
12. Understanding Medicare prescription drug coverage. American Academy of Family Physicians. http://familydoctor.org/familydoctor/en/healthcare-management/insurance-bills/understanding-the-new-medicare-prescription-drug-plan.html. Published 2016. Accessed December 8, 2016.
13. PQA medication quality measures in the health insurance marketplace. Springfield, VA: Pharmacy Quality Alliance. http://pqaalliance.org/measures/qrs.asp. Updated 2016. Accessed December 8, 2016.
14. Fact sheet: summary of the 2014 MTM programs. Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovcontra/downloads/cy2014-mtm-fact-sheet.pdf. Published August 21, 2014. Accessed December 8, 2016.
15. Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. Published 2014. Accessed December 5, 2016.
16. Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy management services: the Minnesota experience. J Am Pharm Assoc (2003). 2008;48(2):203-211.

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