CDTM programs consist of partnerships between physicians and pharmacists in which the pharmacist can start, modify, or continue drug therapy for a specific patient according to a written protocol. Protocols may be specific to a single patient or may cover all patients treated by a physician for a specified condition. For example, in a low-risk patient with T2DM, a protocol might specify that the pharmacist can adjust a patient’s insulin dose as long as the glycated hemoglobin (A1C) or blood glucose remains below a certain threshold, but the physician should be contacted if a threshold is exceeded. CDTM programs also may allow pharmacists to take responsibility for ordering tests and providing patient education. Individual state laws have established CDTM legislation, and the activity of pharmacists within CDTM programs is regulated at the state level. The programs are currently available in all but 3 states: Alabama, Oklahoma, and Maine. In most jurisdictions, CTDM agreements are easily established between physicians and regular retail pharmacists, or pharmacists working in a clinic setting.6,10,11 In New York, CDTM was recently assessed for pharmacists practicing in teaching hospitals only.
Medication therapy management (MTM) programs are a further evolution in pharmaceutical patient care. MTM was introduced as part of Medicare legislation in the mid-2000s as a means for pharmacists and other qualified HCPs to improve the care of selected Medicare beneficiaries with multiple chronic illnesses who require multiple medications. MTM services may help address the need to prevent medication-related morbidity and mortality in patients with T2DM and comorbid conditions. Pharmacists can provide continuity of care by following patient progress between physician visits; by utilizing their clinical expertise to monitor and manage diabetes medication plans; and by educating patients on disease, lifestyle, and adherence issues. This level of service can be provided adequately by pharmacists, pharmacist CDEs, and pharmacists with the BC-ADM credential. In addition, many local, state, and national pharmacy organizations and pharmacy schools are providing targeted training for pharmacists wishing to deliver MTM services.12-14
Overview of MTM services
The US Medicare Modernization Act of 2003 established MTM services as part of Medicare Part D—the prescription drug benefit. The Act requires Medicare insurers to provide MTM services to a defined group of beneficiaries expected to benefit from enhanced medication management. Key goals of MTM services are to counsel patients to improve understanding of their medications, to improve medication adherence, and to detect adverse drug reactions and patterns of improper drug use.15 For the first time, the Act created a mechanism for insurers to compensate pharmacists directly for providing these services. To encourage competition and innovation, the exact nature of MTM services and the criteria for patients to qualify were initially left undefined. Basic program requirements and eligibility criteria have since evolved, although the programs are far from standardized. A consortium of 11 national pharmacy organizations developed a consensus definition of MTM programs that identified pharmacists as the key service providers.16 The eligibility criteria for beneficiaries of MTM programs are described in TABLE 1.17 Benefit plans can offer MTM services to patients with any chronic disease or may limit them to selected diseases. Diabetes is the most frequently targeted disease and is covered by virtually all MTM services (FIGURE).17
Pharmacy organizations next developed a guideline that specified 5 core activities of MTM services to be provided in pharmacies (TABLE 2).18 According to this guideline (hereafter referred to as the “Core Elements of MTM”), patients who qualify for MTM services must receive an annual comprehensive medication therapy review, with additional reviews and ongoing pharmacist monitoring as necessary.17,18 Over-the-counter medications, herbal therapies, and dietary supplements should be included in the medication review. Though face-to-face interaction is preferred, and should be required, services may be provided by telephone and may be either by appointment or on a walk-in basis.18 According to the guideline, patients should be provided with a printed or written document, such as a summary of recommendations or an action plan, to take with them. Services may be provided regardless of whether the pharmacist is dispensing medications to the patient. Physician referrals are also not required for pharmacists to offer MTM services to qualifying patients.18 However, although referral by a physician/ HCP is not required for MTM provided by a pharmacist, the physician/HCP does need to be contacted for anything that requires a change in management (eg, changes to treatment). In my practice, I typically write a summary letter to the patient’s physician/HCP; this includes my assessment of the session and any recommendations. Patients are also encouraged to share their personal medication record and action plan with their HCPs. MTM enrollment requirements were revised in 2010 and now require payers to identify target beneficiaries for automatic enrollment.17