Abstract

OBJECTIVE:

To identify and examine medication therapy management (MTM) practice and compensation models currently being used by public and private sector programs, develop a model for payers to consider in compensating pharmacists for the provision of MTM services, and review how a relative value-based payment system based upon Current Procedural Terminology (CPT) codes might apply to MTM services.

DATA SOURCES:

Peer-reviewed literature; study of existing MTM practice and compensation models; interviews with pharmacists, pharmacy benefit providers, health plans, and policy makers; structured discussions with industry experts.

SUMMARY:

Implementation of MTM represents an opportunity for pharmacists to provide public and private payers with examples of service packages and business models that improve patient therapeutic outcomes. MTM services can lead to overall cost reductions and improved health outcomes. Recommendations for pharmacists, health plans, and Medicare Part D prescription drug plan sponsors are provided. Pharmacists should standardize and package MTM services at varying levels of intensity; determine work values for MTM CPT codes, use standards for billing and service delivery, build supply capacity to meet demand for MTM services, and cultivate patient and provider support for pharmacist-provided MTM services. Plans and sponsors should develop mechanisms for measuring MTM impact on overall health care costs and develop payment systems to cover costs as well as sustain and provide for growth in the number of providers.

CONCLUSION:

The essential components of MTM business and payment models, as outlined in this article, can be effectively mapped to relative value-based CPT codes for pharmacist-provided MTM services. Pharmacy providers, after considering various factors and conditions in their own environment, can develop an optimal MTM service package and business model based on this information.