MTM, CMR, TIP?
Deciphering the alphabet soup and
providing patient care through Medication
Therapy Management
Kim Swanson Ward, PharmD, BCACP
King Soopers Patient Care Coordinator
Colorado Pharmacists Society
2016 Winter CE and Ski Seminar
January 9th - 13th
Conflict of Interest Disclosure
I have no conflicts of interest to disclose.
Objectives
 Describe the history of Medication Therapy Management services
 Describe the implication of quality health system ratings on
Medication Therapy Management
 Review Medication Therapy Management services and requirements
 Identify successful Medication Therapy Management practice settings
 Navigate Medication Therapy Management platforms
 Evaluate how to complete Medication Therapy Management
interventions to improve patient care and health outcomes
So, what is ‘MTM’?
 MTM = Medication Therapy Management
 “MTM is a patient-centric and comprehensive
approach to improve medication use, reduce the
risk of adverse events, and improve medication
adherence. Therefore, the programs include
high-touch interventions to engage the
beneficiary and their prescribers.” Center for
Medicare, CMS 4/7/15
Contract Year 2016 MTM Program Submisstion (v. 4.7.15); CMS.gov
History of MTM
 Began in the 1990s
– Little consistency and lack of reimbursement
 Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA 2003)
– Formalized MTM services as a Part D benefit
 Implementation of Medicare Part D, 2006
– Required plans to offer MTM to qualified enrollees
 Patients with high drug spending, multiple comorbidities, and multiple
medications
 CMS Standardized CMR Format, 2013
http://www.ncbi.nlm.nih.gov/pubmed/19125547
STAR Rating
 Quality and performance rating system for Medicare Part C & D
 Provision of the Affordable Care Act of 2010
 Available before fall annual enrollment period to help beneficiaries
choose a plan that meets their needs
★ means poor performance
★ ★ means below average performance
★ ★ ★ means average performance
★ ★ ★★ means above average performance
★ ★ ★★★ means excellent performance
STAR Rating: Part D Measure Examples
 Plan Members 65 and Older Who Received Prescriptions
for Certain Drugs with a High Risk of Side Effects, When
There May Be Safer Drug Choices
 Taking Diabetes Medication as Directed
 Taking Blood Pressure Medication as Directed
 Taking Cholesterol Medication as Directed
 Members Who Had a Pharmacist (or Other Health
Professional) Help them Understand and Manage Their
Medications
https://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/Downloads/2016-Technical-Notes-Preview-1-v2015_08_05.pdf
MTM Services & Requirements
 CMR = Comprehensive Medication Review
– “A CMR is an interactive, person-to-person or telehealth
medication review and consultation of a beneficiary’s medications
(including prescriptions, over-the-counter (OTC) medications,
herbal therapies, and dietary supplements) by a pharmacist or
qualified provider that is intended to aid in assessing medication
therapy and optimizing patient outcomes.”
– Requirements:
 Patient Takeaway Materials: Cover Letter, Medication Action
Plan (MAP), Personalized Medication List (PML)
– Must be set out to patient within 14 days.
– Standardized paper size, orientation, font, header/footer, etc
https://www.cms.gov/medicare/prescription-drugcoverage/prescriptiondrugcovcontra/downloads/mtm-program-standardized-format-english-andspanish-instructions-samples-v032712.pdf
MTM Services & Requirements
 TIP® = Targeted Intervention Program, OutcomesMTM
– Pre-identified potential drug therapy problems.
 Care Gap Alert, MirixaPro
– Pre-identified potential non-adherence and omissions in care
problems.
 Requirements:
– Program/Platform specific
– No Medicare requirements
Program Policy and Procedure Guide; OutcomesMTM.com
Mirixa FAQ; Mirixa.com
OutcomesMTM TIPs & MirixaPro Care Gap Alerts
PLATFORM NAVIGATION
OutcomesMTM
OutcomesMTM.com
OutcomesMTM
OutcomesMTM.com
OutcomesMTM – Adherence TIP
OutcomesMTM.com
OutcomesMTM – Adherence TIP
OutcomesMTM.com
OutcomesMTM – Adherence TIP
OutcomesMTM.com
OutcomesMTM – Adherence TIP
OutcomesMTM.com
OutcomesMTM – Adherence TIP
OutcomesMTM.com
OutcomesMTM – Adherence TIP
OutcomesMTM.com
OutcomesMTM – Adherence TIP
OutcomesMTM.com
OutcomesMTM – Adherence TIP
OutcomesMTM.com
MirixaPro
Mirixa.com
MirixaPro
Mirixa.com
MirixaPro – Adherence Care Gap Alert
Mirixa.com
MirixaPro – Adherence Care Gap Alert
Mirixa.com
MirixaPro – Adherence Care Gap Alert
Mirixa.com
MirixaPro – Adherence Care Gap Alert
Mirixa.com
MirixaPro – Adherence Care Gap Alert
Mirixa.com
Adherence Counseling….What do I say?
 Introduce yourself and explain reason for call
 Discuss medication indication and benefits of maintained
adherence
 Explore patient barriers (adverse reactions, cost, too many
medications, etc)
 Agree upon solutions (pill box, adherence aids, automatic
refills, medication synchronization, etc)
 Listen, ask open ended questions, and motivate!
ADHERENCE COUNSELING CASES
Adherence Counseling Practice!
 Take turns playing the roll of pharmacist and patient and counsel on
adherence to the maintenance medication. See cases below:
 Case 1:
– Patient A: 55 year old patient with hyperlipidemia and a history of MI 5 years
ago who was prescribed atorvastatin 40 mg qhs x5 years. At the local
pharmacy to pick up your refill. (see medication history below.)
– Pharmacist A: Review the patient’s medication profile and counsel on
adherence to statin therapy when the patient is picking up their refill.
Medication
Day Supply
Fill Date
atorvastatin 40 mg
30
2/15/2015
atorvastatin 40 mg
90
4/25/2015
atorvastatin 40 mg
30
11/5/2015
atorvastatin 40 mg
90
12/3/2015
Adherence Counseling Practice!
 Case 2:
– Patient B: 60 year old patient with type-2 Diabetes diagnosed in January 2015
and prescribed metformin. At the local pharmacy to pick up your refill. (see
medication history below.)
– Pharmacist B: Review the patient’s medication profile and counsel on
adherence to diabetes therapy when the patient is picking up their refill.
Medication
Day Supply
Fill Date
metformin 500 mg QD
30
1/12/2015
metformin 1,000 mg BID
30
2/11/2015
metformin 1,000 mg BID
30
3/11/2015
metformin ER 2000 mg QD
90
4/10/2015
metformin ER 2000 mg QD
90
8/25/2015
metformin 500 mg QD
30
11/1/2015
metformin 500 mg QD
30
11/29/2015
OutcomesMTM TIPs
 Common TIPs in OutcomesMTM:
– Adherence – Need Check-in
– Adherence – Need Check-in + 90 Day Fill
– Adherence – Needs Monitoring
– Adherence – Underuse of Medication
– Cost Effective Alternative
– Suboptimal Drug – High Risk Medication
Program Policy and Procedure Guide; OutcomesMTM.com
MirixaPro Care Gap Alerts
 Common Care Gap Alerts in MirixaPro:
– Adherence Alert
– Omission in Care Alert
– High Risk Medication Alert
Mirixa FAQ; Mirixa.com
OutcomesMTM Resources
OutcomesMTM.com
MirixaPro Resources
Mirixa.com
MirixaPro Resources
Mirixa.com
COMPREHENSIVE MEDICATION
REVIEW (CMR)
What is a CMR?
 A CMR is a “Comprehensive Medication Review”
 Required components:
– Cover Letter
– PMR/PML – “Personal Medication Record/List”
 A professional, clearly typed, list of all the patient’s medications
 Strength, directions and indications listed
– MAP – “Medication Action Plan”
 List of medication problems
 Interactions, needed vaccines, adherence, side effects, etc.
 Must include solutions to problems
https://www.cms.gov/medicare/prescription-drugcoverage/prescriptiondrugcovcontra/downloads/mtm-program-standardized-format-english-andspanish-instructions-samples-v032712.pdf
I have a patient eligible for a CMR….now what?
 Contact patient to inform them of CMR
– Platform requirements will dictate if the CMR must be face-to-face or over the
phone.
 Staffing considerations
– Will need dedicated time for pharmacist to speak with patient.
 Time
– Goal: 15-20 minutes with patient, 60 minutes total time.
 Review takeaways
– Medication list to share with all prescribers (including prescription, OTC, and
supplements)
– Time to ask questions about medications and immunizations.
How to perform a CMR
 Prepare for a CMR
– Print materials (medication list, TIPs or Alerts)
– Review medication list (look for obvious issues:
duplications, interactions, review medications
you are unfamiliar with)
 Interview Patient
 Document CMR and create/send PML/MAP
OutcomesMTM & MirixaPro CMR
PLATFORM NAVIGATION
OutcomesMTM CMR
OutcomesMTM.com
OutcomesMTM CMR
OutcomesMTM.com
OutcomesMTM CMR
OutcomesMTM.com
OutcomesMTM CMR
OutcomesMTM.com
MirixaPro CMR
Mirixa.com
Patient Medication List (PML) &
Medication Action Plan (MAP)
OutcomesMTM.com
Patient Medication List (PML) &
Medication Action Plan (MAP)
OutcomesMTM.com
Patient Medication List (PML) &
Medication Action Plan (MAP)
OutcomesMTM.com
CMR Step-by-Step
 Introduction
 Update patient’s contact info
 Review medication list
 Update medical conditions & allergies
 Review TIPs/Alerts
 Ask patient about any problems or questions they may have
 Evaluate immunization status
 Ask about lifestyle factors
 Review next steps
EXAMPLE MTM COMMUNITY
PHARMACY PRACTICE SETTINGS
Implementation of targeted medication adherence
interventions within a community chain pharmacy practice:
The Pennsylvania Project
 Objective: understand how individual community pharmacists are
implementing targeting adherence interventions at the point of
dispensing.
1.
Identify facilitators and barriers to implementing targeted medication
adherence interventions in community chain pharmacies and
2.
Describe adaptations of the intervention and organizational structure within
each individual pharmacy practice.
 Methods:
– Qualitative research design to study how evidence-based interventions are
executed in real-world setting.
– Classified individual pharmacist characteristics can be classified according to
level of innovativeness. Early adopters vs Traditionalists.
J Am Pharm Assoc (2003) 2014;54:584-593. doi:10.1331/JAPhA.2014.14034
Implementation of targeted medication adherence
interventions within a community chain pharmacy practice:
The Pennsylvania Project
 Results:
– 39 Early Adopters and 7 Traditionalists met inclusion criteria
– Pharmacist Feedback:
 Theme 1: Need to understand the relationship of the patient care programs to the
corporate visoin
 Theme 2: Continual support and mentoring needed
 Theme 3: Anticipated barriers
 Theme 4: Active patient engagement is a key facilitator
 Theme 5: Establish best practices
J Am Pharm Assoc (2003) 2014;54:584-593. doi:10.1331/JAPhA.2014.14034
King Soopers/City Market
 Division of Kroger with 145 grocery based pharmacies serving
Denver metro and rural Colorado communities
 MTM pilot stores beginning in mid-2000s
 All pharmacy implementation began in March 2014
 Onsite training followed by 4 hour, live training course for 500+
pharmacists
 Follow-up coaching and program management
King Soopers/City Market
 Program implementation
– Every pharmacy responsible for 100% TIP completion and meeting sales goal
– 1-4 hours per week allocated to earned pharmacy hours for staffing purposes
– Pharmacists complete TIPs and CMRs during pharmacist overlap hours via
phone and in-person consultation
– Clinical management oversee results and carryout follow-up mentoring
– Phase 2 training to include pharmacy interns and technicians
 Quantitative Results:
– 2014: 8163 TIPs (avg. 56 per pharmacy); 1390 CMRs (avg 9 per pharmacy)
– 2015:
MTM Impacts on Patient Care
 Improved adherence
 Improved knowledge of medication and health
awareness
 Decreased adverse drug reactions
 Improve Star Rating and other quality measures
 Improved patient satisfaction and pharmacy loyalty
Objectives
 Describe the history of Medication Therapy Management services
 Describe the implication of quality health system ratings on
Medication Therapy Management
 Review Medication Therapy Management services and requirements
 Identify successful Medication Therapy Management practice settings
 Navigate Medication Therapy Management platforms
 Gain an understanding of how to complete Medication Therapy
Management interventions to improve patient care and health
outcomes
Questions