Medication therapy management, comprehensive medication management, MTM, patient-centered comprehensive care…the list of terms could go on and on. These terms all represent the attempt to describe services provided (hopefully by pharmacists) for individual patients in an effort to optimize therapy outcomes. Many pharmacists today are using these terms and practicing in such a way as to meet the primary aim of what these terms describe. However, many within the pharmacy profession (myself included, until I began researching the topic in some depth) continue to have a vague understanding of what these terms mean, how they are applied, what is actually done and what we as pharmacists should be doing to provide these types of services. In this issue of the Mental Health Clinician, we provide some clarification, guidance, and examples. We highlight questions that have been answered, questions that continue to be asked, and next steps for psychiatric pharmacists who want to become involved with MTM.

Medication Therapy Management (MTM) services are built on the philosophy and process of pharmaceutical care that was established and implemented in pharmacy practice in the early 1990's. The concept and definition of MTM has evolved over the years. The term Medication Therapy Management became most widely used when the Centers for Medicare & Medicaid Services (CMS) adopted it in January 2003 legislation to refer to the new, additional service required for certain patients receiving Medicare Part D benefits.¹ The pharmacy profession officially defined MTM for itself in a consensus statement based on the input and approval of 11 different pharmacy organizations in 2004.² This definition was then revised in 2008 (MTM 2.0)³ to “focus on MTM in settings where patients can be actively involved in managing their medications. MTM services, as described in this model, are distinct from medication dispensing and focus on a patient-centered, rather than an individual product-centered, process of care. MTM services encompass the assessment and evaluation of the patient's complete medication therapy regimen, rather than focusing on an individual medication product. This model framework describes core elements of MTM service delivery in pharmacy practice and does not represent a specific minimum or maximum level of all services that could be delivered by pharmacists.”^3p.3

The MTM service model in pharmacy practice includes the following five core elements:³

The reader is encouraged to consult the full initiative and to further explore each of these core elements. The article in this issue by Scarpa, et al. serves as a case-based example of how these core elements can be applied to the care of a patient in practice.

There is a significant need for MTM services in the US healthcare system today. According to the American Pharmacists Association's home page for MTM-related resources and the Institute of Medicine, MTM services are needed because “Medication-related problems and medication mismanagement are a massive public health problem in the United States. Experts estimate that 1.5 million preventable adverse events occur each year that result in $177 billion in injury and death.”^4–6 A substantial body of evidence indicates that MTM services, regardless of medical area or specialty, improve outcomes for patients, result in a positive return on investment, are accepted by patients and physicians, and ought to be expanded to all patients who can benefit from this type of service. Psychiatric and neurologic pharmacists are improving therapy outcomes for patients by delivering MTM services and/or providing comprehensive care as part of multi-disciplinary teams. Gable and Stunson⁷ report on an assessment of pharmacists working on an Assertive Community Treatment team, in which a total of 341 interventions for 29 mentally ill clients were completed by the pharmacist over a 6 month period. Fike⁸ focuses her MTM provision on improving the lives of those with metabolic syndrome induced by antipsychotics. This issue highlights several other examples and innovative practices in which psychiatric or neurologic pharmacists are putting their MTM skills to good use.

Payment approaches for MTM services have evolved and expanded as the services themselves have expanded and been more fully recognized.⁹ In its 2010 resource guide, the Patient-Centered Primary Care Collaborative Medication Management Task Force nicely summarized the current payment climate for medication management services provided by pharmacists serving as a member of a multi-disciplinary healthcare team. “The [American Medical Association] Current Procedural Terminology Editorial Panel has approved three CPT codes for use when pharmacists provide face-to-face medication therapy management services to patients. The codes may be used to document service delivery and bill any health plan that provides a medication therapy management benefit, including those covered under Medicare Part D. The time-based codes are designated for use for medication therapy management services performed face-to-face for a patient.”^10p.16 This resource guide also contains a helpful appendix with a description of the billing codes issued for MTM provided by pharmacists in these settings. In addition, some CPNP members report success even when asking patients to pay out of pocket for MTM services by a pharmacist, indicating that patients recognize the value and potential cost savings to them. Other successful MTM practices have been supported through grant funds, appropriated funds from state government-sponsored programs, and even state lawsuit settlement funds. However, pharmacist reimbursement for MTM services and acceptance by lawmakers continues to be a challenge. Pharmacists conducting MTM services are encouraged to bill for those services in order to develop a critical mass so that payers and lawmakers alike recognize pharmacists as valuable (and payable) members of the healthcare team.

Medication management consultant and expert, Dr. Linda M. Strand, PharmD, Ph.D, D.Sc.(Hon), speaking during her keynote address at the 2011 CPNP Annual Meeting this spring, delivered a call to action for pharmacists to break away from what has already been done in providing medication management services in our healthcare system. Dr. Strand stated, "We [as pharmacists] are at a critical point where we might gain everything or we might lose everything. We have a lot of work to do.” At this juncture, it is of utmost importance for the pharmacy profession to embrace the principles of the medical home model and operationalize these principles to provide comprehensive medication management services to our patients. The medical home, also known as the Primary Care Medical Home (PCMH) “strives to provide care to patients that is structured, delivered, and coordinated around the specific needs of each patient.” Strand stated that critical to the success of this practice structure is the complete and comprehensive evaluation of a medication regimen, especially in the case of patients with complicated medication regimens or those not yet at goal. In this model, the pharmacist's expertise is suited to providing thorough medication evaluations, assessing each medication for appropriateness, efficacy, safety, and adherence ability. In order for this process to add value to the care of the patient, it must include an individualized care plan that achieves the intended goals of therapy with appropriate follow-up to determine actual patient outcomes. Dr Strand boldly declared “There are no barriers [for pharmacists to deliver and get paid for medication-management services]—there is only the work you have to do get a practice started successfully.”