Medication therapy management: Comparison of protocols towards a gold standard

Background: Certified Geriatric Pharmacists (CGPs), among others, provide medication therapy management (MTM) reviews for older adults. MTM services can promote patient understanding, increase safety, reduce hospitalization, and reduce health care costs. In 2006 Medicare implemented requirements for MTM under Part D according to the 2003 Medicare Modernization Act. In 2004, pharmacy stakeholders developed a definition of MTM under the leadership of the American Pharmacists Association (APhA). The definition was later updated in 2008. The Centers for Medicare and Medicaid Services (CMS) issued more specific MTM parameters beginning in 2010. These emerging and even competing protocols, programs, and definitions warrant closer scrutiny and may reveal a set of best practices. Objective: to compare MTM protocols and then synthesize them in order to determine what may constitute an ideal gold standard of MTM service. Methods: We analyzed four MTM protocols qualitatively and comparatively: APhA 2004 and 2008, CMS 2010, and from a local CGP. After separating each program element and entering it into a table, we matched each item across the protocols in order to identify similarities and differences. From this table we produced a synthesized example of a gold standard protocol. Results: None of the four protocols matched exactly and potentially important differences were noted. First, the target population varied. CMS prescribed specific eligibility requirements, the APhA recognized a universal potential benefit from MTM, and the CGP responded to the mandates of various funding streams. Second, the five common MTM core service elements were: conducting a medication therapy review, generating a personal medication record, devising a medication action plan, executing an intervention and/or referral, and conducting follow-up including documentation. Third, each protocol offers unique variants of these core elements. Examples of unique features include: in-person contact and a list of actions for the patient (APhA), telephone consultation and utilization of other trained professionals (CMS), and a comprehensive 7-step follow-up consultation (CGP). Specific differences in method of patient follow-up include: mail, fax or in-person (CMS); mail and telephone (CGP); unspecified (APhA). Discussion/Conclusion: MTM programs and their protocols have evolved, presumably based upon experience in practice. Medicare policy diverges from other professional standards. Each protocol has strengths. An ideal gold-standard practice would draw from these assets. MTM services addressing health literacy challenges and the specific methods of communication prescribed may have significant consequences.