Tuesday, March 30, 2010

Pharmacy's MTM Challenge

President Obama signed the Patient Protection and Affordable Care Act into law on Tuesday. Section 3503 (page 1055 of the full text pdf) describes new programs for Medication Therapy Management (MTM) services provided by licensed pharmacists. I’m a fan of the MTM concept because it should improve health care outcomes and reduce costs.

But many pharmacies will have to rethink their businesses to allow store-based pharmacists to take full advantage of MTM opportunities. The latest National Pharmacist Workforce Survey (NPWS) shows pharmacists perceive themselves as overworked and not able to spend enough time on patient care services.

MTM money will presumably provide the financial incentives to fix this misalignment, but money won’t be enough. The pharmacy industry will have to rethink its business model while simultaneously navigating an increasingly competitive environment focused on low-cost prescription fulfillment, pharmacy automation, and call-center counseling from mail-order pharmacies. 

The big 3 Pharmacy Benefit Managers (PBMs) with mail pharmacies have already figured this out. Manufacturers should be thinking about how to support pharmacy-based MTM services that will benefit adherence and compliance.


Almost 7 out of 10 pharmacists (across all practice settings) rate their workload level as "high" or "excessively high." Pay attention to the big jump versus 2004.The chart below is based on responses from 905 pharmacists and appears on page 41 of the 2009 NPWS. (Click to enlarge.)

The average brick-and-mortar pharmacy has also gotten much busier. The average chain pharmacy filled about 81 thousand prescriptions per year in 2008, up sharply from roughly 59 thousand per year filled in 1998. The average independent pharmacy also filled more prescriptions in 2008 versus 1998.


The Workforce survey also asked pharmacists about what they actually do each day and what they want to be doing each day. Here are the two major categories used in the survey:

  • Medication Dispensing: preparing, distributing, and administering medication products, including associated consultation, interacting with patients about selection and use of over-the-counter products, and interactions with other professionals during the medication dispensing process.
  • Patient Care Services: assessing and evaluating patient medication-related needs, monitoring and adjusting patients’ treatments to attain desired outcome, and other services designed for patient care management.
As you can see below, retail pharmacists want to be more involved in patient care services compared to their current workload (-12 point gap), but medication dispensing crowds out those activities.
Two notes:
  • The original data appear on pages 50 and 52 of the NPWS. Since the results did not differ significantly across pharmacy formats, I computed a weighted retail average from the Independent, Chain, Mass Merchant, and Supermarket responses.
  • The survey’s definition of Medication Dispensing contains some elements of “Medication Therapy Management.” The Other category (not broken out in my chart) showed pharmacists wanting to do less business management and more research or education.

When thinking about MTM in light of the data above, I'm reminded of something I learned in grad school.

In theory, theory and practice are the same thing.

In practice, they’re different.



Readers who enjoy a repast featuring unleavened bread may also enjoy The 2010 Facebook Haggadah.

Personally, I liked the the 5769 version better. Feh, everyone's a critic these days!


  1. Ripples in a pond. Congress casts a stone and the ripples multiply.

    Loved the Facebook link! I wish you a joyous Passover!


  2. One big reason many specialty pharmacies have thrived is because they have found the balance between dispensing and patient care. As long as we have a system where we have created pharmacy as a commodity with free and $4 scripts (one example) pharmacy will continue to viewed as a production operation where the "big boxes" are grabbing share from eachother hoping to sell more private label and higher margin non-rx products. The public's and government's perception of pharmacy today will be squewed by what they see in circulars and painted on window banners. They will not see what happens behind the counter and from counseling booths and other innovative pharmacy practice settings. If we step back and look at the past and present of specialty pharmacy, those pioneers made some strides and so far by in large have not made their services a commodity. They are getting paid Fair Market Value for those services. The challenge there however is most of the revenue is derived from pharma in managing complex therapies. But the discipline is there also.
    Retail pharmacy will continue to be dominated by the lick, stick and pour that we call a profession until ALL player step up and act like a profession. Let's quit confusing pharmacy with consumer products. We put services on "sale"..... pharmacist must provide a standard of care beyond just pills in a bottle. When we can as a total profession act as professionals we stand a chance at getting paid for those services. Until then perception is reality and our adminstration can sign all the bills they want.

  3. David Schwed RPhMarch 30, 2010

    Bravo Adam: A post with which I can fully agree. As a moving forces within pharmacy who actively advocated for, and participated in the consensus process and first practice model panels, I have long recognized the need to differentiate and formalize patient care services by pharmacists (whether referred to as MTM or Pharmaceutical Care or the more intensive Disease Management). The most significant barrier is not practice management, although practice design, management and provider training are significant steps). It is the margin squeeze which prevents management from scheduling time for low revenue patient care activities by pharmacists. MTM revenue itself cannot yet support nor sustain ambulatory pharmacy practice models with significant overhead expense. Without about a decade or more for additional development, implementation and Social Security Act recognition of pharmacists as providers, the goal becomes attainable only where owner motivation is high despite those daunting barriers. So Adam, when you're a cheerleader for reimbursement models that erode pharmacy margins, remember that the "savings" realized is not without consequence.

  4. Adam,

    Great article. I live the experience everday in providing the ability for pharmacies to be able to successfully implement MTM C & P workflow solutions to our member chain pharmacies such that they can touch their patients effectively via pharma sponsored MTM C & P and related awareness programs. The pharmacy model is changing to where MTM and its attributes are being deployed successfully. The tide is turning and word of mouth on how to accomplish is spreading.

  5. Agreed -

    It is a mindset change for the entire industry. We must all look at the total 'enterprise' cost of healthcare. I was involved in it in other industries and it is a slow but meaningful process. The consumer must not automatically look for the sale sticker and look to his pharmacist, the pharmacist must not look to maximize profit on each individual script and the PBM's and wholesalers must not always push more as better, but look to the pharmacist and doctors for their knowledge.

    To this end the possibility of ris based pricing where all parties take the risk in the overall health costs of a member can be explored. It's a difficultissue to broach, and I certainly don't have the answers, but it has worked in other industries. It will take a partnership approach for sure.

  6. Dr. Fein,

    Are you familiar with Walgreen's Power program? Here is an article from Drug Topics:

    Do you think that Walgreen's will be able to do more MTM because they are using central fill with their stores? Will other chains start copying this model?

    Thank you.

  7. Re: Walgreen's POWER program

    Yes. POWER combines the central-fill efficiencies of mail-order pharmacies with in-person consultation from pharmacists in a retail setting and expanded use of call centers. In theory, a store-based pharmacist has more time to provide other services--flu vaccines, MTM, whatever.

    See Walgreen's Future Profit Potential from last October for more on what this program means.

    As far as I know, POWER is only operational in Florida and Arizona.


  8. I attended the Delivering MTM in the Community Pharmacy session at APhA 2010 in March. Personally, I believe that MTM services are the only way to get pharmacy back to being a profession and not a commodity.

    But there's is a huge problem. For years, pharmacists have given away their professional knowledge. We have fallen into the "good customer service" trap. The people who come to our pharmacies are not customers, they are patients. The chains have retrained pharmacists to view these people as customers.

    As long as the chains continue to dominate the marketplace, MTMs will not become a reality in a retail setting. The chains don't want to add the extra labor hours necessary to be able to adequately handle the MTM caseloads. Where I work, we barely have enough pharmacist hours to give 45 second counseling tips to our patients. I honestly don't see the chains rethinking their business model to incorporate MTM services.

    And to be honest, I don't want to see the chains pursue the MTM arena. If they do, the payment goes to the chain. The individual pharmacists should be compensated for their knowledge. I am attempting to start an MTM consulting business as a second revenue stream for my family. It's hard, but the patients I see will go away knowing that they received personal MTM counseling. In a chain setting, I can see the sessions lasting 20 minutes with the pharmacist basically going down a check-off sheet, with the corresponding price wars over the MTM sessions.

    But back to APhA 2010. At the meeting, the only pharmacists that I met who are delivering MTM services are either in academia or managed care. There were several community pharmacists there who want to implement MTM into their business, but none that I met who have done so successfully. I am patiently waiting to see an article about a pharmacy/pharmacist who has an MTM program that is self-sustaining.

  9. Fantastic article. Glad that I didn't lose faith in you!

  10. Adam, nice writeup....but there is something you really need to know about MTM. A little bit of detail before you get into how MTM co's truly operate.

    1. It's a great concept. MTM is a mechanism for pharmacists to educate their patients on the importance of compliance, potential drug/food interactions, and informing them of therapeutic alternatives....those products that work in a similar fashion, but for much less money.

    2. MTM services are normally paid to the pharmacy by the payer source, often Medicare, an insurance company, or a self funded group.

    3. The MTM services are normally paid through an intermediary. Currently, to the best of my knowledge, there are three groups offering a formal MTM program in USA. Pharmacies must contract with these MTM co's to participate and obtain the MTM claims.

    4. A pharmacist worth his oats would offer MTM to his patient base in prior years, simply to keep his clientele strong...with the belief that the patient education was worth the increased loyalty.

    5. As the PBM's force transparency upon the pharmacies with lower reimbursements on generics, pharmacies no longer have an incentive to therapeutically sub patients to cheaper products...due to lower margins. Thus MTM solves that low margin problem in an open and honest fashion.

    6. Somewhat like the PBM business, self funded groups, Medicare, and others, will only pay the MTM processing company so much per life (PMPM) for a service.

    7. Thus, if too many MTM cases are pushed down to the pharmacies from the MTM processor, then no margin is left for the MTM co. If not enough cases are pushed down, then the client/payer is not satisified, but increased dollars are kept in house with the MTM co.

    Isn't it a little strange that someone has to tell the pharmacist to perform the MTM....to do their actual job before we actually do it?

    Bottom line, it's all about the slow and gradual evolvement of our pharmacy reimbursement system. The product is slowly being pulled away from the educational services that are offered by the pharmacy/ist. Ultimately, there indeed will be a program in where the RP handles the MTM with out a push or lead from a processing co.

    Adam, a great chag to you and your family!

  11. As a someone that is a part of administering MTM programs in a retail pharmacy setting, I can tell you that one of the challenges is ROI. The DM space ran into this buzz-saw several years ago. If the feds are willing to pay payers for this benefit regardless of ROI, that's great for those getting paid. However, if the payers must shoulder the burden, they are going to be picky about the types of cases they direct to MTM. Payers love easy money, such as switching patients to generics. However. more complex MTM that involves coordination between pharmacist and physician can quickly get expensive. Ultimately payers need to see that real medical costs are reduced through improved outcomes.

  12. A step in the right direction,albeit a baby step. For the MTM to be effective, it needs to be produced by THE PHARMACIST....not pharmacies, not the PBM, not the insurer. We still have not corrected the initial problem(s) created in 2003 and put in place in 2006, when MTM was made law. That is, MTM should have been implemented and a component of the qualified pharmacist...as recommended by MEDPAC (2000, 2002); The CMS allowed Big PhRMa and the insurers to capture it and guess what, get paid PMPM up front, then dribble something down not to pharmacists but rather to pharmacies, i.e., credenitaling them. Does anyone else see the backwardness and politics here??
    Second, the current legislation has only set aside funding for MTM as a GRANT program, so it's not across the board to pharmacies. Hello...one has to apply for the funding...
    Third and most important, all of this would be moot if pharmacists were recognized by the CMS as health care providers...

  13. AnonymousJuly 10, 2010

    I have been doing MTM for about a year at a chain pharmacy. I do MTM on my days off as I have to travel to meet the patients and cover a rather large area. We all do mini MTM in our jobs, but a full sitdown takes time.
    I love working with the patients and they fully enjoy our time together. MTM saves money, but better outcomes for my patients is always the goal. Once you start doing MTM, you find how our current health care system lets patients down.. poly-pharmacy, expired drugs, wrong doses etc.
    What we all need to work on now is getting better pay for these services and outcomes are the key.