Few health plans cover MTM services because pharmacists lack Medicare provider status

If pharmacists had provider status, McGrath could provide MTM services to everyone who needs them

“Jean” wasn’t taking her cholesterol medication. Because this was affecting her health plan’s Medicare star rating, the plan asked Stephanie McGrath, PharmD, to intervene. 

The plan covered one targeted medication therapy management (MTM) session in which McGrath, who practices as a clinical pharmacist for Rite Aid, would address the barriers to Jean’s taking her statin. But when McGrath spoke to Jean, she learned that nonadherence to her statin was just one of her problems.

“The patient described an episode the day before when her blood sugar was high. She inappropriately treated with too much insulin, and then she went hypoglycemic and improperly treated that,” McGrath recalled. “As I’m talking to this patient, more and more issues are coming up, and I’m thinking a one-time targeted intervention isn’t going to cut it. This patient really needs comprehensive MTM.”

Millions of Americans could benefit from a pharmacist’s help

Jean is just one of millions of Americans who take multiple medications and could benefit from a pharmacist’s help in understanding how to use them correctly. As medication experts, pharmacists are considered among the most accessible health care providers. They can be found in every drug store, and anyone can walk up and ask them a question without an appointment.

Though misuse of medications is one of the top reasons for preventable hospitalizations, McGrath, like other pharmacists profiled in this series, can only provide MTM services to help patients understand complicated medication regimens if their health plans cover such a service or if patients are able to pay for them out of pocket. Few health plans cover MTM services because Medicare does not include pharmacists in its list of health professionals with “provider status.” 

At a time when the health care system is focused on cutting costs and reducing hospital admissions and emergency department visits while improving quality, McGrath has seen firsthand the ways in which pharmacists can contribute to these goals. When pharmacists’ services are covered for patients with diabetes, for example, McGrath can help them reach their blood sugar goals in as little as a quarter of the time it might take with a physician’s care alone.

Managing patients with diabetes

McGrath is particularly well qualified to manage patients with diabetes, as her pharmacy is a site certified to provide diabetes self-management education through the American Association of Diabetes Educators. 

“I can make recommendations to the physician, and working together, we can much more quickly titrate the patient’s insulin regimen and reach their blood sugar goals than the patient and the physician would if they only saw each other once every 3 to 6 months to a year,” McGrath said.

Providing MTM services to everyone who needs them

If pharmacists had Medicare provider status, McGrath could provide MTM services to everyone who needed them, not just the individuals that health plans authorize on a case-by-case basis. 

“I was seeing one patient and making lots of headway with his diabetes. Then all the receipts he would submit to his health insurance were denied. We finally received a response from them saying that pharmacists cannot be providers. Period,” she said.

“It was incredibly frustrating for me, for the patient, and for his physicians because we had really made some progress with his disease.”

A place at the table

McGrath emphasizes that provider status isn’t about competing with physicians or trying to replace them. It’s about having a place at the table in the patient’s care.

“When the services are covered, or the patient pays out of pocket, and we are able to work closely with the patient and physician, that patient’s care just escalates exponentially and the physicians are happier, and the patient’s happier.”