What Is MTM and How Are Data + AI Changing It?

Three days after a hospital stay for shortness of breath, 70-year-old Carlos R. fainted while walking his dog. He brushed it off, thinking it was dehydration. But during a virtual medication review with his pharmacist, they uncovered the real issue. Carlos had been taking two beta blockers, unaware that his new prescription was meant to replace the old one. The double dose had dropped his blood pressure to dangerous levels. The pharmacist alerted his doctor, who quickly adjusted the regimen.

Medication Therapy Management ensures that every medication a patient takes is safe, effective, and truly needed.

Carlos's experience isn't rare, and it exemplifies why Medication Therapy Management (MTM) exists. A comprehensive medication check-up ensures patient medications are appropriate, effective, safe, and being taken as intended.¹ Medication mismanagement, from skipped doses to dangerous drug interactions, is estimated to cost the U.S. healthcare system over $528 billion each year in avoidable medical bills and thousands of lives.² MTM was created as a remedy for this crisis, by leveraging the unique expertise of pharmacists to improve medication safety and effectiveness.

What is MTM?

Medication Therapy Management became an official part of the U.S. healthcare system in 2006, when Medicare began requiring prescription drug plans to offer these services to high-risk seniors.³ But the concept has been around longer in pharmacy circles. The National Board of Medication Therapy Management defines MTM through five essential components that guide its delivery:²

The truth about how patients take their medications often doesn’t show up in charts. MTM only works when patients feel secure enough to speak honestly, but many don’t. Sharing the truth, like pausing a mental health treatment because of side effects or rationing an inhaler to save money, is harder than it sounds.

Medication Therapy Management is designed to catch these issues that often slip through the cracks in our fragmented, fast-paced healthcare system. By taking the time to listen, pharmacists can uncover the real reasons behind non-adherence or subpar results and then help fix them, whether through counseling, finding a cheaper alternative, or looping in the prescriber for a major change.

Pharmacists, Plans, and Providers Behind MTM

Medicare & Medicaid's Role

In the United States, Medicare Part D plans are the biggest drivers of MTM. By law, every Medicare drug plan must have an MTM program and offer it at no cost to members who meet certain criteria.⁴ Traditionally, those criteria focused on patients with multiple chronic diseases, taking multiple medications, and likely to exceed a specified annual drug cost. For example, a plan might target someone with at least three chronic conditions, on eight or more medications, and likely to spend over $4,000 a year on medications. These thresholds meant only a minority of Medicare beneficiaries qualified (~7% in recent years) typically those with complex, expensive health needs.⁵

With Medicare expanding MTM eligibility in 2025, states and Medicaid programs are following suit, recognizing the value of proactive medication management across broader patient populations.

Starting in 2025, Medicare is broadening that net. A recent rule change is lowering the cost threshold to about $1,623 in annual Part D drug costs and adding conditions like HIV/AIDS to the list of chronic illnesses to be targeted.⁶ The expansion recognizes what clinicians have long known: you don’t have to be on 8+ meds for a medication check-up to be worthwhile. Even a handful of prescriptions can pose risks if not optimally managed.

Outside of Medicare, Medicaid and private insurers are increasingly exploring MTM as well. As of 2020, about 11 state Medicaid programs reimbursed pharmacists for MTM services in some form. States like Minnesota, Ohio, and North Carolina have reported success in using MTM to improve care for Medicaid patients with chronic conditions. Minnesota was one of the first states to cover MTM for Medicaid recipients, and over time, it saw an average savings of around $800 per patient per year, thanks to interventions that prevented complications. Ohio’s Medicaid MTM program notably reduced emergency room visits and hospital admissions among patients who participated.⁷ These programs show that when pharmacists are empowered to comprehensively manage medications regularly, the health system saves money in the long run.

Who provides MTM?

Pharmacists are the front-line providers of MTM in most cases. These might be community pharmacists at the local drugstore or clinical pharmacists working in call centers, clinics, or within integrated health systems.⁸ A common model is through large MTM vendor platforms, where a health plan identifies eligible patients and these vendors facilitate the reviews, often by partnering with community pharmacies. For example, a plan might alert Joe’s Pharmacy that three of their patients are eligible for MTM; the pharmacists at Joe’s Pharmacy can then enroll those patients and bill the service through the platform. In other cases, especially within health systems or Accountable Care Organizations, pharmacists on the care team will perform MTM as part of their routine work with patients. Regardless of the setting, pharmacists conducting MTM need strong communication skills, clinical knowledge across many disease states, and the ability to coordinate with physicians. MTM is an interdisciplinary effort: clinicians like doctors and nurse practitioners are critical partners, because if a pharmacist finds a serious medication-related problem, they’ll likely need to coordinate with the prescriber to resolve it.

By funding MTM programs, insurers hope to drive better outcomes and capture quality-based incentives, making follow-through just as important as offering the service.

The stakeholders in MTM include more than just pharmacists, providers, and their patients. Health plans (insurance companies) have a big interest and don’t offer MTM just to satisfy a mandate. They’re hoping that MTM will reduce costly healthcare utilization (e.g., ER visits and hospital stays) and improve quality metrics. They fund these services, either by paying their own in-house pharmacists or contracting with specialized MTM vendors. In Medicare, for instance, plans are rated on their quality, and one such quality measure has been the complete medication review (CMR) completion rate – essentially, how many eligible members actually got a comprehensive medication review. Plans that do a good job engaging patients in MTM can earn higher star ratings, which translate to financial bonuses.⁹ This creates a strong incentive for plans to not only offer MTM but ensure it provides benefit to patients. Some plans integrate MTM into broader care management programs, working closely with physicians, while others outsource to companies that have networks of pharmacists conducting medication reviews.

Who Pays for MTM?

People often ask “How do pharmacists get paid for MTM?” This has been a sticking point historically. Under Medicare’s design, pharmacists don’t bill Medicare directly for MTM services because they still aren’t recognized as independent providers under Medicare law. Instead, Medicare pays the Part D plan, and the plan pays the pharmacist (or MTM vendor) according to the contract they’ve arranged.³ Many community pharmacists provide MTM under contracts that pay a flat fee per comprehensive review (~$50-75 for a CMR) and smaller fees for follow-up or targeted interventions (~$10-20).¹⁰ In health-system settings, pharmacists might be salaried, and MTM is part of their role.

Meanwhile, some billing codes do exist for MTM (CPT codes 99605, 99606, 99607 can be used for specific scenarios).³ A few state Medicaid programs and private insurers allow pharmacists to submit those codes for payment. But because pharmacists are not universally recognized as providers, getting reimbursement can require jumping through hoops. The lack of straightforward billing has been cited as limiting the expansion of MTM outside of special programs. Advocacy groups like the American Pharmacists Association have pushed for “provider status” for pharmacists at the federal level, which would let them directly bill Medicare for services like MTM. While that hasn’t yet come to fruition nationally, incremental progress is being made at state levels and in pilot programs.¹¹

MTM can prevent harm and improve outcomes. The challenge is delivering it consistently, personally, and with smart, reliable technology.

Despite these challenges, the value of MTM is increasingly apparent to healthcare leaders. Many health systems have internalized MTM into their care processes.¹² For instance, some primary care clinics now embed a clinical pharmacist on-site who meets with patients (especially those with chronic diseases like diabetes, hypertension, or heart failure) to fine-tune their medications, a process often referred to as Comprehensive Medication Management (CMM), an advanced practice model similar to MTM. And as healthcare shifts toward value-based care, where providers are rewarded for keeping patients healthy, rather than paid per service, MTM is finding new opportunities. MTM services are increasingly built into value-based contracts to drive better outcomes. A notable example is HealthPartners in Minnesota, where pharmacists are rewarded with performance-based payments tied to both clinical outcomes and patient engagement in MTM for Medicare and Medicaid populations.⁷

The Real-World Impact of MTM

After nearly 15 years of experience with MTM in Medicare and numerous programs in other settings, we have a growing body of evidence about its impact. Broadly speaking, MTM tends to improve medication-related outcomes, but the extent can vary depending on how the program is implemented. The studies and reports have shown the following:

• Medication adherence

  Medication Therapy Management helps patients stick to their medications by uncovering and addressing the real reasons behind nonadherence. An analysis of over 9,000 patients found that 95.3% reported improvements in their health and well-being due to MTM.¹³ Health plans are now turning to MTM not just for better outcomes, but to improve their Medicare star ratings too.

• Clinical outcomes

  MTM helps patients gain better control of chronic conditions like high blood pressure and diabetes by identifying and resolving medication-related problems. In one 10-year program, pharmacists flagged over 38,000 issues, most often missing therapies or incorrect doses, and helped 55% of patients reach treatment goals.¹³ MTM also reduces unnecessary medications, lowering the risk of side effects and harmful interactions.

• Patient safety

  One of MTM’s strongest benefits is preventing medication-related harm. Pharmacists catch dangerous side effects, drug interactions, and high-risk meds before they lead to ER visits or hospitalizations. In Ohio’s Medicaid program, for example, patients who received MTM had fewer emergency visits and hospital stays, protecting both patients and healthcare budgets.⁷

• Healthcare costs and Return on Investment

  Whether MTM saves money overall is still up for debate. A major Medicare pilot didn’t show broad cost reductions, but it revealed that timing, personalization, and patient engagement are key to making MTM work.¹⁴ One review of 19 studies found that for every dollar spent on MTM, ROI ranged from $1.29 to as high as $18.50.¹⁵

• Patient satisfaction and empowerment

  Patients trust and value MTM - 95% in one program said it improved their health and well-being.¹³ They feel more confident managing their medications, knowing they have someone to turn to with questions. Providers benefit too, with fewer urgent calls, fewer medication errors, and better outcomes for high-risk patients.

Personalizing MTM with Data + AI

Medication therapy management is fast evolving with the help of data analytics, digital health tools, and artificial intelligence. The MTM of the future is more personalized, more proactive, and more seamlessly integrated into our healthcare experience:

Policies to Redefine MTM

MTM is part of a bigger shift toward smarter, more connected care. There’s growing momentum behind team-based, coordinated care, alongside a broader shift toward value-based care and the pressing need to better manage an aging population with complex health needs. These favor an expanded role for MTM. For MTM to realize its full potential, the healthcare system must tackle a few important priorities.

• Greater integration into routine care

  MTM works best when it’s part of everyday care, not just a once-a-year check-in. Medication reviews should happen during major health changes like hospital discharges or new diagnoses. While some systems are starting to build this in, making MTM a routine part of chronic care is still a work in progress.

• Sustainable payment models

  For MTM to grow, pharmacists need to be paid in ways that reflect the time and impact of their work. Medicare’s 2025 expansion will help, but sustainable models, like outcome-based payments or broader billing rights, are key. Momentum is building, with states expanding Medicaid coverage and some employers including MTM in their wellness programs.¹⁶

• Leveraging advanced technologies

  Technology is shaping the future of MTM, with tools like AI that identify high-risk patients and telehealth making services more accessible and efficient. CMS now allows annual medication reviews to happen by phone or video, and new quality measures are in the works to better reflect MTM’s real impact.⁶ Effectively analyzing the data we already collect and tracking outcomes like adherence gains or resolved medication issues could spark greater investment and smarter innovation in MTM .

• Addressing patient engagement

  Getting patients to engage with MTM is half the battle. Even the best program won’t work if people ignore the outreach. Reframing it as a “medication check-up” and focusing on what matters to patients, like saving money or avoiding side effects, can make them more likely to say yes and participate.

• Expanding scope and reaching more settings

  MTM isn’t just for outpatient care. It has the potential to improve safety in hospitals, long-term care, and even hospice. Pharmacists can catch high-risk medication interactions, like opioids and sedatives, before they cause harm. With CMS expanding MTM requirements in 2025, there’s growing momentum to bring these services into more settings where they’re urgently needed.

Inside an MTM Visit

Tasha, a 41-year-old single mom with lupus and depression, managed her health between childcare, two jobs, and weekly pharmacy runs. She took seven daily medications - including immunosuppressants, a mood stabilizer, and antihypertensives - but still felt drained and foggy most days.

When her state Medicaid program launched a pharmacist-led Medication Therapy Management pilot for high-risk patients, her name came up. She was skeptical, but agreed to a 30-minute phone call with the pharmacist.

During the review, it became clear Tasha had been spacing her morning medications out over the day because she thought “too many at once” might be harmful. This unintentionally reduced the effectiveness of her lupus medication. She also hadn’t been taking her antidepressant consistently because it caused nausea and didn’t realize a simple change in timing and food intake could reduce that side effect. The pharmacist walked her through each prescription, helped set up a new routine, and got approval for a once-daily alternative that fit her life better. They also discovered she qualified for a patient assistance program to reduce her out-of-pocket costs. A few weeks later, Tasha noticed a big shift: fewer flares, steadier mood, and less confusion.

As healthcare evolves, patients will have steady support managing their medications, guided by smart technology and trusted care teams.

Progress in MTM can be gradual, especially in more complex cases. Some reveal bigger challenges, like patients who simply cannot afford their medications. In those instances, pharmacists might work to find generic alternatives or get the patient connected with financial assistance programs. Other times, the pharmacist might discover a serious issue that requires urgent action. One example is a patient on two blood thinners that should never be combined. In that case, the pharmacist would contact the prescriber right away to correct the regimen. MTM serves as a safety net, catching errors and omissions before they cause harm.

MTM of the Future

MTM is a lasting part of care, though its future form may look very different. If we were to step into 2030, we might see an environment where every primary care office has a pharmacist on the team, every complex patient gets a medication review as routinely as a lab test, and sophisticated AI quietly ensures no important detail is overlooked in those reviews. Patients might interact with their “digital pharmacist” between visits, but the heart of MTM will remain the human connection.

Through data and AI , we will amplify the reach and precision of MTM, turning what was once a periodic check-in into a dynamic, ongoing layer of care. By combining algorithms with integrated patient data , we can more accurately identify patients who need immediate support, personalize care recommendations, and automate routine tasks, freeing up time for what matters most. As these technologies evolve, MTM will move from behind-the-scenes support to a critical part of everyday care, focused on making medications safer, more useful, and more effective. Soon, that won’t be the exception. It’ll be the standard.