Enhanced MTM: Aligning and Incentivizing to Improve Outcomes

In November 2014, the Agency for Healthcare Research and Quality (AHRQ) delivered what can be described as a polite rebuke of medication therapy management (MTM) services, which attempt to optimize drug therapy through improved medication use. The Centers for Medicare and Medicaid Services (CMS) requires Medicare Part D plans to offer such programs to eligible beneficiaries. 

The AHRQ-funded meta-analysis of 44 studies, by Meera Viswanathan, PhD, and colleagues, evaluated how well MTM interventions worked in outpatients with chronic illnesses. Researchers concluded that the evidence was “insufficient for most outcomes,” and found that “[MTM] interventions may reduce the frequency of some medication-related problems, including nonadherence, and lower some health care use and costs, but the evidence is insufficient with respect to improvement in health outcomes,” according to the study in
JAMA Internal Medicine.  

AHRQ followed up with its take on the state of MTM, as well as implications for stakeholders. It concluded that: 

•  MTM is here to stay, a widespread practice shaped by Medicare Part D

•  Medicare Part D MTM programs are centrally administered, offered mainly via the phone, and thus not as well integrated into routine care

•  Integration can occur through participation in accountable care organizations or patient-centered medical homes

•  Stakeholders need to better understand and work on the MTM components that are difference-making

•  In order to create MTM interventions that actually and measurably improve care, patients and providers need to be engaged in MTM interventions for a reasonable amount of time. 

CMS Enhanced MTM Pilot Program

Nearly 3 years later, how are things going? Two quality care experts weighed in at the recent AMCP Managed Care & Specialty Pharmacy annual meeting. We also asked two First Report Managed Care Editorial Advisory Board members with MTM experience for their take.

The reason MTM programs are needed is no secret, noted the two AMCP presenters—Jessica Frank, PharmD, vice president of quality at OutcomesMTM in West Des Moines, Iowa and Michael Taday, PharmD, director of pharmacy professional practice and clinical operations at Humana. They cited a study from Health Affairs showing that the number of 55 to 64 year-olds taking more than five medications is on the rise; by 2020 nearly 160 million Americans will likely be living with at least one chronic disease; and—most telling—half of patients leave medical appointments without adequately understanding what was discussed.

It adds up to poor outcomes and increased costs, noted Drs Frank and Taday. By 2023, chronic illnesses are expected to cost the US health system an estimated $4.2 trillion, according to estimates from the CDC. 

In the current MTM program set-up by CMS, prescription drug plans (PDPs) are responsible for only prescription drug costs, not medical costs, which means that the intended rewards of MTM, avoidance of medical costs, are not realized by the PDPs. This makes it difficult to incentivize and improve care through MTM. 

Additionally, with AHRQ concluding that more evidence is needed to determine whether MTM programs adequately impact outcomes, and medication and chronic disease costs only soaring higher, what’s the answer? CMS is hoping that enhanced MTM (eMTM), a test model that allows regulatory flexibility, will offer greater impact on outcomes, according to Drs Frank and Taday. They explained the differences between eMTM and MTM, how it addresses the value of medications in chronic disease management, and how it can improve patients’ quality of life and lower overall costs. 

Medicare Part D’s eMTM model launched in January. CMS chose five regions, and allowed plans in those regions to apply to participate. In the end 22 plans representing  approximately 1.6 million beneficiaries in Virginia, Florida, Louisiana, Arizona, Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, and Wyoming were chosen. Participating payers included: 

•  Blue Cross and Blue Shield Northern Plains Alliance

•  Blue Cross and Blue Shield of Florida

•  CVS Health

•  Humana

•  UnitedHealthcare

•  WellCare Prescription Insurance 

Alignment Through Incentives

According to its website, CMS and the participants “are testing changes to the Part D program that would achieve better alignment of PDP sponsor and government financial interests, while also creating incentives for robust investment and developing innovative MTM targeting and interventions.” CMS is seeking to get PDP sponsors to right-size their MTM investment, and “create innovative strategies to optimize medication use, improve care coordination, and strengthen health care system linkages.”

Payers and provider incentives include regulatory waivers to allow testing of innovative program elements; a prospective payment to support more extensive interventions; and a performance payment based on achieving a 2% reduction in fee-for-service expenditures. What’s more, stars could be at stake, namely CMS’s STAR ratings for comprehensive medication reviews (CMR). Drs Frank and Taday pointed out that the CMR cut points for Medicare Part D plans are rising, making the hurdle to achieve a specific STAR rating higher. All the more reason to implement impactful MTM programs. 

Humana’s eMTM model focuses on delivering services where patients choose, and triaging services based on patient need/profile, noted Dr Taday at the AMCP meeting. Humana’s members can receive services in physician practices, at the retail pharmacy, from medical clinical program partners, or via internal telephone-based pharmacists. 

As for the types of services offered, Dr Taday explained that:

•  Members with gaps in care receive targeted medication review, medication education, an over-the-counter consult, and resource education

•  Those with chronic conditions and gaps in care receive all of the above plus medication adherence monitoring

•  Those with chronic conditions, gaps in care, and high drug spend receive all this, plus CMR and medication reconciliation. 

In the end, Humana—as well as the others participating in the program—are aiming for what Drs Frank and Taday presented as five “E’s”: 

•  Entice, by adding value. Otherwise members will continue to decline MTM

•  Enter, or bring people in. Improve on the customer experience

•  Engage to drive successful CMRs. Collect and share data; allow pharmacists to spend time on medication recommendations

•  Exit, or connect with primary care physicians. CMR need to be designed with physicians in  mind, which will lead to improved follow-up and the ability to measure outcomes

•  Extend the program and successfully close the loop. Figure out how to make sure the CMR happens within the member/physician relationship, not just via fax

Best Practices 

This is good guidance to follow whether part of the CMS pilot program, or gearing up for what is likely to be coming in the future if the program is expanded. What else is important? 

Catherine Cooke, PharmD, BCPS, PAHM, research associate professor at the University of Maryland School of Pharmacy—who has worked with CMS on the MTM program and the eMTM model—said it is necessary to “allow the MTM provider flexibility to determine duration of care, and to integrate the provider into the system.” Additionally, Dr Cooke advised “engaging members/beneficiaries by listening to their needs and preferences for MTM.”

Dr Cooke, who is also president of PosiHealth, Inc, which helps stakeholders assess the effectiveness of therapeutic interventions, pointed to research that shows that one-third of beneficiaries who received a CMR did not remember the medication action plan and personal medication list that followed the review. 

“The prescriptive nature of MTM programs has not engaged the member to allow us to hear how best to implement it, ” she said. 

Charles Karnack, PharmD, BCNSP, assistant professor of clinical pharmacy at Duquesne University, said that it is important to have adequate staffing, since the process can be labor intensive. Additionally, he warned of ‘garbage-in-garbage-out’ syndrome unless you make sure information is accurate and timely. Payers can help by supporting software and hardware upgrades, and by fully buying into methods that improve patient compliance—such as personal contact and refill histories from affiliated outpatient pharmacies. 

“Payers also need to be widely available to answer coverage questions—not just during ‘banking hours,’” Dr Karnack said. “Delayed care often ends up being no care or the wrong care.” 

Potential Pitfalls 

The episodic nature of some MTM programs can be a detriment, said Dr Cooke, as can the lack of a relationship between MTM provider, patient, and prescriber.  Miscommunication is also a potential downfall, which can show itself in several ways, added Dr Karnack. For instance, “when patient discharge and medication listings are unavailable, delayed, inaccurate, or constantly changing. Or when there is lack of or poor coordination with outpatient pharmacies.” He added that patients can be overwhelmed by too many inquiries, or not understand their disease and the important role medicine has in managing it. 

According to Dr Frank, the most common pitfall is failing to engage community pharmacies. 

“Community pharmacists not only have relationships with their patients but also with prescribers, long-term care facilities, social workers, and other important members of the health care team,” she told First Report Managed Care in an interview. Furthermore, Dr Frank noted that community pharmacists are the key “to engag[ing] in any effort to coordinate care and optimize medication use to reduce health care costs.”

Dr Frank also talked about a key strategy to minimize the aforementioned episodic nature of therapy: Using alternative approaches to risk stratification. Knowing the beneficiary’s risk for medication-related complications, such as pre-existing medication therapy problems, result “in MTM interventions that vary in intensity and are tailored to the needs of the beneficiary.” 

In the end, Drs Frank and Taday noted during their AMCP presentation, meaningful MTM needs to be about more than checking boxes on a to-do list. Ideally, MTM is “an engaging, always-on conversation about medications in a context that is connected and shared across the care team to achieve best health for members.”