Medication Therapy Management beyond Medicare Part D

Minneapolis—At a pharmacy partnership briefing session at the AMCP meeting, 2 pharmacists discussed medication therapy management (MTM) as it relates to Medicare Part D in a presentation titled MTM: Medicare Part D and Beyond. Jessica Frank, PharmD, director of clinical services at Outcomes Pharmaceutical Health Care (Outcomes), and Twila Johnson, PharmD, director of pharmacy services at Security Health Plan (SHP) of Wisconsin, shared the podium. They began by outlining the objectives of their presentation: (1) explain the Centers for Medicare & Medicaid Services (CMS) regulations regarding the provision of MTM services in Medicare Part D plans; (2) identify the benefits of offering MTM services to Medicare beneficiaries who do not meet CMS targeting criteria; and (3) compare the results of pharmacist-provided MTM services for Medicare versus commercial populations. In 2009, SHP contracted with Outcomes to administer the MTM benefit to Medicare beneficiaries who were eligible for the Part D benefit. In 2010, the partnership was expanded to include Medicare and commercial beneficiaries, creating a total population of beneficiaries eligible for Part D as well as those eligible for a commercial pharmacy benefit. The SHP MTM benefit covers services such as comprehensive medication reviews, prescriber consultations to manage costs and resolve problems associated with a particular drug therapy, patient compliance consultations to address issues of overuse or underuse of medications, and patient education efforts to assist during periods of new or changed medication regimens and to assess patients’ use of over-the-counter medications. Services covered by the benefit may be initiated by a pharmacist or by the plan. An example of a plan-initiated service is a Targeted Intervention Program (TIP). In TIP, Outcomes conducts retrospective data analyses to identify potential MTM interventions and then deploys interventions to dispensing network pharmacies accompanied by instructions and supportive documentation. The pharmacists then review potential drug therapy issues and take actions as appropriate. Bills for the MTM services provided are documented and submitted by the pharmacists. Under CMS regulations, Part D sponsors such as prescription drug plans and Medicare Advantage prescription drug plans are required to offer an MTM program to targeted beneficiaries. The Medicare Modernization Act of 2003 defined MTM as services designed to (1) enhance enrollee understanding, (2) increase enrollee adherence, and (3) detect adverse events and patterns of overuse or underuse of prescription medications. The presenters pointed out that in establishing targeting criteria, CMS sets the “floor, not the ceiling” for which patients should be targeted. Criteria for MTM eligibility include ≥2 chronic diseases, >8 Part D drugs, and an annual drug spend of ≥$3000. By using a targeted approach, members who are on the verge of becoming at risk or who have cost-savings opportunities but no comorbidities are missed, the speakers noted. They outlined some of the advantages of offering MTM services to members who do not meet targeting criteria, including taking a proactive approach that offers preventive services, drug product cost-savings by targeting all utilizers of the pharmacy benefit, lowered per member per month costs because costs are distributed across the entire member population, and ensuring parity in benefits for all members. At the conclusion of the presentation, the speakers offered data on estimated cost avoidance (ECA) and return on investment in 2010 at SHP: for Medicare programs, ECA was $471 per claim and $614 per patient, and $246 drug product cost-savings per patient. Comparable data for commercial members were $434 ECA per claim, $519 ECA per patient, and $280 drug product cost-savings per patient.