Using MTM to Improve Medicare Part D Star Ratings

San Francisco—Medication therapy management (MTM) services have evolved over the years from their early adoption by self-insured employees and other innovators to mandated use by Medicare Part D plans. Created to facilitate positive therapeutic and economic results from medication management, the services provided by MTMs have included comprehensive medication reviews, prescriber consultation, patient education and monitoring, and patient compliance consultation.

Since 2010, MTM services have undergone a rapid evolution under the additional attention by the Centers for Medicare & Medicaid Services (CMS) that has increased reporting requirements and data validation. Plans are now looking beyond Part D targeted beneficiaries to nontargeted beneficiaries, expanding MTM services into the area of prevention. MTM is also being viewed as a strategy to improve quality or Star Ratings. What has emerged is a systematic, network-based approach to MTM services in which specially-trained, local pharmacists deliver MTM services (supply) and contract with healthcare payers to cover MTM on behalf of one or more members (demand) to document and report the value of these services to contracted clients (value or return on investment).

In a Contemporary Issues session at the AMCP meeting titled MTM Cast Studies: Validation of Hard Dollar Savings and MTM as a Strategy to Improve Medicare Part D Star Ratings, Jessica Frank, PharmD, director of clinical services, Outcomes Pharmaceutical Health Care, West Des Moines, Iowa, presented a couple of case studies to illustrate how these more recent evolutions of MTM services are contributing to enhancing quality and reducing cost.

Dr. Frank first presented a case study illustrating the drug product cost savings of a comprehensive, face-to-face MTM program for a large state employee/dependent population. Using comprehensive and targeted medication reviews that included prescriber consultations as well as patient adherence consultations and patient education and monitoring, the MTM program delivered a total of 9753 services to patients in 528 participating local MTM centers between July 1, 2010, and June 30, 2011.

Of the total costs related to MTM services during this time period, 13% were due to drug product costs and 87% to nondrug costs. The costs avoided by using the MTM services were estimated to be 28% for drugs and 72% for other nondrug costs, based on estimate cost avoidance.

To validate that the MTM program actually did confer these savings, the pharmacy claims during that time period were matched with the MTM claims and the final drug cost (a combination of payment by the client and patient copayment) was subtracted from the initial drug cost (again, a combination of payment by the client and patient copayment). Overall, 1058 claims were able to be matched and were used in the validation calculation.

Results of these calculations validated drug product cost savings of about $953,560 with a return on investment of about $2:$1. These results show that the MTM program paid for itself and that the quality and safety improvements offered are basically free.

In the second case study, Dr. Frank showed how face-to-face, comprehensive MTM services can be used as a strategy to increase Medicare C and D Star Ratings. She showed that plans that enroll total populations into an MTM plan see better performance on Star Ratings for patient safety measures compared to plans opting for selective enrollment. She said that in 2013, CMS will be issuing a letter encouraging plans to use patient safety reports to identify beneficiaries to target for MTM plans.