NEWS

By Bronwyn Mixter

Oct. 21 — Medicare Part D's current medication therapy management (MTM) program hasn't met its promise and a new model that the CMS is testing could improve the program, a CMS official and other stakeholders told the House Energy and Commerce Health Subcommittee Oct. 21.

Tim Gronniger, director of delivery system reform at the Centers for Medicare & Medicaid Services, told the subcommittee that only 11 percent of Part D beneficiaries currently participate in the MTM program and that the CMS estimates 25 percent of beneficiaries could benefit from the program. The CMS “believes the full benefits of MTM haven't been realized in Medicare” and the enhanced MTM model will test strategies to improve Part D's MTM program.

“MTM can improve health care and outcomes for patients and has the potential to lower overall health-care costs,” Gronniger said.

A background memo from the House subcommittee noted that the goal of MTM is to ensure that covered Part D drugs are appropriately used to “optimize therapeutic outcomes through improved medication use for beneficiaries enrolled in standalone Prescription Drug plans and Medicare Advantage Prescription Drug plans.”

New Model 

On Sept. 28, the CMS announced it will test a new model intended to encourage innovation by Part D prescription drug plans in designing their MTM programs in which enrollees are targeted for consultations and management strategies on their prescriptions. The program, called the Part D Enhanced Medication Therapy Management model, will offer prescription drug plans in 11 states the chance to design and implement innovative strategies to improve medication use and care coordination. The five-year model will begin Jan. 1, 2017, in Virginia, Florida, Louisiana, Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming and Arizona.

At the hearing, Gronninger said the enhanced model “will assess whether providing selected stand-alone Medicare Prescription Drug Plans (PDPs) with regulatory flexibilities and an alternative payment methodology to realign financial incentives to design and implement innovative programs will better achieve Medicare's original vision for MTM programs.” Gronniger said, “Through this model, Part D plans will improve their investment in medication therapy management and identify new, effective strategies to optimize medication use and improve care coordination across Medicare.”

Gronniger said patients are required to meet certain criteria to participate in the MTM program, which are “based on numbers of medications, chronic conditions and expected annual prescription drug costs.”

“These criteria may lead to some beneficiaries who don't benefit from MTM being included in the programs, while missing some beneficiaries who would benefit from MTM programs,” Gronniger said.

Key Elements of Model 

Gronniger said in his written testimony that the key elements of the Enhanced MTM model include:

• the ability to offer different MTM services to individual enrollees based on their level of medication-related risk, with interventions tailored to those enrollees' specific barriers to improvement;

• the ability to offer a more expansive set of MTM related items and services, as well as cost sharing assistance to financially needy beneficiaries;

• the flexibility to experiment with alternative communication strategies to improve coordination and engagement of beneficiaries, pharmacists and medical providers;

• a plan-specific prospective payment to support more extensive MTM interventions that will be outside of a plan's annual Part D bid and will therefore not affect plan premiums;

• the opportunity to qualify for a performance payment in the form of an increased beneficiary premium subsidy (in a future year) for plans that successfully achieve a 2 percent reduction in expected beneficiary fee-for-service expenditures (net of model prospective payments);

• the ability to request beneficiary-level Parts A and B claims data and potentially accountable care organization alignment information from the CMS to assist with identification and care coordination of individuals at risk of medication-related problems; and

• a new MTM encounter data collection effort leveraging existing work by industry experts to develop MTM-specific code sets, which will support the vision of the Office of National Coordinator for Health Information Technology for prescription drug data interoperability.

 

Support for Model 

S. Lawrence Kocot, principal and national leader at audit and advisory firm KPMG, told the hearing that the model “has the potential to unleash greater innovation in the MTM program to provide a higher quality prescription drug benefit for Medicare Part D beneficiaries.”

Kocot said the model “will enable CMS to produce new evidence about the effectiveness of medication therapy management interventions that may be applied to the Medicare Prescription Drug Program more broadly.” Kocot is with KPMG's Center for Healthcare Regulatory Insight.

Mark Merritt, president and chief executive officer of the Pharmaceutical Care Management Association (PCMA), told the hearing that the current MTM program “is misaligned on its incentives and misallocates resources” and the PCMA “strongly” supports the enhanced MTM model.

The PCMA represents pharmacy benefit managers.

Merritt said the existing MTM program doesn't offer economic incentives to innovate.

The model “is designed to test 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 innovation in better MTM targeting and interventions,” Merritt said. “Perhaps most importantly, the model aims to offer a degree of financial alignment for MTM services by sharing a portion of the savings that accrue to the traditional Medicare program from MTM so that these savings can result in lower premiums for beneficiaries.”

To contact the reporter on this story: Bronwyn Mixter in Washington at bmixter@bna.com

To contact the editor responsible for this story: Brian Broderick at bbroderick@bna.com

More information on the hearing is available at http://energycommerce.house.gov/hearing/examining-medicare-part-d-medication-therapy-management-program.