1% is not good enough: Why MTM is needed today


Brad Tice, RPh, PharmD, MBA, FAPhA

Product Leader
Medication Therapy Management
Cardinal Health

Healthcare leaders are being pushed hard across the board to lower costs while raising quality.

Medication Therapy Management (MTM) has been hailed by many, including the federal government, as one way to accomplish this important goal, especially in Medicare Part D. In fact, the Center for Medicare & Medicaid Services (CMS) calls MTM a “cornerstone” of Part D’s future and a practice that will “serve as a model for achieving quality.”

So, then, why do only 1% of eligible Medicare Part D beneficiaries get MTM services today? And what must health insurance plans do to reap the MTM benefits in CMS’ Five-Star Quality Ratings System and other ways?

Today, only a small share of Medicare Part D beneficiaries receive MTM services because health plans identify only 10% of members as eligible and, of these, only 10% get a Comprehensive Medication Review (CMR). That means only 1% of Part D beneficiaries – 10% of 10%! – get this “cornerstone” benefit of Part D’s future. This large disconnect between health plans and CMS cannot last.

CMS’ original target was that 20% to 30% of Part D members would be eligible for a CMR. In January 2014, CMS proposed to increase that to 55% of eligible beneficiaries. In its 2014 Part D final rule, CMS states what it expects from plans: “(W)e believe that MTM must evolve and become a cornerstone of the Medicare Prescription Drug Benefit.” In short, 1% is not good enough.

CMS’ 2014 final rule acknowledges that the traditional mass-outreach efforts have not been adequate, either for locating eligible patients or delivering MTM services to those who qualify. “Part D sponsors’ strategies for outreach and service provision cannot be ‘one size fits all’ and must be appropriately geared to social and demographic subpopulations within the overall targeted population in order to be effective,” CMS stated.

It is likely that we will see important changes from CMS over the next 18 months to encourage plans to deliver MTM services to more beneficiaries. So, how can health plans maximize the benefits of MTM services, both short and long term? This article focuses on four keys for success. Each will be detailed in greater length a future article.

Improve your reach.

Reach members where they receive care. Partnerships with providers who see patients frequently – retail pharmacies and long-term care facilities, for example – are crucial for connecting to the high-risk Part D patients whom CMS wants to receive MTM services. While call centers and direct mail campaigns have a role, the general, one-size-fits-all campaigns are expensive and not very effective. Health plans must identify and target subgroups. Leveraging data to identify those members who can most effectively be reached and impacted to drive value, as well as where and how to reach those members, can truly drive value creation. In these precision efforts, scale, data depth and analytical sophistication are enormously valuable.

Find new allies.

When incentives are properly aligned, pharmacists have a proven ability to improve patient care in a cost effective way. Properly structuring payments will dramatically improve outcomes. Today, few health plans have direct payment or other relationships with pharmacies. Given the fragmented nature of health care delivery, MTM at the pharmacy level is an extraordinarily effective way to make sure high-risk patients take the right medications at the right time. View the pharmacist as a Star Ratings ally.

Measure and maximize ROI.

A lot of focus has been on the question, “What is the ROI on MTM services?” First ask, “What is the cost of inappropriate medication use?” The answer is about $300 billion annually. Then ask, “What is the ROI on a physician visit? On other forms of care?” Many services are difficult to measure, yet what is clear, especially in the case of pharmacists’ services, is the cost of not performing them is extremely high. In the case of medication use, the payer has already paid for the physician visit, labs, procedures, etc. If a medication is not used correctly, most of these costs will have gone to waste, not to mention the savings that will be missed from the prevention of disease progression. To get the most meaningful view of the cost of care, health plans should compare spend across populations using control groups, propensity scoring and/or matched cohorts.

Leverage data to find new models of care.

While payers need to manage their populations across often broad geographies, individual care for these populations occurs at a local level. Therefore, collaborating with providers, who have the local reach, is key to innovation. These collaborative initiatives -- electronic data sharing, business models that incorporate pharmacists, MTM consultations on specialty medications, care across distribution channels and so on -- are the waves of the future. And, in the future, data and analytics will fuel change. As described above, data is key to identifying where and how to reach members. Analytics (based on these data)is key to identifying new models of care that align incentives appropriately between providers and payers in order to yield true value for everyone in the healthcare ecosystem.

The future importance of MTM services is clear, even if implementation can seem complex. The powerful health and economic benefits of MTM services – in addition to the regulatory push – will drive health plans where they need to go. Moreover, early adopters of a well-executed MTM program should expect to gain a competitive advantage over plans that delay.

Now is the time for health plans to take a fresh look at what is not working in their MTM service model. Health plans, providers, pharmacists and CMS all agree that reaching just 1% of Part D members is not acceptable. That’s why rules, regulations and rewards will change to grow this number. The next step is for health plans to embrace the challenge of making MTM services the cornerstone benefit that it is intended to be.

1 CMS 2014 Part D final rule, page 35: http://www.gpo.gov/fdsys/pkg/FR-2014-01-10/pdf/2013-31497.pdf; and 2005 final rule on Medicare Part D, page 107: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/downloads/CMS-4068-F3Column.pdf
2 CMS 2014 final rule for Part D, page 23: http://www.gpo.gov/fdsys/pkg/FR-2014-05-23/pdf/2014-11734.pdf
3 CMS 2014 final rule for Part D, page 25: http://www.gpo.gov/fdsys/pkg/FR-2014-05-23/pdf/2014-11734.pdf
4 CMS 2014 final rule: http://www.gpo.gov/fdsys/pkg/FR-2014-01-10/pdf/2013-31497.pdf
5 NEHI Research Brief, “Thinking Outside the Pillbox: A System-wide approach to Improving Patient Medication Adherence for Chronic Disease.” NEHI, 2009