Are the MTM stars aligning for pharmacists?


Brad Tice, RPh, PharmD, MBA, FAPhA

Product Leader
Medication Therapy Management
Cardinal Health

Medication Therapy Management (MTM) programs in Medicare Part D have been around for years.

But only a very small percentage – perhaps less than one percent – of Medicare Part D beneficiaries actually receive a Comprehensive Medication Review. On the surface, that statistic that doesn't seem to bode well for the future of MTM. However, Brad Tice, MTM product leader for Cardinal Health, says that the future of MTM looks brighter now than ever. In this interview, Tice discusses why he's so optimistic.

Q: What services are included in MTM and who can benefit from these services?

A: MTM services include medication therapy reviews, pharmacotherapy consults, adherence consultations, anticoagulation management, immunizations, health and wellness programs and many other clinical services. The goal of MTM services is to help patients get the best benefits from their medications by actively managing each patient's drug therapy and by identifying, preventing and resolving medication-related problems.

Patients who are most likely to benefit from MTM services include those who are on two or more medications (with those using several medications especially in need), those who manage several health conditions, those who have questions or problems with their medications, those who take medications that require close monitoring, those who have been hospitalized, and those who obtain their medications from more than one pharmacy.

Q: Why is expanding MTM so important?

A: Medication-related problems have a significant detrimental impact on the U.S. health care system – both in terms of patient care quality, and overall healthcare costs. Think of the patient groups described above: patients who have recently been hospitalized; who are managing multiple health conditions; who are taking several medications. If they don’t fully understand their medications, how to take them, the importance of taking them, how they interact with each other; if they don’t fully understand dosage or other guidelines – they can’t get the full benefit of the medications, and they put their own health at risk from potential medication-related adverse events.

MTM services – especially when personally delivered by a trusted community pharmacist – are a mechanism to improve patient health while reducing adverse medication events and overall healthcare costs. Studies indicate that for every $1 spent on MTM services, $3-$12 is saved. In addition to costs savings, patients also realize significant improvements in key health measures.1

Q: If MTM services have such significant potential to improve patient care quality and reduce costs, why aren’t they used more frequently?

A: The answer to that question is complex, but it all boils down to this: too few patients are eligible to receive MTM services through Medicare or through their health plan; and pharmacists do not currently receive enough reimbursement to cover their costs for delivering MTM services. In essence, we know that MTM services will help patients and drive down costs; but there’s still a lot of work to be done when figuring out how to expand access to these services and how to pay for them.

Q: What changes do you see on the horizon for MTM?

A: I see many changes on the horizon – most of which I believe are laying the groundwork for a greater demand for MTM services to help improve population health.

For example, CMS is currently considering lowering the thresholds for MTM eligibility to include Medicare Part D beneficiaries who are taking two or more medications in the course of a year. The expectation is that this expansion will increase the MTM eligibility from 10% to up to 55% of seniors who sign up for Medicare Part D drug benefits.

CMS is also placing additional pressure on health plans to provide MTM services to under-served populations, including minorities and those receiving low-income subsidies. Moreover, CMS has indicated that it continues to expect MTM to be a cornerstone of the Part D benefit.

I think these trends point to a significant shift in the demand for MTM services, which I believe will soon translate into more pharmacists offering MTM services, and more action on the part of public and private health plans to provide fair reimbursement to pharmacists for delivering MTM services.

Q: What role do Star Ratings play in MTM adoption?

A: CMS introduced a bonus payment program in 2012, which pays health plans based on quality measure ratings This program has become known as the Star Ratings program because health plans are given a “star rating” (on a scale from 1 to 5), based on their performance. Scores are based on measures that are proxies for quality, like the number of patients with diabetes who are on an ACE/ARB (a class of medications shown to help prevent kidney damage in people with diabetes) or the percent of elderly patients who are on a high-risk medication – one that could lead to a fall or injury, for example.

Measures specific to medication use are weighted heavier in the overall Star Ratings formula, and one measures the percent of MTM-eligible beneficiaries who receive a Comprehensive Mediation Review (CMR) each year. This has more than doubled the percentage of MTM-eligible beneficiaries who receive a CMR. As more Americans become eligible for MTM services, I believe health plans and pharmacists alike will feel increasing pressure to deliver MTM services to patients – so they can continue to drive high Star Ratings.

Q: What are the challenges when it comes to pharmacists receiving compensation for providing MTM services?

A: One of the big questions is whether or not the MTM benefit in Medicare Part D will be sufficient recognition for pharmacists to get paid for the delivery of their high-value services. The pharmacy profession has responded through APhA, NACDS, NCPA  and others to push for changes to the Social Security Act to officially name pharmacists as “providers” who can be reimbursed for the medical services they deliver.

In March of 2014, HR 4190 was introduced in the U.S. House of Representatives by Reps. Brett Guthrie (R-KY), G.K. Buterfield (D-NC), and Todd Young (R-IN) to enable patient access to Medicare part B services by state-licensed pharmacists in medically underserved communities – and for pharmacists to receive reimbursement for delivering those services. Efforts like these – to expand access to MTM while also ensuring pharmacists are reimbursed for delivering those services – are critical to MTM expansion. Cardinal Health is supporting this legislation and I encourage encourage both pharmacists and patients alike to reach out to their legislators to encourage them to support this legislation.

Q: What’s the latest on CMS’ proposed changes to the Medicare Part D benefit?

A: On January 10, 2014, CMS published significant proposed changes to the Medicare Part D benefit. These included changes to reduce or prevent closed networks, reduce mail order, eliminate “protected classes” of medications and increase the percent of patients who are MTM eligible to up to 55% of the Part D population. The industry responded with over 7,500 comments during the comment period. CMS has since communicated that it will not currently move forward with many of the changes, but that it is still considering the mail-order and MTM changes.

CMS’ payment advisory board, MedPAC, recently encouraged CMS to consider alternative methods of program design to bring MTM services closer to the patient and the patient’s care team, including the pharmacist.

Q: So what does all of this really mean?

A: Combined, this is a collection of events signaling what I believe is a major trend. I believe that government officials - and many players in the healthcare system - are realizing what pharmacy has been saying for a long time: MTM services can dramatically reduce medication errors and improve patient health - yet to be successfully implemented, these services need to be available to a much broader population, delivered by a pharmacist who has direct interaction with the patient, and who receives reimbursement for delivering these high-value services.

At Cardinal Health, we believe that the expansion of MTM services can ultimately serve everyone in the healthcare system. Patients can benefit from fewer medication-related errors and health problems; pharmacists can benefit by having the opportunity to work more closely with patients - and by being reimbursed for high-value medical services they provide. Health plans, the federal government and taxpayers can ultimately benefit by reduced health care costs fueled by fewer medication-related errors and health issues.

I believe that the stars are indeed aligning for MTM services to empower pharmacists and patients to work in collaboration to improve population health, all while driving down health care costs.

1 Isetts BJ, Schondelmeyer SW, Artz MB, Lenarz LA, Heaton AH, Wadd WB, Brown LM, Cipolle RJ, Clinical and Economic Outcomes of Medication Therapy Management Services: The Minnesota Experience, J. AM. PHARM. ASSOC. 48(2): 203-11 (2008).