Medication Therapy Management (MTM) has always been an important component of the Medicare Advantage Part D plan structure. Potential changes to Part D would not only significantly increase the number of Medicare beneficiaries eligible for MTM enrollment, but they could also adversely impact Medicare star ratings and member outcomes if MTM programs can’t appropriately scale to meet demand.
While proposed changes have yet to be finalized, now’s the time for Part D plan sponsors to unpack what expanded MTM program eligibility would mean and how they can effectively plan to meet increased demand and maintain or improve their star ratings.
Member Outcomes: MTM Program Role
Ever since Medicare Part D went into effect in 2006, plan sponsors have been required to incorporate an MTM program into its benefit structure. Plan sponsors must submit MTM program descriptions to the Centers for Medicare & Medicaid Services (CMS) annually for review and approval.
General requirements of the MTM program aim to improve member outcomes by best ensuring that covered Part D drugs are used appropriately and reducing the risk of medication errors and adverse events, such as undesired drug interactions. An MTM program can be offered in an ambulatory or institutional setting, and it can be furnished by a clinical pharmacist or another qualified provider, but according to CMS, it “[m]ust be developed in cooperation with licensed and practicing pharmacists and physicians.”
One of the most critical components of MTM is the comprehensive medication review (CMR). All Medicare Part D plan sponsors must make CMR available to all members who meet the eligibility criteria for MTM. Currently, these criteria are a diagnosis of no more than three chronic conditions from a core list of at least five, prescriptions for no more than eight Part D drugs, and annual drug costs that exceed the MTM program’s annual threshold of $4,935 for 2023 and $5,330 for 2024. Eligible members must be offered a CMR within 60 days of enrollment and subsequently within 365 days.
MTM, CMR, and Medicare Star Ratings
CMS uses star ratings to assess Medicare Advantage Part D (MA-PD) plans and standalone Part D plans (PDPs) on metrics ranging from quality to cost to member experience. Ratings are based on a scale from 1 (low) to 5 (high). Medicare Advantage Part D plan sponsors are rated on up to 38 specific measures, while standalone Part D plan sponsors are rated on up to 12 measures.
For the 2023 and 2024 plan years, there are five Medicare Part D Star Ratings directly or indirectly tied to the strength of an MTM program:
- MTM program completion rate for CMR
- Statin use in individuals with diabetes
- Medication adherence for cholesterol
- Medication adherence for diabetes medications
Medication adherence is important for Medicare star ratings because of its impact on care quality, healthcare costs, and member satisfaction. For example, an individual diagnosed with type 2 diabetes and struggling to achieve glycemic control faces an increased risk of emergency department visits, hospital admissions, and high out-of-pocket care costs.
Key Motivations for Enhancing Your MTM Program
There are two important reasons for Part D plan sponsors that are looking to improve member outcomes to consider MTM program enhancements.
The first is that as Part D plan performance improves year over year across the industry, the threshold for success gets higher. CMS data shows the national average for MTM CMR completion for MA-PD plans is nearly 83% and has risen nearly 6% since 2021. The MTM CMR completion rate for PDPs stands at more than 53% and has risen more than 9% in two years. In other words, Part D plan sponsors that can’t improve MTM performance are more likely to see star ratings decrease over time.
The second is an impending increase in MTM program eligibility. Under the 2024 Medicare Advantage and Part D proposed rule, Part D population enrollment in MTM would more than double from less than 10% to nearly 25%. Increased eligibility would result from broader eligibility requirements: coverage of all (not just some) core chronic conditions, prescriptions for five (not eight) Part D drugs, and an annual cost threshold just above $1,000 (not nearly $5,000).
MTM Healthcare Solutions and Clinical Pharmacist Services
A thoughtful approach to end-to-end MTM program improvement will help Part D plan sponsors better meet the needs of newly eligible members.
Such an approach begins with outreach. If the CMS proposed rule is finalized, then plans would face a sudden increase in the number of members eligible for MTM CMR within the 60-day enrollment window. Mailers, phone calls, and other traditional methods of outreach may not scale to meet this need. Using purpose-built MTM healthcare solutions to automate outreach and enrollment, documenting that an MTM CMR has occurred, and generating medication records and summaries are some ways that health plan sponsors could handle an increase in volume.
It continues with medication management. Plans would need to significantly increase their capacity to administer the annual CMR, as well as the quarterly targeted medication review, to satisfy Medicare requirements and meet the sliding scale of star ratings for MTM CMR completion.
Here, partnership with clinical pharmacist services — which research has shown are indirectly tied to the majority of all Part D stars measures — could empower Part D plan sponsors to engage with and educate members, encourage timely medication refills, and provide consultations once new medications have been prescribed. Additionally, MTM healthcare solutions could facilitate telehealth consultations with clinical pharmacists, thus providing members with an added level of convenience, improved MTM services, and a boost to satisfaction with their Part D plan.
Cureatr is a leading provider of MTM services. We leverage the skills of clinical pharmacists to improve MTM participation, member engagement, and overall compliance. Find out how we can help you by booking a meeting.