Two decades after the Medicare Modernization Act of 2003 created Medicare Part D, nearly 50 million Americans are enrolled in a standalone prescription drug benefit program. One of the cornerstones of Part D plans is medication therapy management (MTM), a mandatory program for assisting members who take multiple high-cost medications for numerous chronic conditions.
The American Pharmacists Association (APhA) defines MTM as a service that optimizes therapeutic outcomes for patients by creating a medication action plan (sometimes referred to as a med action plan), educating patients, monitoring how a patient responds to the therapy, and documenting care.
Here, we’ll examine how the Centers for Medicare & Medicaid Services (CMS) administers MTM, including what benefits and challenges Part D plans face in implementing MTM requirements, such as the comprehensive medication review (CMR).
Here are ten things health plans should know about MTM.
What are the goals and requirements of CMS MTM?
1. CMS sets specific requirements for a medication therapy management program under Part D. Along with the principles described in the APhA definition, CMS requires MTM programs to reduce the risk of adverse events, establish fees for pharmacists or other medical professionals who support the program, and align MTM with any other care management plans an individual already has. An MTM program must also be “developed in cooperation with licensed and practicing pharmacists and physicians.” Each Part D plan sponsor is required to incorporate MTM into its benefits structure and submit its MTM program description to CMS annually for review and approval.
2. Under Medicare Part D, MTM is available to qualified members at no cost. Plan sponsors are reimbursed under a fee-for-service model. Currently, members are eligible if they have been diagnosed with no more than three chronic conditions from a core list of at least five, are taking no more than eight Part D drugs, and exceed the medication therapy management program’s annual cost threshold, which is $4,935 for 2023 and $5,330 for 2024. Plan sponsors are allowed to expand eligibility beyond these minimum requirements, and nearly 30% of plans have done so.
3. CMS has indicated that MTM programs can be administered by licensed pharmacists or other qualified providers. Many medication therapy management programs involve multiple providers. Data from CMS shows that 100% of programs leverage a pharmacist, 74% use registered nurses, and about 25% involve a physician. In addition, program sponsors may distinguish between services provided in ambulatory care settings and institutional settings such as skilled nursing facilities.
What is a comprehensive medication review (CMR), and why is it important?
4. Part D plan sponsors must make a comprehensive medication review (CMR) available annually to all members eligible for their MTM programs. This medication review can occur in person, over the phone, or via telehealth. The pharmacist or qualified provider leading the review should assess the therapies a member is taking, identify problems such as drug interactions or side effects, prioritize these problems, and create a plan to resolve them. The assessment should include prescription drugs, over-the-counter medications, herbal therapies, and other supplements.
5. The National Board of Medication Therapy Management outlines several other requirements. Part D plan sponsors must offer eligible members a CMR within 60 days of enrollment and subsequently within 365 days. Under CMS rules, plan sponsors must retain records of when offers are made, when a medication review is performed, and who participates in the review (a member and/or an authorized caregiver). Plans must also retain summaries of all CMRs that occur. The “offer” of a CMR does not meet CMS requirements if a plan sponsor cannot reach a member due to an invalid phone number or mailing address.
6. Plan sponsors are also required to perform targeted medication reviews (TMR) at least once per quarter. While the CMR is regarded as a real-time consultation, the TMR addresses specific issues with one or more medications. Plan sponsors must assess each TMR to determine if follow-up interventions are necessary. Under CMS rules, these interventions may be communicated directly to the pharmacist or qualified provider.
What are the benefits and challenges of medication therapy management?
7. Research has shown that MTM programs improve medication adherence. In certain patients, medication therapy management contributes to lower rates of hospitalization as well as lower costs for hospital care. Additionally, MTM programs have been shown to improve clinical outcomes for patients managing hypertension or high cholesterol.
8. Current utilization of MTM remains low. Though there’s been a 5% increase in Part D plans offered in the U.S. from 2022 to 2023, CMS data shows that less than 54% of patients eligible for a comprehensive medication review actually complete one. Notably, the rate is much higher — nearly 83% — for Medicare Advantage plans.
Research also points to racial and ethnic disparities in MTM utilization: Asian, Black, and Hispanic members are more likely than white members to opt out of MTM altogether, while Asian and Hispanic members are less likely than white members to be offered a CMR after MTM program enrollment.
What changes may be in store for medication therapy management?
9. In December 2022, CMS proposed a significant expansion in the number of Medicare beneficiaries eligible for MTM, from a current eligibility rate of about 8% to an estimated rate of 25%. CMS intended to do this by requiring Part D plan sponsors to include all core chronic diseases, lowering the maximum number of drugs from eight to five, and lowering the cost threshold to align with the average annual cost of generic medications (down to about $1,000). Though these changes were not included in the CMS 2024 Final Rule for Medicare Advantage and Part D plans, CMS is expected to address MTM eligibility changes in a subsequent 2024 final rule.
10. Several factors have been linked to the lax adoption of MTM. These include a lack of clarity about its core components; a lack of standardization in program implementation, documentation, and billing; and poor coordination between licensed pharmacists, physicians, and other providers in program administration. Research has suggested that increased engagement of community-based clinical pharmacists has the potential to increase MTM program enrollment and improve outcomes.
Cureatr: An Industry Leader in Medication Therapy Management
With significant medication therapy management changes on the horizon, it’s important for health plans to ensure they are working with the right MTM partner. Cureatr is a leading provider of medication therapy management services. We leverage the skills of clinical pharmacists to best ensure compliance and member engagement and provide a proven approach to MTM designed to fit the needs of each plan that we serve. Find out how we can help you by booking a meeting.