The Centers for Medicare & Medicaid Services (CMS) released its 2024 Medicare Advantage and Part D Final Rule in April. Notably absent from all 724 pages of the final rule? Proposed changes to eligibility requirements for the Part D Medication Therapy Management (MTM) Program.
As we await an expected second final rule that should provide some clarity around MTM, we can still glean insight from the requirements outlined in the 2024 proposed rule. CMS’s expected updates to the Part D Medication Therapy Management Program suggest that health plan providers should anticipate an increased focus on medication therapy management, specifically regarding Medicare’s Star Ratings Program.
MTM, Healthcare Delivery, and Realities on the Ground
A confluence of factors propels this growing focus on medication therapy management. First, the number of Americans “aging into” Medicare eligibility continues to rise yearly. This is happening alongside several other realities, such as:
- advances in complex medication regimens;
- increasing medication usage;
- rising healthcare costs overall;
- and the growing importance placed on patient-centered care/engagement.
Combine these factors and a clear trend emerges: More people are being treated with a growing — and increasingly complex — number of medication-related interventions.
That’s before we consider the updates proposed in the Part D Final Rule. Expect that new eligibility criteria will dramatically alter the MTM Program and the delivery of MTM services in a number of ways.
Perhaps the most apparent change to expect is a significant growth in the number of people eligible for the program, including members of historically underserved groups, such as minority and lower-income populations. The December 2022 proposed rule projects an increase in the number of Part D participants enrolled in MTM from 4.5 million members (9% of all members) to 11 million (23% of all members).
Similarly, Part D sponsors should expect an expansion in the number of targeted chronic conditions to 10, including HIV/AIDS. Proposed changes to the rule require that all 10 chronic conditions on the list be targeted. However, the most significant driver of increased eligibility is a lowering of the annual cost threshold by nearly $4,000.
Medication Therapy Management (MTM) Program Requirements
On the most basic level, MTM programs were established because medications don’t work if patients don’t take them, take them incorrectly, or shouldn’t be taking them at all. When patients do not adhere to their medication regimen or take unnecessary medications, these can lead to suboptimal outcomes and patient harm.
CMS requires Plan D sponsors to establish an MTM program that:
- is designed to ensure that covered Part D drugs prescribed to targeted beneficiaries … [and] are appropriately used to optimize therapeutic outcomes through improved medication use;
- is designed to reduce the risk of adverse events, including adverse drug interactions, for targeted beneficiaries;
- may be furnished by a pharmacist or other qualified provider;
- may distinguish between services in ambulatory and institutional settings; and
- must be developed in cooperation with licensed and practicing pharmacists and physicians.
CMS explicitly encourages Plan D sponsors to actively promote MTM programs to eligible participants, employing multiple approaches to raise awareness and highlight the value of MTM services among beneficiaries. Plan sponsors should develop effective engagement strategies appropriate for their beneficiary population and business model.
Why put more focus on your MTM program now? The increasing urgency is driven by the implications of the forthcoming second edition of the 2024 Medicare Advantage and Part D Rule, expected to be released by CMS before the end of 2023.
For Plan D sponsors, medication adherence measures — key indicators that MTM programs are meant to improve — are an important factor in the CMS star ratings system. Star ratings, updated each year, assist Medicare consumers in comparing the quality of available Medicare health and drug plans.
Plan D sponsors may recall that, in 2016, CMS added a Stars measure called "Medication Therapy Management Program Completion Rate for Comprehensive Medication Review (CMR)." This measure requires your Medicare members (18-plus years old) enrolled in the MTM Program for at least 60 days to receive a CMR at any time in the reporting period.
With the potential of a growing eligible population anticipated in the impending ruling, plan sponsors must consider revising their strategy for implementing MTM services – specifically how to execute the CMR – with a member population that will likely balloon. Consider these questions: Do you have the capacity to support this change and the ability to at least maintain or hopefully improve performance and member experience?
Any decline in your MTM program completion rate for CMR could have an impact on overall ratings. With this in mind, let’s examine the CMR in more detail.
MTM Program Completion Rates for CMR
A comprehensive medication review (CMR) plays a vital role in every MTM program. Per CMS, “A CMR is a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them with the patient, caregiver and/or prescriber. [CMR] is designed to improve patients’ knowledge of their prescriptions, over-the-counter medications, herbal therapies, and dietary supplements, identify and address problems or concerns that patients may have, and empower patients to self-manage their medications and their health conditions.”
Put plainly, the CMR is a periodic (annual, at minimum) check of any and all medications and supplements a patient takes. It’s intended to look for any potential adverse reactions, reduce the risk of medication-related accidents, and avoid similar negative outcomes. A CMR also gives the caregiver and/or prescriber a chance to get a “full picture” of the patient’s health conditions and interventions.
At a minimum, MTM services require CMRs as one of four mandatory criteria:
- Interventions for both beneficiaries and prescribers.
- An annual comprehensive medication review (CMR) with written summaries in CMS’ standardized format.
- Quarterly targeted medication reviews (TRMs) with follow-up interventions when necessary.
- Information about safe disposal of prescription drugs that are controlled substances, drug takeback programs, in-home disposal, and cost-effective means to safely dispose of such drugs.
The core ideas behind the growing emphasis on MTM programs, CMR, and medication adherence are perhaps best encapsulated by this quote from the Pharmacy Quality Alliance, whose stated mission is “improving medication safety, adherence, and appropriate use”: “As our healthcare system shifts toward patient-centered and value-based care models, there is a need to advance how we evaluate the quality of MTM services. This can support the broader implementation of standardized best practices and payment that rewards positive outcomes.”
Have Questions About How to Improve Your Medication Therapy Management (MTM) Program?
Cureatr is a leading provider of MTM services, and we can help your plan be prepared for potential — and likely — changes to MTM requirements. The impending second release of the CMS 2024 Medicare Advantage and Part D Final Rule is set to dramatically alter the delivery of MTM services and expectations of Part D sponsors.
Cureatr MTM services leverage the skills of clinical pharmacists to best ensure compliance and member engagement for effective MTM program and CMR delivery. We combine that with cutting-edge healthcare data, technology, insights, and exceptional patient relationship-building to help our partners meet evolving, complex MTM requirements. Find out how we can help your MTM Program by booking a meeting.
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