The test of the Enhanced Medication Therapy Management (EMTM) Model began January 1, 2017. The EMTM Model seeks to determine whether providing Part D sponsors with additional payment incentives and MTM regulatory flexibilities achieves the key goals of MTM—“optimized therapeutic outcomes through improved medication use, and reduced risk of adverse events while reducing net Medicare expenditures.” Exactly what will Part D sponsors need to do to be eligible for the payment incentives and what criteria will be used to determine if the key goals have been met?

Part D sponsors have submitted detailed descriptions of alternative enhanced MTM program eligibility, targeting criteria and interventions to the Center for Medicare and Medicaid Innovation. The alternatives include new cost thresholds, number of chronic conditions, number of current medications, optimal medication usage, patient safety, patient population, and other demographic and clinical factors. All of these changes from the current Medicare Part D MTM program were subject to approval by the Centers for Medicare and Medicaid Services (CMS).

The EMTM Model is providing plan sponsors with payment incentives including a new per-member-per-month (PMPM) prospective payment to provide funding for the provision of enhanced benefits and services and resources. To accurately monitor sponsors’ implementation of their approved enhanced MTM program and to evaluate the overall success of the EMTM Model, CMS will be collecting enhanced MTM encounter data. The data collection will include 17 unique data elements and three monitoring measures. The three monitoring measures include:

  1. Percentage of beneficiaries discharged from the hospital who received enhanced MTM services.
  • Track percentage of high-risk patients discharged from the hospital who received enhanced MTM services within 7 days.
  • The targeting criteria of high risk patients will be determined by the PDP and approved by CMS.
  • Exclusions are targeted patients discharged to hospice, acute rehabilitation, or skilled nursing facilities.
  1. Percentage of targeted beneficiaries with at least one medication therapy issue
  • Targeted beneficiaries are those that meet the CMS approved targeting criteria.
  • “Identified medication therapy issue” means any issue that can be resolved by enhanced MTM interventions. (drug–drug interactions, patient confusion, affordability issues, etc.)
  • Valid issues will be defined by a specific list of SNOMED (Systematized Nomenclature of Medicine) CT codes.
  1. Percentage of MTM recommendations that are implemented
  • Percentage of encounter records for enhanced MTM recommendations that have a corresponding change in Part D claims.
  • “Implemented” means that there is a corresponding change in a patient’s drug claims (or other supporting documentation) that relates to the intervention.
  • “Intervention” includes recommended actions as represented by the SNOMED CT Codes (start drug therapy, stop drug therapy, change medication dose, etc.)

These measures are not tied to performance payments; they are for informational and monitoring purposes only.  The purpose of these measures is to provide CMS with a measure of the difference between the services provided to the “at risk” group—the population of beneficiaries targeted for EMTM Model—and the “treated” group, those who actually received enhanced MTM interventions. Evaluation of health outcomes (e.g., mortality, preventable hospitalizations) and patient satisfaction will be reserved for a more formal evaluation.

CMS will also offer a performance-based incentive payment at a fixed $2.00 per-member in return for a minimum savings rate of 2%, in reduction in Medicare costs of care and successful data and quality reporting. Eligibility for the performance payment incentive will be calculated based on cost reductions in Parts A and B costs net of model prospective payments. CMS is setting a minimum savings rate of 2%, because they believe this level is consistent with their general expectations about the magnitude of the potential impact of this model, and is also sufficiently large that the risk of paying performance payments based on random variations in expenditures is limited.

CMS has developed new MTM-related data and metric collection requirements for both monitoring and evaluation purposes and will include data on specific beneficiary-level interventions and outcomes. These will be identified through the use of Systematized Nomenclature of Medicine (SNOMED) codes. SNOMED codes are not currently widely used, but can be used to represent clinically relevant information in a consistent and reliable manner. SNOMED codes will be discussed in greater detail in the next blog.

Enhanced MTM Model: Monitoring Success

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