It is both exciting and rewarding to see pharmacists, pharmacies and the services pharmacists provide mentioned numerous times in the September 28, 2015 Centers for Medicare and Medicaid Services (CMS) announcement of the Part D Enhanced Medication Therapy Management Model (EMTM). These mentions include:

The Part D Enhanced MTM Model is intended to incentivize strengthened linkages among sponsors, pharmacies, and prescribers.

Stand-alone basic PDP sponsors and subcontracted MTM vendors may seek to engage pharmacies more extensively in the MTM process, and may further subcontract certain duties or contract with them to increase beneficiary and prescriber engagement in the MTM process.

Pharmacies are situated to provide a unique set of additional appropriate-medication-use-related items or services to beneficiaries that are associated with the dispensing of medication. Those might include home delivery, prescription synchronization, or compliance packaging.

Test of this EMTM model will begin January 1, 2017 with a five year performance period. Six Part D Prescription Drug Plan (PDP) sponsors that operate a total of 22 Plan Benefit Packages and provide benefits to an estimated 1.6 million beneficiaries in eligible Part D Regions will participate in the first year of the model. The test will determine whether providing Part D Prescription Drug Plan (PDP) sponsors with additional payment incentives and regulatory flexibilities will stimulate enhancements in the current Part D MTM program. It is hoped that direct financial subsidies from CMS will encourage Part D PDP sponsors to invest more in MTM programs (i.e. payment to pharmacists and pharmacies ) leading to improved therapeutic outcomes, while reducing net Medicare expenditures.

In the previous blog, I shared with you that in the September 28 EMTM announcement “pharmacist” or “pharmacies” was mentioned 35 times, with payment to pharmacists mentioned in 5 separate sections.. Let’s take a closer look at some quotes in the announcement:

Greater reliance on local pharmacists to identify at-risk individuals and to be authorized and compensated at negotiated rates by the plan for providing targeted counseling and other MTM services;Greater reliance on clinical pharmacist screening or mediation of communications with prescribers;

Providing beneficiary medication histories to physicians or other providers in accessible and clinically relevant formats;

Enabling physicians to order pharmacist consults directly from a standardized list of services on electronic medical record order entry screens;

Development of effective means to acknowledge, track, and measure over-the-counter (OTC) medications to detect and prevent harms that can arise from use of OTC products when combined with prescription medications;

Prospective medication refilling and pre-notification of prescription ordering, or prescription refill synchronization.

As part of this EMTM model, regulatory flexibilities and payment incentives will be offered to the PDP sponsors chosen to participate in this model. It will still be up to the organized pharmacists’ community to be front and center promoting the value pharmacists can bring to this model and seek payment. In most of the CMS announcement document the words “may” or “might” are used when it comes to payment for pharmacists services. Even in the section in EMTM Announcement titled MTM Services Delivered through Pharmacies, it mentions

Stand-alone basic PDP sponsors and subcontracted MTM vendors may seek to engage pharmacies in the MTM process, and may further subcontract certain duties or contract with them to engage in the MTM process. Pharmacies might be compensated by the PDP to perform the consultative MTM function.

Especially disturbing was the mention in the waiver section:

This includes waiver of the requirement that MTM “may be furnished by a pharmacist” to the extent necessary to test this model,

and in the MTM Services Delivered through Pharmacies section:

CMS will require that contracted items and services, and the protocols and criteria for the dispensing of items and services, must be submitted to CMS for approval regardless of whether they are to be dispensed by a pharmacy or not. At this level of intervention, increased costs incurred for the pharmacy’s items and services must be borne by the stand-alone basic PDP sponsor, and separately contracted and accounted for in a manner that can be audited by CMS.

We have documents, studies, and reports all demonstrating the value pharmacists bring in improving outcomes and reducing costs. Even CMS acknowledges in its own study that the Part D MTM programs

“substantially improved medication adherence for beneficiaries with congestive heart failure, chronic obstructive pulmonary disease (COPD), and diabetes. The study found that this led to significant savings in hospital costs, including reductions of nearly $400 to $525 in overall hospitalization costs  per patient for beneficiaries with diabetes and congestive heart failure.”

The opportunity is here and now and it is important that we seal the deal and make sure that some of the “free money” participating PDP sponsors will be getting as part of this model will be paid to pharmacists and pharmacies to continue to do what we do so well.

Opportunity is knocking – will we answer? In the next blog we will take a look at what CMS is requiring for data collection and tracking of quality indicators. Until then, you may go to Announcement (PDF) for more information about the Enhanced Medication Therapy Management Model.

Enhanced MTM: Opportunity Knocks

Post navigation

Leave a Reply

Your email address will not be published. Required fields are marked *