Over 80% of the plans participating in the CMS Enhanced Medication Therapy Management (MTM) model test showed reductions in medical spending! Read more about Enhanced MTM in our post from 2017.
The Centers for Medicare and Medicaid Services (CMS) Innovation Center’s Part D Enhanced MTM model test began January 1, 2017. This 5-year model program had 6 Part D sponsors operating 22 Prescription Benefit Plans (PBP) participating in this model to test whether providing Part D sponsors with additional payment incentives and regulatory flexibilities would promote innovative MTM programs that will lead to improved outcomes and reduced costs. The CMS Enhanced MTM model test rollout announcement mentioned pharmacy or pharmacist 35 times. In at least 5 separate sections, payment to pharmacies and pharmacist is mentioned. 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.
Part D sponsors submitted detailed descriptions of alternative enhanced MTM program eligibility, targeting criteria and interventions to the Centers for Medicare and Medicaid Innovation. The alternatives included 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 CMS.
The Enhanced MTM Model offers a performance-based payment to participating prescription drug plans (PDPs) in a Part D region if their enrolled members’ medical (Part A and B) expenses are reduced by at least 2 percent in a given plan year compared to a benchmark that simulated their performance if they were not in the model.
To accurately monitor sponsors’ implementation of their approved enhanced MTM program and to evaluate the overall success of the Enhanced MTM Model, CMS is collecting enhanced MTM encounter data. 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.
First Year Results
The first year performance-based results of the CMS Innovation Center Part D Enhanced MTM model were released on November 30, 2018. The 1.7 million beneficiaries enrolled in the participating plans spent approximately $325 million less than the anticipated spending benchmark. Of the 22 Prescription Benefit Plans :
- Eleven out of 22 participating plans were eligible to receive the performance-based payment because their medical spending was reduced by 2 percent or more.
- Seven participating plans showed reductions in medical spending, but the reductions were less than 2 percent and therefore the plans were ineligible to receive the performance-based payment.
- Four plans had shown increases in spending and were therefore ineligible to receive the performance-based payment.
The second year performance-based results of the CMS Innovation Center’s Part D Enhanced MTM model were released on October 8, 2019. The 1.7 million beneficiaries enrolled in the participating plans spent approximately $684 million less than the anticipated spending benchmark. Of the 22 Prescription Benefit Plans:
- Fourteen out of 22 participating plans were eligible to receive the performance based payment because their medical spending was reduced by 2 percent or more.
- Six participating plans showed reductions in medical spending, but the reductions were less than 2 percent and therefore the plans were ineligible to receive the performance-based payment.
- Two plans showed increases in spending and were therefore ineligible to receive the performance-based payment.
(The results reported above for both year 1 and 2 were based on a comparison of PBP’s spending compared to a benchmark.)
Performance-based payments will begin in Year 3 with the results of Year 1 will determining payments in Year 3; Year 2 results determining payments in Year 4, etc.
Evaluation and Opportunity
CMS contracted with Acumen, LLC and its partner Westat, Inc. (“the Acumen team”) to conduct a mixed-methods evaluation of the Enhanced MTM Model. This First Evaluation Report for the Enhanced MTM Model, which covers the first 20 months (January 2017 – August 2018) of Model implementation, describes the Model, participating Part D sponsors, and beneficiaries eligible for services, and presents qualitative findings related to Model implementation, successes, and challenges from the early perspectives of participating sponsors and vendors, their workforce, and the beneficiaries enrolled in participating plans. Click for the complete evaluation report.
In a 1/14/16 article in the Pharmacy Times, the anticipated implications of Enhanced MTM on community pharmacies were presented and the opportunities discussed. These included:
- Specific services that community pharmacists are contracted to provide (either directly with the PDP or by an MTM vendor) could differ significantly from what is currently required such as more than just 1 annual Targeted Medication Review (TMR), more frequent Comprehensive Medication Reviews (CMRs);
- More actively involved community pharmacists in identification of eligible patients for MTM;
- Increasing beneficiary acceptance of CMRs through more pharmacist personalized strategies;
- Improved relationships of pharmacists with physicians in coordination of care efforts;
- Additional pharmacist interventions, such as value-added products and services, to complement their MTM program; for example adherence packaging and medication synchronization;
- Pharmacist access to beneficiaries’ Part A and B claims data;
- Electronic exchange of interoperable MTM documentation;
- Creation of new MTM metrics to better optimize patient eligibility criteria and approaches for tailoring service delivery.
As the model test continues, we will continue to monitor how pharmacists and pharmacies implement the opportunities presented.