In September 2015, the Centers for Medicare and Medicaid Services (CMS) announced a Part D Enhanced Medication Therapy Management (MTM) Model and began looking for participants in a five year test of this model. The concept of an enhanced medication therapy management model was something the pharmacy community had been hoping for since the passage of the Affordable Care Act.

As a former pharmacy association state executive and an alumni member of the National Alliance of State Pharmacy Associations, I receive their excellent weekly updates of new developments in our profession. In their early October update, there was one particular headline that caught my eye – “Participants Selected for Part D Enhanced Medication Therapy Management Model.”

The Enhanced MTM model test will begin January 1, 2017 with a five-year performance period. This is a major moment for pharmacy. It’s a big deal!

Why is this such a big deal? The Medicare Modernization Act (MMA), which created the Part D program, required that every Part D plan offer an MTM program as a quality improvement feature. Part D MTM regulations required uniform service offerings to beneficiaries who meet the plan’s MTM program criteria, which needed to be expressed in terms of numbers of medications and chronic conditions, and expected annual prescription drug costs. According to CMS, Medication Therapy Management refers to the activities and resources devoted to optimizing medication use by specific patients. In general,

“MTM refers to activities intended to optimize therapeutic outcomes by ensuring that patients are taking their medications safely and as prescribed, addressing any barriers to their doing so, and bringing issues to the attention of the treating physician if any changes should be considered.”

The Affordable Care Act established the Center for Medicare and Medicaid Innovation for the purpose of testing

“innovative payment and service delivery models to reduce program expenditures … while preserving or enhancing the quality of care”.

There was a concern the current Medicare Part D criteria for offering MTM services could result in a misallocation of MTM resources because of an over or under identification of beneficiaries who would most benefit from MTM services, therefore the Part D Enhanced MTM Model test was developed.

The key elements of this model include:

Regulatory flexibilities

  • Allow stratification of beneficiaries with respect to medication-related risk and offer different levels and types of MTM services.
  • Allow the provision of incentives based on each beneficiary’s risk level and individual barriers, to ensure MTM participation.
  • Allow inclusion of a wide variety of intervention activities such as patient education and follow-up strategies with beneficiaries and providers.

Payment Reform

  • A direct (“outside the bid”) prospective payment to Prescription Drug Plan sponsors to support the cost of the expansion interventions, and
  • A performance payment to plans that are successful in improving outcomes and reducing Part A/B expenditures

In a nutshell and in the words of CMS

“The Enhanced Medication Therapy Management (MTM) model is an opportunity for Part D basic stand-alone prescription drug plans (PDPs) to offer innovative MTM programs aimed at improving quality of care while also reducing costs. The Enhanced MTM 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 (including adverse drug interactions)—while reducing net Medicare expenditures.”

This sounds like the perfect opportunity for pharmacists to demonstrate the value of their services and the important role they can play as a member of the health care team. The September 28, 2015 CMS Announcement of the Enhanced MTM model test mentions pharmacy or pharmacist 35 times. In at least 5 separate sections, payment to pharmacies and pharmacist is mentioned. Definitely a big deal!

Look for more on this model MTM program in future posts.

What Is Enhanced MTM?

Post navigation

Leave a Reply

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