5: Payer Perspective

KEY POINTS

• Plan sponsors are approached about medication therapy management (MTM) from various players for a variety of reasons.

• Some plans offer MTM to some or all of their members due to contractual agreements, while others provide MTM to improve patient outcomes and reduce healthcare costs.

• Medicare Part D sponsors are mandated to provide MTM to beneficiaries who meet certain requirements as outlined by the Centers for Medicare and Medicaid Services.

• A Medicare Advantage Plan (MAPD) may choose to use MTM programs to supplement efforts to improve quality measures.

• When establishing an MTM program, plan payers must determine membership criteria, service offerings, and service delivery methods as well as whether to insource or outsource the program to meet the desired outcomes.

• Plans can use national pharmacy organizations, MTM vendors, pharmacy benefit managers, and individual MTM providers as sources for determining program services and potential outcomes.

• MTM service providers should respond to plan requests for information and requests for proposals in order to be considered as a potential vendor for the plan.

• Plans may contract for reimbursement of MTM services through a variety of methods.

• Vendors of MTM services should be prepared for required audits by plan payers (eg, delegation audits, data validation audits, etc).

• Quality assurance is a key component of any MTM program and should be implemented by every MTM provider.

• All clinical programs, including MTM, should be continuously evaluated to ensure that desired outcomes are achieved and that improvements are implemented.

INTRODUCTION

Plan sponsors are often approached by internal and external parties to consider medication therapy management (MTM) as a plan service to improve patient outcomes. A payer must determine which members to enroll, what services to provide, what service providers to use, and how to measure success.

A plan's perspective on the establishment, oversight, and management of an MTM program will vary depending on the reasons it was initiated. Commercial, employer group, and government-sponsored plans tend to establish MTM programs to either satisfy regulatory requirements or to manage healthcare outcomes for an anticipated return on investment (ROI).

The 2003 Medicare Modernization Act (MMA) mandated that all Medicare Part D plan sponsors offer MTM services.¹ Under guidelines set by the states, Medicaid sponsors can be contractually obligated to perform MTM through state contracts. Based on expected ROIs, plan sponsors may identify population-specific parameters that may warrant drug therapy interventions through MTM.

DETERMINING MTM CRITERIA

Determining membership criteria is an essential step for any payer establishing an MTM program. The 2003 MMA mandated that all Part D plan sponsors offer MTM services to beneficiaries who meet certain requirements:

1. Multiple chronic disease states

2. Multiple medications covered by Part D

3. Annual costs for Part D medications exceeding a specified threshold determined by the United States Secretary of Health and Human Services¹

State requirements ...