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KEY POINTS

KEY POINTS

  • Participation in Part D medication therapy management (MTM) programs is lower than predicted, and this has frustrated Part D plan sponsors and the federal government, especially considering MTM’s success in some Medicaid and private-sector programs.

  • The Centers for Medicare and Medicaid Services (CMS) defines MTM as a patient-centric and comprehensive approach to improve medication use, reduce the risk of adverse events, and improve medication adherence.

  • The MTM scope of services within Part D is evolving. This requires constant surveillance of the literature and CMS communications.

  • Under Part D, free MTM services are generally reserved for enrollees who meet criteria related to their annual Part D drug costs, number of prescription drugs, and prevalence of certain chronic diseases.

  • The Centers for Medicare and Medicaid Innovation (CMMI) have developed the Enhanced MTM Model to allow sponsors regulatory flexibility and financial resources to design MTM programs that best fit their beneficiaries’ needs. The goal of this innovative MTM model is to align the interest of Part D sponsors and CMS.

  • MTM is showing promise in other non-Medicare drug benefit programs.

  • The Patient Protection and Affordable Care Act (PL 111-148) authorized grants for “medication management services” in all practice settings (Section 3503), noting that such services will help manage chronic disease, reduce medical errors, and improve patient adherence to therapies while reducing ­acute-care costs and hospital readmissions. However, funds were never appropriated for this section.

  • Part D’s inherent structure makes it particularly challenging to create and sustain robust MTM programs. However, CMS research (2013) identified effective MTM practices of highly effective drug plans.

BACKGROUND AND PROGRAM EXPECTATIONS

Federal law requires Medicare Part D drug plan sponsors to offer MTM programs to help targeted enrollees avoid drug-related problems and optimize medication benefits. In 2006, such programs were hailed as a “win-win” proposition for plans, pharmacists, and beneficiaries.1 However, today, MTM participation is lower than predicted, and it is still not possible to evaluate whether Part D MTM programs are working as intended. This has frustrated Part D plan sponsors and the federal government, especially considering MTM’s success in some Medicaid and private-sector programs. This chapter describes policy strategies implemented by CMS to increase MTM participation and improve health outcomes while reducing Medicare expenditure. Additionally, other medication management services beyond standard Part D MTM are profiled.

For most people, the term “pharmacists’ services” may conjure up traditional pill-counting and -dispensing functions and nothing more. Since 2006, however, Medicare’s voluntary prescription drug benefit, Part D, has played an important role in expanding the scope of such services. Part D plans must provide MTM programs to help eligible enrollees avoid drug-related problems and achieve desired clinical benefits from medications.2

In 2016 CMS defined MTM as a patient-centric and comprehensive approach to improve medication use, reduce the risk of adverse events, and improve medication adherence.3 Historically, MTM services represent a bundling of ...

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