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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 & Medicaid Services (CMS).
CMS’ Center for Medicare & Medicaid Innovation (Innovation Center) announced a model test spanning 5 years to further explore benefits of MTM for stand-alone Part D sponsors.
A Medicare Advantage Plan 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.
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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.
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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).
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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.
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The value of MTM in stand-alone Part D plans is being further evaluated through the Part D Enhanced Medication Therapy Management (EMTM) model test. Announced by the Centers for Medicare & Medicaid Services (CMS) Center for Medicare & Medicaid Innovation (Innovation Center), this model test will run for a 5-year performance period and ...