CMS Ups Expectations for Delivery of MTM and CMRs

Eileen Koutnik-Fotopoulos

San Francisco—“The need for pharmacy integration throughout the health plan organization is crucial as trends in the industry focus on medication therapy management (MTM), drug utilization review (DUR), and Medicare Star Ratings,” Brad Tice, PharmD, and Cyndi Barham, PharmD, told attendees during a Contemporary Issues session at the AMCP meeting. Dr. Tice, chief clinical officer, PharmMD, and Dr. Barham, senior director, quality initiatives, PharmMD, gave a presentation titled MTM: Changes, Growth, Medicare Star Ratings, and Trends in the Industry.

Initiated in 2003 by the Centers for Medicare & Medicaid Services (CMS), MTM has become an integral component of effective healthcare administration for Medicare Part D eligible beneficiaries. Since its inception, it has expanded into 3 key health market segments: Medicare, Medicaid, and commercial/self-insured health plans. CMS is concerned, however, about low enrollment numbers in MTM programs. Therefore, CMS is reexamining MTM eligibility criteria.

Key changes for MTM eligibility include:

• Adding Alzheimer’s disease and end-stage renal disease to the list of core chronic diseases for targeting

• Adding atrial fibrillation and chronic noncancer pain to the list of noncore chronic diseases

• Requiring plan sponsors to target 5 out of the 9 core chronic conditions, which modifies the current criteria of targeting 4 out of 7 core chronic diseases

• Increasing the percentage of members who will be eligible for MTM.

CMS stated in its 2010 MTM Fact Sheet that they expected 25% of Medicare beneficiaries to be eligible for MTM. Current data shows 10% to 13% are being identified as eligible by health plan sponsors.

Requirements for comprehensive medication review (CMR) delivery rates are also increasing. The average percentage of MTM eligible beneficiaries receiving a person-to-person CMR is approximately 8%. CMS is expecting that figure to increase to 15%. As a result, members must be targeted for a CMR within 60 days of identification eligibility. Plan sponsors should address problems or concerns of patients and perform more outreach using multiple and nonpassive methods.

Dr. Tice and Dr. Barham also outlined Level Three: Improved Retrospective DUR Programming and Case Management Requirements. Part D sponsors should create and monitor beneficiary-level reports to identify patterns of apparent duplicative drug use over sustained periods of time and/or across multiple drug products. Clinical staff should review the reports and the beneficiaries’ medication histories, and, when warranted, intervene with prescribers, pharmacies, and beneficiaries to ascertain medical necessity. CMS will develop monitoring protocols to ensure sponsors are implementing effective controls against overutilization.

The CMS Star Ratings program was also discussed during the presentation. The Star Rating system is a set of >40 quality measures defined by CMS that are used to rate and rank Medicare Advantage plans and prescription drug plans. Each measure is rated on a scale of 1 to 5. Health plans have a vested interest in maximizing their Star-related activities to ensure continued performance bonuses.

CMS changes for 2012 Part C and Part D Plan Ratings include:

• Weighting of the measures to provide greater weight to clinical outcomes and lesser weight to process measures

• Controlling for the concentration of providers in a geographic area

• Rewarding contracts for quality improvement

• Reducing the overall and/or summary Plan Ratings for contracts with serious compliance issues.

“Now is an important time for pharmacy departments to integrate programs,” Dr. Tice and Dr. Barham concluded. “Plans need to act now and think strategically to design programs and develop infrastructure, systems, and processes to ensure success.”