Medicare Part D’s Medication Therapy Management (MTM) program intends to optimize clinical benefits and avoid drug-related problems among eligible beneficiaries. MTM services—involving pharmaceutical and clinical interventions—are offered at no cost to beneficiaries who meet criteria related to annual Part D drug costs, the prevalence of chronic diseases and number of prescription drugs.[1]

The program has, however, failed to thrive since its establishment in 2006. In 2014 CMS estimated that of the 2.5 million beneficiaries eligible for MTM services 13% opted-out and only 10% received an annual comprehensive medication review—a central and mandated feature of the model.[2] Critics have noted unsupported infrastructure, uniform service offering requirements that restrict effective resource allocation and a lack of financial incentives for plan sponsors as barriers to uptake.

Ready for a revival, the Centers for Medicare & Medicaid Services (CMS) has announced a new model encouraging investment and innovations in medication management: the Part D Enhanced MTM Model.[3]

The Model targets sponsors of stand-alone individual market basic prescription drug plans in designated regions. Participating plans are offered two anticipated advantages: (1) regulatory flexibility to allow for individualized—and risk-stratified—interventions and (2) additional financial incentives including a performance payment. The performance payment will be in the form of a premium subsidy in a future year, translating into a competitive advantage for successful plans thereby able to offer their products to consumers at a lower price.

The Enhanced MTM Model will be tested across a 5-year period, from 2017 through 2021, and in 5 of the 34 Part D regions: Region 7 (Virginia), Region 11 (Florida), Region 21 (Louisiana), Region 25 (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming), and Region 28 (Arizona).

This is a welcome complement to integration and coordination transformations promoted by other Medicare initiatives such as accountable care organizations. A recent report from the IMS Institute for Healthcare Informatics estimated that mismanaged medication use (e.g., mismanaged polypharmacy, nonadherence, delayed evidence-based practice and the suboptimal use of generic drugs) was associated with $213 billion unnecessary medical spending.[4] Moreover, medication management impacts quality indicators focused on successful care transitions, including hospital readmissions. While participation in the pilot is limited, results will likely be of interest to additional parties seeking best practices related to the identification of patients most likely to benefit from medication management, the achievement of desired outcomes, effective payment models and performance evaluation.

CMS is hosting a webinar on the Enhanced MTM Model on October 21, 2015.[5]

[1] 42 C.F.R. § 423.153(d).

[2] Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs, 79 Fed. Reg. 100, 299946 (May 23, 2014).

[3] The announcement, including guidance for the preparation of proposals, is available here.

[4] The IMS Institute for Healthcare Informatics report can be found here.

[5] More information on the webinar is available here.