Why is MTM necessary? Drug therapy problems present a serious issue in healthcare in the United States.  According to the American Society of Consultant Pharmacists (ASCP), experts estimate that 1.5 million preventable adverse events occur each year, resulting in $177 billion in injury and death.

The people who can benefit the most from MTM are those with chronic conditions and prescribed multiple medications.  More than 77% of seniors between the ages of 65 and 79 suffer from one or more chronic diseases. The number rises to 85% for those over age 80.  Medication-related problems are estimated to be one of the top five causes of death in that age group, and a major cause of confusion, depression, falls, disability, and loss of independence.  Common drug therapy problems include: unnecessary drug therapy, drug use problems, ineffective drug therapy, adverse drug events, and more .  More statistics on the effect of drug therapy problems on seniors' health as well as the economic impact may be found on the ASCP fact sheet.

MTM and Medicare Part D Plans (PDP & MA-PD)

In an effort to lower these alarming statistics, the Center for Medicaid and Medicare Services (CMS) has made an MTM program one of several required elements in the development of a Medicare Part D sponsor's bid as of 2013. Under 423.153(d), a part D sponsor must have an established MTM program that:

  • Ensures optimum therapeutic outcomes for targeted beneficiaries through improved medication use
  • Reduces the risk of adverse events
  • Is developed in cooperation with licensed and practicing pharmacists and physicians
  • Describes the resources and time required to implement the program if using outside personnel and establishes the fees for pharmacists or others
  • May be furnished by pharmacists or other qualified providers
  • May distinguish between services in ambulatory and institutional settings
  • Is coordinated with any care management plan established for a targeted individual under a chronic care improvement program (CCIP)

Plan sponsors must offer a minimum level of MTM services to each beneficiary enrolled in the program that includes all of the following:

  • Interventions for both beneficiaries and prescribers
  • An annual comprehensive medication review (CMR) with written summaries in CMS' standardized format.
  • The beneficiary's CMR must include an interactive, person-to-person, or Telehealth consultation performed by a pharmacist or other qualified provider; and may result in a recommended medication action plan.
  • If a beneficiary is offered the annual CMR and is unable to accept the offer to participate, the pharmacist or other qualified provider may perform the CMR with the beneficiary's prescriber, caregiver, or other authorized individual.
  • Quarterly targeted medication reviews (TMRs) with follow-up interventions when necessary.

Sponsors also have the option to provide value added expanded services such as: general education, newsletters, refill reminders, case management referrals, and other miscellaneous interventions to improve medication use.  As well as standalone PDP plans, Medicare advantage plans with prescription drug coverage (MA-PDP) plans have MTM programs.  Each MTM program must be approved by CMS annually

Who provides MTM?

According to CMS, over 86% of programs utilize outside personnel.  Outside personnel include: a Prescription Benefit Management (PBM) company, MTM vendor, disease management vendor, community pharmacists, and LTC pharmacists.  Part D Sponsors are required to explain how their fees account for the time and resources associated with their MTM program.  They have the flexibility to determine the billing mechanisms and establish fees for pharmacists and other qualified providers associated with providing the MTM services. These arrangements are between the Part D sponsors and the providers of the services.

How can a beneficiary enroll in an MTM program?

Sponsors must enroll targeted beneficiaries using an opt-out method of enrollment only.  Sponsors must target beneficiaries for enrollment in the MTM program at least quarterly during each plan year. CMS defines beneficiaries eligible by the following criteria: having multiple chronic diseases, taking multiple Part D drugs, and are likely to incur $3,017 for covered Part D drugs.  Sponsors have the option to make positive changes to eligibility requirements to increase the number of beneficiaries able to receive MTM services.  For example, a sponsor may expand the list of chronic diseases that apply and decrease the number of Part D drugs required (minimum is 2). These changes must be submitted to and approved by CMS annually.

In order to see if one is eligible, he or she can find out using this spreadsheet downloaded from CMS. This spreadsheet allows one to search by plan or by patient health information and drug list, and you can filter by plan type (PDP, MA-PD, etc), contract ID, or plan name. If a sponsor has expanded the eligibility requirements, the spreadsheet shows the specific qualifications for each plan such as the minimum number of Part D drugs the patient takes or specific number chronic health conditions required.  As of this year, sponsors are now required to have a dedicated "Medication Therapy Management Program" page linked from their Medicare drug plan website (such as the services or benefits page) with specific information about their MTM program written in plain language appropriate for beneficiaries.  The spreadsheet provides links to the plan websites.

How do MTM programs affect CMS Star Ratings?

As mentioned earlier under the section MTM and Medicare Part D plans, a minimum service of MTM programs is to provide targeted beneficiaries (including those in long term care) with a Comprehensive Medication Review (CMR).  A CMR is an interactive, person-to-person or telehealth medication review and consultation of a beneficiary's medications (including prescriptions, over-the-counter (OTC) medications, herbal therapies, and dietary supplements) by a pharmacist or qualified provider.  The percent of Medication Therapy Management (MTM) program enrollees who received and completed a Comprehensive Medication Review (CMR) during the reporting period is a display measure for Part D plans. This means that this percentage is not directly incorporated into a plan's star rating, but the information is reviewed and collected by CMS.

In CMS’s final 2015 advance notice and call letter, CMS announced they will wait until 2016 to incorporate the display measure for the medication therapy management (MTM) program completion rate for comprehensive medication reviews (CMR) into the Part D star ratings. This is because the Part D proposed rule contained so many changes to MTM that CMS wanted the dust to settle for a year before those changes start affecting star ratings, according to APhA Associate Director of Health Policy Michael H Ghobrial, PharmD, JD.