Medications can prevent or manage many acute and chronic illnesses, but when used inappropriately, patients fail to experience the best possible outcomes and may experience negative effects. Adverse drug effects, drug-drug interactions, inadequate dosing, and nonadherence often lead to potentially avoidable medical problems. Medication Therapy Management (MTM) is an effective pharmacy intervention that can have far-reaching results in improving health and controlling chronic conditions. MTM services have been shown to improve medication appropriateness and adherence, reduce health plan medication expenditures, and reduce hospitalizations.1 An estimated annual savings of $200 – $350 per participant can be achieved through MTM programs.2 Despite these benefits, less than half of individuals eligible to receive MTM in Medicare Part D plans receive this service.2
Offered by government-sponsored and commercial health plans, MTM programs are designed to optimize drug regimens to create better therapeutic outcomes and thus provide significant value to members. This is especially true for those taking several medications for multiple medical conditions, such as diabetes and chronic heart failure. Data has shown the opportunity for cost-savings is even greater if medication adherence resources are focused on patients with three or more chronic conditions, such as hypertension, diabetes, and high cholesterol.3
NCQA identifies consistent medication reconciliation, a key part of MTM programs, as one of the services that increases care quality and decreases rehospitalization. By reinforcing the correct use of drugs, medication reconciliation contributes to safe care transitions from the hospital to post-acute care settings and from post-acute care settings to the community. For example, the new 2019 measure Hospitalization Following Discharge from a Skilled Nursing Facility assesses the percentage of skilled nursing facility discharges resulting in hospitalization within 30 days and 60 days. Older adults in this population frequently have multiple medical conditions and greater use of medications, therefore medication reconciliation is an important quality-improvement activity that can help reduce readmissions in this setting.
The MTM services and medication reconciliation measures have strong links to the Medicare Star Ratings program. Medicare Part D sponsors are required to offer a CMS-approved MTM program for eligible members of their plan. Requirements from CMS change each year to foster continuous improvement. The minimum level of services in a Part D MTM program includes:
For targeted beneficiaries enrolled in the MTM program that are in an LTC setting, sponsors are not required to offer the interactive CMR component, but still must perform quarterly medication reviews and offer interventions targeted to the beneficiaries’ prescribers.
While almost all Part D programs offer the interactive, person-to-person comprehensive medication review services by phone, MTM programs offering services through face-to-face interaction (82.4% in 2017) and/or through telehealth technologies (interactive audio and video systems) (48.3% in 2017) are increasing.4
Health plans can link a variety of quality improvement activities to an MTM program. For Medicare Advantage plans, several Part C Star Rating measures involve drug therapy, such as osteoporosis in women who have had a fracture and are controlling blood pressure. By tying the comprehensive medication review to quality goals, health plans can help to achieve the greatest return in member outcomes, quality performance improvement, and cost savings resulting from their MTM investment.
MTM touches numerous HEDIS measures.
Beyond HEDIS, MTM impacts numerous Medicare Advantage Star Ratings measures.
Reaching out and engaging members in their drug therapy requires significant resources including clinicians such as pharmacists and support staff to complete comprehensive medication reviews and follow up. Since this service is time intensive, health plans must prioritize these activities. Advanced analytics can help health plans establish a list of members at high risk for health complications who may benefit the most from these services. The following checklist outlines steps to guide health plans in identifying qualified members and providing these members with effective MTM services.
Optimizing medication regimens through MTM services remains one of the most effective quality-improvement activities. Compared to other interventions designed to improve health outcomes, taking correct medications may be one of the more simple behavior changes for a member to make. While MTM services require an investment from the health plan, they can bring significant value with better HEDIS and other quality rating results. As part of a larger integrated strategy, MTM services can help plans achieve better health outcomes and lower costs of care across multiple domains.
1 Viswanathan M, Kahwati LC, Golin CE, et al. Medication therapy management interventions in outpatient settings: a systematic review and meta-analysis. JAMA Intern Med. 2015;175:76–87.
2 Centers for Medicare & Medicaid Services. Evidence Supporting Enhanced Medication Therapy Management. https://innovation.cms.gov/Files/x/mtm-evidencebase.pdf. Accessed June 22, 2018.
3 Kymes SM, Pierce RL, Girdish C1, Matlin OS, Brennan T, Shrank WH. Association among change in medical costs, level of comorbidity, and change in adherence behavior. Am J Manag Care. 2016 ;22(8):e295-301.
4 Centers for Medicare & Medicaid Services. 2017 Medicare Part D Medication Therapy Management (MTM)
Programs Fact Sheet. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/CY2017-MTM-Fact-Sheet.pdf. Published August 16, 2017. Accessed June 13, 2018.
* HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA)