HEDIS® Guide 2019 MTM Pharmacy Intervention

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Medication Therapy Management: An Intervention with Far-Reaching Quality Impacts

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.

Link to Medicare Star Ratings

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:

  • Interventions for beneficiaries and prescribers.
  • An annual comprehensive medication review (CMR) – a systematic process of collecting member-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them with patient, caregiver, and/or prescriber.
  • Quarterly targeted medication reviews with follow-up interventions when necessary.

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

Numerous Quality Domains Impacted By MTM

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 is an intervention with far-reaching quality measure impacts

MTM touches numerous HEDIS measures.

Direct HEDIS Medication Reconciliation Measures Measures with Medication Component Readmissions Measures Experience of Care HEDIS Measures
  • Medication Reconciliation Post Discharge
  • Transitions of Care
  • Use of High Risk Medications in the Elderly
  • Annual Monitoring for Patients on Persistent Medications
  • Pharmacotherapy Management of COPD Exacerbation
  • Controlling High Blood Pressure
  • Persistence of Beta-Blocker Treatment After a Heart Attack
  • Statin Therapy for Patients With Cardiovascular Disease
  • Comprehensive Diabetes Care
  • Statin Therapy for Patients With Diabetes
  • Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
  • Osteoporosis Management in Women Who Had a Fracture
  • Antidepressant Medication Management
  • Adherence to Antipsychotic Medications for People with Schizophrenia
  • Plan All-Cause Readmissions
  • Hospitalization Following Discharge From a Skilled Nursing Facility (New for HEDIS 2019)
  • Rating of Health Plan
  • Getting Needed Care
  • How Well Doctors Communicate

Beyond HEDIS, MTM impacts numerous Medicare Advantage Star Ratings measures.

The MTM Measure Other Part D Measures Part C Measures Experience of Care Measures
  • MTM Program Completion Rate for CMR
  • Medication Adherence for Diabetes
  • Medication Adherence for Cholesterol (Statins)
  • Medication Adherence for Hypertension (RAS Antagonists)
  • Annual Flu Vaccine
  • Care for Older Adults – Medication Review
  • Osteoporosis Management in Women who had a Fracture
  • Diabetes Care – Blood Sugar Controlled
  • Rheumatoid Arthritis Management
  • Improving Bladder Control
  • Plan All-Cause Readmissions
  • Statin Use in Persons with Diabetes
  • Statin Therapy for Persons with Cardiovascular Disease
  • Getting Needed Care
  • Customer Service
  • Rating of Health Care Quality
  • Rating of Health Plan
  • Care Coordination

Prioritizing the Use of MTM

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.

MTM Program Checklist

  • Use predictive analytics to stratify the population and create a list of high-risk members who qualify for MTM services.
  • Use predictive analytics to further stratify the population based on members who are not adhering to medications.
  • Evaluate member with a detailed profile (a holistic view) gained from pharmacy and medical claims detail, member interview, laboratory, and other clinical data sources.
  • Complete member gap analysis for members identified as candidates for MTM.
  • Identify multiple care domains from the overall quality plan to impact through MTM services.
  • Prioritize the top care domains for addressing through the MTM program.
  • Hire or contract with pharmacists trained and certified in MTM and the impact this service can have in improving quality measures.
  • Provide MTM services to qualified members.
  • Evaluate MTM services results and adjust program for continuous improvement.


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)

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