CMS proposes expansion of MTM services in 2015


Medicare patients with only two chronic diseases and two Rx meds would be eligible for CMS-funded MTM services.

The Centers for Medicare and Medicaid Services (CMS) has issued a proposal that could be good news for pharmacists who offer Medication Therapy Management (MTM) services to Medicare Part D beneficiaries.

The proposed rule released by CMS at the beginning of January 2014 would encourage greater patient access to MTM services in 2015 by targeting patients who have as few as two chronic diseases and take only two prescription medications, with a total drug spend of $620. This is in stark contrast to the 2010 eligibility requirement for MTM services, which states that health plan sponsors should not require more than three chronic diseases and more than eight Part D drugs, with a cost threshold of $3,000.

The reasoning behind the new proposed rule can be found in a 2007 evaluation ( conducted on behalf of the state of Minnesota by Principal Investigator Brian J. Isetts, PhD, BCPS, Associate Professor, University of Minnesota College of Pharmacy, and colleagues, which validated use of the resource-based relative value scale for MTM services. This evaluation showed that a patient taking two medications for just one indication had a risk of at least one drug-therapy problem. Patients with at least two indications could be taking three to five medications, with a risk of two drug-therapy problems, CMS said.

The annual cost threshold was also adjusted from $3,000 to $620 to reflect the increasing use of less expensive generic drugs by Part D beneficiaries. “We believe this increase in the use of lower-cost generics may contribute to low MTM program enrollment rates, which currently hover around 8%, and may also be a driver in racial disparity in MTM program enrollment,” the CMS proposal stated.



A sustainable practice model

Randy McDonough, PharmD, owner of two community pharmacies Iowa City, Iowa, is a proponent and practitioner of MTM services and writer of a monthly column on MTM pearls for the American Pharmacists Association’s Pharmacy Today. He is encouraged, he said, by the CMS proposal, which will open up MTM services to many more Part D beneficiaries.

“In the past, the numbers of patients identified as eligible by plan sponsors was low for most pharmacies. This makes it challenging for pharmacists to incorporate MTM services, when it impacts such an insignificant part of their practice,” McDonough told Drug Topics. “This new proposal should increase the number of eligible patients for a pharmacy, making it more realistic to develop a practice and business model that can be sustained in the future.”

He hopes that health plan sponsors will embrace the CMS proposal and increase the pool of eligible patients, McDonough said. In the past, CMS has found it disappointing that so few patients have received MTM services.

“A lot of people put the blame on pharmacists, and in some cases, it has been the pharmacists’ fault for not taking care of patients who are eligible in their practice,” said McDonough. “However, when you have a busy pharmacy and are trying to create a practice change, doing it for as few as 12 patients makes it challenging. It has to be a sustainable practice model that incorporates a lot of patients on a regular basis.”


Be prepared

Are you ready to become an interventionist? asks McDonough. That’s what you’ll need to be to deliver MTM services. You will have to identify and resolve drug therapy problems that you find during comprehensive medication reviews.

“Be becoming interventionists and documenting their interventions, pharmacists are able to demonstrate their clinical skills and therapeutic knowledge to these other stakeholders [patients, other healthcare providers, and payers]. Having an efficient documentation system is key, as this serves as a patient-care tool, legal record, and proof of care record, if audited,” said McDonough.

Pharmacists need to understand their state’s current pharmacy practice act and how they can use their technicians appropriately and effectively, he said, adding that patient-care processes need to be developed to ensure that every patient receives the same high-quality care.

Finally, said McDonough, pharmacists need to prepare a marketing and promotional plan that can differentiate them from other pharmacists. The main issues that need be conveyed are the pharmacist’s knowledge and skills in drug-therapy management, good time management, the proper resources to deliver MTM services, and good collaboration with other healthcare providers.

CMS is accepting comments on its proposal online at through March 7.

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