Medicare Part D: New MTM model emphasizes medication adherence

November 10, 2015

CMS will now offer payers enticements to increase patient med adherence under the existing MTM model. The Part D effort is specifically focused on stand-alone Part D plans.

In September 2015, the Centers for Medicare and Medicaid Services (CMS) expanded its Medicare Part D program to include medication adherence for beneficiaries of its Medicare Part D plans.

Ned MilenkovichAlthough  “medication therapy management” (MTM) is a cognitive intervention of longstanding in pharmacy practice, CMS will now offer payers enticements to increase patient adherence to their medications under the existing MTM model. The Part D effort is specifically focused on stand-alone Part D plans.

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Substantial improvement

The new Part D MTM model will address whether providing Part D sponsors with additional payment incentives and regulatory flexibilities will sharpen the MTM program, leading to improved therapeutic outcomes while reducing net Medicare expenditures. Stand-alone basic Part D plans can benefit through implemention of innovative strategies to optimize medication use, improve coordination of care, and strengthen system linkages.

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Tailored MTM services will be available for participating Part D plans. Factors such as the enrollee’s level of medication-related risk and current barriers to improvement will be used to determine the appropriate services to provide.

This approach is a substantial improvement over the current model, which provides uniform service offerings to all Part D enrollees who meet the program’s criteria. The criteria, which are based on numbers of medications, chronic conditions, and expected annual prescription drug costs, do not include a variable to account for the enrollee’s specific needs or risk factors.

The new MTM model comes as stand-alone Part D plan premiums are projected to increase, while the number of plans will decrease.

Big changes

Avalere Health, a healthcare consulting firm based in Washington D.C., has released the following figures:

Ten of the most popular Part D plans, representing more than 80% of Part D plan enrollment, will have an average premium increase of 8% in 2016. This will increase many beneficiaries’ premiums to more than $40 a month, a first since the program’s inception in 2006. The number of plans is dropping 13.5%, from 1,001 currently to 886 next year.

“Medicare beneficiaries should carefully review their prescription drug plan options in 2016 to make sure they choose a plan that is right for them,” Colin Shannon, senior manager at Avalere Health, said in a statement. “With many plans taking large premium increases in 2016, those beneficiaries who choose not to change plans will likely pay more in premiums than if they look for lower-cost options.”

 

Nonadherence grows

Stakeholders hope that the new model will be a beacon for change, as medication nonadherence has been steadily increasing. For instance, a 2014 Health Affairs analysis found that nonadherence increased from 14.4% in 2009 to 17% in 2011 among elderly beneficiaries with four or more chronic conditions.

Similarly, among the sickest elderly, the percentage that forwent basic needs in order to purchase medications went from 6.8% in 2009 to 10.2% in 2011.

The new MTM model will begin its five-year pilot in five regions: Arizona, Florida, Louisiana, Virginia, and a larger region that includes Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, and Wyoming.

Officials at CMS call the changes extremely positive. “As part of our approach to building a healthcare delivery system that results in better care, smarter spending, and healthier people, CMS will test changes to the Part D program to give prescription drug plans stronger incentives and flexibility to improve prescription drug safety and efficacy,” said Dr. Patrick Conway, CMS deputy administrator for innovation and quality, in a statement about the model.