More Medicare beneficiaries could benefit from MTM services

February 10, 2014

Study finds that current eligibility criteria are too stringent. If plans lowered the drug-count requirement to the federal minimum of two, MTM eligibility would increase by almost two-thirds.

A study published in the January issue of Journal of Managed Care Pharmacy (http://bit.ly/mtmrule) supports the use of medication therapy management (MTM) services and backs the CMS proposed rule calling for greater access to MTM for Medicare beneficiaries.

Under the current 2011 MTM eligibility criteria, Medicare beneficiaries must have at least three chronic medical conditions, take eight or more medications, and spend approximately $3,000 annually on their drugs. The CMS proposed rule calls for Medicare Part D sponsors to design plans that would offer MTM services to beneficiaries who have only one chronic condition and take a minimum of only two medications, with a much lower annual drug spend of $650.

The study

The study selected a random sample of Medicare Part D beneficiaries who had at least one chronic disease - diabetes, chronic heart failure (CHF), or chronic obstructive pulmonary disease (COPD) - and followed them for three years (2006-2008). Patterns of drug exposure and adherence to angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and COPD controller drugs were monitored and compared among enrollees who were eligible for MTM services and those who were not.

“We found that use of evidence-based medications among Medicare Part D enrollees with diabetes, CHF, and COPD was suboptimal by virtually any standard of care,” Bruce Stuart, PhD, and colleagues wrote. They continued, “[In addition], the evidence regarding drug adherence among users of evidence-based medications was even more troubling.”

Adherence rates above PDC (percentage of days covered) ≥0.8 in any year were achieved by fewer than 35% of COPD patients. In none of the disease cohorts were adherence rates above PDC≥0.8 achieved by more than 62% of the Medicare beneficiaries. In addition, approximately 41% to 85% of non-MTM-eligible patients had PDC values below 0.8 in all three years of the study.

Eight chronic drugs

“We discovered that the most restrictive of the 2011 modal criteria [for MTM services] is the requirement that beneficiaries take eight or more different chronic Part D drugs. Because Part D plans are not required to set the threshold that high, one must assume they do so in order to limit the number of enrollees offered MTM services,” Stuart and colleagues noted. “Were plans to lower the drug count threshold to the federal minimum of 2, we estimate that MTM eligibility would increase by almost two thirds.”

Indeed, patients who currently do not qualify for MTM could benefit from improved adherence, which would include individuals who have fewer chronic conditions, spend less on drugs, and take fewer drugs, the authors noted.