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As many pharmacists are aware, all Medicare Part D plans must offer medication therapy management (MTM) to assist beneficiaries who (1) have multiple chronic diseases, (2) take multiple medications, and (3) are likely to spend more than $4,000 on medications annually. MTM services are intended to promote patient understanding about medication use, increase adherence to drug regimens, and detect drug-related problems.
MTM services under Part D are the financial responsibility of the prescription drug program (PDP) as part of the administrative overhead provided by CMS. There is little or no incentive for a stand-alone PDP to provide a comprehensive program because MTM is just one more administrative expense to be managed. Medicare Advantage-Prescription Drug (MA-PD) programs have a greater incentive to provide MTM because any reduction in the use of other medical services due to better medication use generates savings for the plan.
Pharmacists and other qualified healthcare professionals can be contracted to provide MTM under an agreement that is separate from the dispensing function. Most Part D sponsors employ pharmacists in their MTM program, but very few are using community pharmacists. CMS reported that out of 553 MTM programs in operation for 2006, 46% relied on internal programs whereas 36% contracted with a third party. The agency estimated that 18% of plans created MTM services that included community pharmacists in their program, a proportion that is consistent with a survey published recently by APhA.
Therefore, a pharmacist may have an agreement for MTM services with one PDP but not with another plan in the same region. This could lead to a potentially confusing array of program services for beneficiaries and challenges for pharmacists who want to participate. Having standard billing codes, a single interface with programs, and being held to the same quality standards would facilitate future participation of all parties in MTM programs.
CCRx, developed by NCPA, is one example of an Internet-based program for managing service. The plan refers patients to a pharmacist in the network and provides the pharmacist with a medication history, any clinical alerts, and money-saving tips to discuss with the beneficiary in a face-to-face session. The pharmacists submit bills for service to CMTM using the same interface.
CMS supported the launch of the Pharmacy Quality Alliance (PQA) in response to the call for measurement of outcomes to document the quality and value of services provided. The alliance is a partnership among pharmacy organizations, health plans, employers, consumers, and many others that will suggest strategies for defining and measuring pharmacy performance. After CMS selects the criteria for quality standards, it will use integrated data from Parts A, B, and D to characterize those beneficiaries who appear to benefit from MTM.
In addition to the PQA initiative, the Medicare Modernization Act gave quality improvement organizations (QIOs) the authority to provide assistance to MA and PDP plans. There are 53 QIOs operating in every state, territory, and the District of Columbia. Under a three-year contract from CMS, QIOs in Florida, Maryland, and the District of Columbia will follow roughly 55,000 Medicare beneficiaries for 12 months and perform analyses of clinical data. Outcomes Pharmaceutical Health Care, with its national network of pharmacists and programs from Humana and CCRx, is involved in QIO assessments. A report on the findings is due late this year. Other MTM initiatives outside of the Medicare program are being organized for evaluation in Iowa, Minnesota, and adjoining states.
THE AUTHOR is associate professor, Department of Pharmacy Health Care Administration, University of Florida College of Pharmacy.