2020 was an unprecedented year for the healthcare industry. Due to the suspension of costly elective procedures, the ...
Medication therapy management (MTM) was established in 2006, in an effort to improve therapeutic outcomes and medication safety. Since that date, the Centers for Medicare & Medicaid Services (CMS) have been updating the requirements of the program every year to improve it, especially in terms of patients’ and healthcare providers’ engagement.
Some of the changes since 2006 include:
- Changing the annual cost threshold
- Decreasing the eligibility threshold (in 2010 and 2012)
- Adding an annual medication review and a written summary to medication therapy management services (in 2010 and 2013)
- Adding a new CMS Star metric, the comprehensive medication review completion rate. (in 2016)
- Requiring Medicare Part D plans to describe their MTM program on their websites to increase access and understanding of their services. (in 2013)
Despite many adjustments over the years, patients’ engagement remains low and a small proportion of interventions are implemented by providers (for example in 2014, only about 20% of medication-therapy problems were resolved for people who received a comprehensive medication review (CMR).
We can then wonder what the future holds for MTM. Is the model sustainable the way it’s delivered now?
To answer these questions, let’s look at the results of the enhanced MTM pilot, which was conducted from 2017 to 2022, and at the latest changes in the requirements for medication therapy management programs.
In this article we will discuss:
- The enhanced Medication Therapy Management pilot
- CMS rules for the 2024 contract year
- The future of MTM
The enhanced Medication Therapy Management pilot
What is the enhanced MTM?
In 2017, in an effort to increase patient participation and engagement in MTM, the CMS launched a pilot called the Part D Enhanced MTM.
The goal of this pilot was to see if payment incentives and more flexibility in MTM programs would improve patient outcomes while reducing CMS costs.
Several national health plans were selected and allowed to offer various types of interventions.
For instance, some health plans targeted patients based on medication use (e.g. potential drug therapy problems, new medication, high-risk medication). Other plans targeted beneficiaries based on high cost, presence of chronic conditions, the occurrence of transition of care (e.g. discharge from hospital), or vaccination status.
The interventions offered included:
- Transitional services. Medication therapy management services were offered at clinically meaningful times, such as after hospital discharges.
- Medication adherence services. These services investigated and addressed medication non-adherence or risk of non-adherence amongst beneficiaries.
- Chronic disease management services. For instance, one health plan offered body weight scales and remote weight monitoring to its beneficiaries with congestive heart failure.
- Comprehensive medication reviews (CMR).
What have been the results of the enhanced MTM pilot?
In February 2023, a report analyzing the results of the 5-year pilot was published. The enhanced MTM model had mixed results.
On the one hand, the eligibility rates for enhanced MTM programs were higher than the traditional MTM eligibility rate (66 to 77 % compared to 6 to 10 %). Throughout the pilot years, the percentage of Medicare beneficiaries who received significant MTM services increased from 23% (year 1) to about 30% (year 5).
On the other hand, the enhanced model didn’t have statistically significant impacts on gross or net Medicare expenditures. And it didn’t lead to improvement in measures of medication optimization (e.g. adherence to oral anti-diabetic medications, drug-drug interactions, or opioid use) among enhanced MTM participants compared to the control groups.
Another significant change for MTM was the new policy and technical changes to the part D programs for the contract year 2024.
CMS rules for the 2024 contract year
In December 2022, the CMS issued the final rule with the goal among others, to improve access to care and promote health equity for more beneficiaries. The final rule adopted includes:
- The creation of a health equity index reward to encourage health plans to improve care for beneficiaries with certain social risk factors, like dual Medicare-Medicaid eligibility, low-income subsidies, and disability.
- Expansion of the list of people who must receive culturally competent care from Medicare Part A plans — due to their increased risk of health disparities. These specific groups included:
- People with limited English proficiency or reading skills;
- Minority groups of people;
- Individuals with disabilities;
- People identifying as lesbian, gay, bisexual, or other diverse sexual orientations;
- Individuals who identify as transgender, nonbinary, and other diverse gender identities, or people who were born intersex;
- People living in rural areas and other areas with high levels of deprivation;
- Individual otherwise adversely affected by persistent poverty or inequality
- Policies to improve access to behavioral health.
- Requirement that Medicare Advantage plans include providers’ cultural and linguistic capabilities in provider directories.
- Requirement that quality improvement programs of Medicare Advantage organizations include efforts to reduce health disparities.
These new changes are to come into effect in 2024.
Based on these new rules and the results of the Enhanced MTM pilot, what is the future of MTM?
The future of MTM
The current focus of MTM is the number of medication reviews completed and making sure that beneficiaries received their yearly CMRs and their quarterly targeted medication reviews. The only MTM-related Star rating is the completion rate of CMRs.
However, if plans want to begin to reduce health disparities and truly enhance care, they must look for ways to efficiently outreach to patients with the greatest needs and successfully engage them to not only complete a CMR, but to help optimize their medications.
Leverage predictive analytics and machine learning for enhanced interventions
To improve the quality of their MTM interventions, health plans will have to utilize their data more efficiently to determine which beneficiaries are at risk of experiencing medication-related problems and those that can truly benefit from MTM services.
For instance, one of the learnings from the enhanced MTM pilot was that offering CMRs at regular intervals to all beneficiaries may have less value than targeting a specific subset of individuals who can actually benefit from the service.
Arine’s platform enables health plans to predict the risk trajectories of their members and stratifies them accordingly. By combining data on medication history and recent health events with social and behavioral information, Arine’s medication intelligence platform allows health plans to not only identify members at increased risk but ensure that providers can intervene before an anticipated medication-related event. As a result, clinical teams are able to maximize the impact of their interventions.
The platform then leverages artificial intelligence (AI) and uses the results of these interventions to further refine its patient targeting and improve the recommendations provided.
More patient-centered MTM interventions
Interventions that match patients’ priorities
Although in its definition, MTM is described as a patient-centered process; in reality, it often ends up being a checklist for MTM providers to go through.
A learning from the enhanced MTM pilot is that to improve patient engagement, health plans have to offer MTM services addressing issues that are priorities for members (E.g. practical interventions to help manage their chronic conditions) and offer these services at clinically meaningful times.
For instance, a patient may benefit the most from MTM services after they have been discharged from the hospital with new medications or when they start a therapy regimen.
Such an approach is different from the traditional MTM model in which beneficiaries are offered MTM services at regular intervals regardless of their own care goals or current health status.
Culturally appropriate interventions
The new rules also have the goal of ensuring that health plans provide culturally appropriate care to their beneficiaries. In other words, health plans have to find better ways to move beyond the traditional check-the-box approach and provide their beneficiaries with patient-centered MTM interventions.
For example, a patient who is fasting may not take their medication during their fasting period or may be experiencing more side effects. Uncovering the reason behind their medication-related problem can help the health care team work with the patient and come up with a medication regimen that respects their care goals.
Interventions that take into account social determinants of health
Offering more patient-centered MTM programs also requires health plans to take into account social determinants of health, such as access to transportation, housing status, or income level when offering patients MTM interventions. A person with mobility issues, who doesn’t have regular access to the pharmacy may not be able to easily fill their prescriptions and take their medications as directed no matter how often their regimen is adjusted.
Arine’s platform utilizes patient-specific data to create personalized questions that enable the clinical team to uncover specific reasons for medication non-adherence or other medication-related problems. Then, after integrating the health plan data and the patient-reported data, the medication intelligence platform is able to automatically provide targeted and timely recommendations for a given patient. In the case of a health plan member with mobility issues, the platform might prompt a care team member to recommend mail-order prescription medications or to arrange for pharmacy deliveries.
Better prescriber engagement
Since prescribers are the final decision-makers in changing medication therapies, in order to improve implementation rates for medication recommendations, health plans must find ways to improve the collaboration between pharmacists and prescribers.
During the enhanced MTM pilot, health plans tried different strategies to engage providers, such as the ability to refer beneficiaries for MTM services, requesting providers endorse beneficiaries’ participation in the services, or providing prescribers in-person education about MTM services. None of these strategies was shown to have a notably positive impact on collaboration.
Strategies that showed promise were:
- Dedicating a pharmacy staff member to fax recommendations to the provider after the service is completed, then follow up.
- Dedicating special time for a staff member to call prescribers regarding pending recommendations.
These strategies, although promising, can be too labor-intensive and time-consuming for health plans to sustain. Instead, using artificial intelligence technology to deliver to prescribers the information they need may be a more efficient way to improve the collaboration between members of the care team.
Leveraging AI for high-impact interventions
In order to have the greatest impact on health outcomes, it is critical that care team recommendations are actionable, have the necessary information to support provider and patient adoption, and are timely.
The interventions suggested by the Arine Platform include both patient-specific background (e.g. clinical, behavioral, or social) underlying tailored recommendations. as well as details from relevant clinical guidelines. This data is included with clear next steps to be considered (e.g. revising dosing of a specific medication, changing a medication based on clinical indicators, etc.), ensuring that providers have all the necessary information to enable easy adoption of the recommendations.
Likewise, the targeted recommendations from the Arine Platform are always prioritized and timely. As new information is received daily by the platform, Arine’s medication intelligence updates and re-prioritizes interventions for each patient. This approach helps ensure that recommended actions are relevant and result in improved patient care while reducing provider abrasion.
Traditional MTM programs struggle to accomplish what the MTM model initially intended: to significantly reduce medication-related problems while lowering overall health expenses.
To make MTM sustainable in the future, health plans will need to enhance patient and prescriber engagement by providing patient-centered MTM recommendations, improving collaboration between members of the care team, and leveraging technology platforms that can enable the scalability of these approaches.
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