It’s been just over a decade since Medicare Part D began. In that time, we’ve seen some amazing changes in our industry. More patients have access to the medications they need, and the professional services of pharmacists are recognized and reimbursed. The Part D benefit included coverage for Medication Therapy Management (MTM), a milestone for the profession. In the years since, MTM has evolved and improved, impacting millions of patients.
The Centers for Medicare and Medicaid Services (CMS) is responsible for oversight of the Part D program, including MTM. Among the requirements for Part D sponsors, an MTM Program (MTMP) must:
- Ensure optimum therapeutic outcomes for targeted beneficiaries through improved medication use
- Reduce the risk of adverse events
- Be developed in cooperation with licensed and practicing pharmacists and physicians
- Describe the resources and time required to implement the program, if using outside personnel, and establish the fees for pharmacists or others
- Be furnished by pharmacists or other qualified providers
- Distinguish between services in ambulatory and institutional settings
- Be coordinated with any care management plan established for a targeted individual under a chronic care improvement program (CCIP)
Each year, plan sponsors must submit their program to CMS for approval, and each year CMS has the ability to modify the program requirements. Part D beneficiaries (patients) qualify for MTM services based upon their health (i.e., must have at least one chronic condition from a specified list) and their medications (the number of prescriptions and their total cost). The cost criteria changes slightly from year to year. For calendar year 2012, the total (plan and beneficiary cost) had to be more than $3,100. For calendar year 2016, that increased to just over $3,500. We all know that with one or more chronic conditions, meeting that cost threshold is commonly achieved.
CMS is also working on a demonstration project for 2017 called Enhanced MTM. This program will run for four years in five Part D regions. The goal is to see if offering Part D plan sponsors additional incentives — and some regulatory flexibility — will improve outcomes and reduce costs.
States and private payers aren’t waiting for the results of the demonstration project; they’re supporting MTM programs right now, and work is being done to demonstrate the return on investment (ROI). As examples:
Minnesota implemented MTM services for low-income patients with complex medical and drug-related needs. A study of the program indicated that pharmacists received an average of $92.50 per patient visit, based on the complexity of care for the given patient. They resolved an average of 3.1 drug therapy problems per patient, usually issues of inadequate therapy. Patients averaged six medical conditions and 14 drugs each.
Study Results: MTM services resulted in a 31% reduction in total health expenditures per patient, from $11,965 to $8,197, and a 14% increase in meeting patient’s goals. The savings exceeded the cost of MTM services by more than 12 to 1.
In the 2016 OutcomesMTM Trend Report, Passport Health Plan, a local, nonprofit, community-based health plan that administers Kentucky Medicaid benefits, saw an MTM ROI of 9.43:1 in the first year of the program.
Fairview pharmacy services
Fairview Pharmacy Services MTM program has served thousands of patients, and the services provided by Fairview’s MTM pharmacists have had a significant impact.
According to the study “Best Practices: Improving Patient Outcomes and Costs in an ACO through Comprehensive Medication Therapy Management” (Brummel et. al. JMCP Journal of Managed Care & Specialty Pharmacy; Vol. 20, No. 12, December 2014), “Patient-centered MTM services can result in positive return on investment (ROI) in both the short and long term.”
Study results: One study, conducted with BlueCross BlueShield of Minnesota from 2001-2002, showed a 12:1 ROI when comparing the overall healthcare costs of Fairview patients receiving MTM services to patients who did not receive those services. Total health expenditures decreased from $11,965 to $8,197 per person, creating a reduction in total annual health expenditures that exceeded the cost of providing MTM services by more than 12 to 1.
Another study, which examined Fairview’s MTM program from September 1998 to September 2008, found that “pharmacist-estimated cost savings to the health system over the 10-year period were $2,913,850 ($86 per encounter), and the total cost of MTM was $2,258,302 ($67 per encounter), for an estimated ROI of $1.29 for every dollar spent.”
Payers and MTM providers are looking beyond the original concepts of MTM outlined in Medicare Part D and addressing issues such as gaps in care, medication reconciliation, and medication synchronization, all with the goal of optimizing drug therapy. New models, such as those that include a clinical pharmacist within an accountable care organization (ACO) are growing.
The opportunities for pharmacists to provide — and be reimbursed for — MTM services continue to grow.
Marsha K. Millonig, MBA, BPharm, is president and CEO of Catalyst Enterprises, LLC, and an Associate Fellow at the University of Minnesota College of Pharmacy’s Center for Leading Healthcare Change.