2010 MTM Guidelines2010 MTM Guidelines for Medicare Part D Sponsorsfor Medicare Part D Sponsors

Presented by:

Diane Burman, R.Ph., CHC, Director of Medicare Programs/Compliance Officer Margaret Shepherd, R. Ph., Manager MTM/Formulary

Prepared by: Michael DeVincenzo, Pharm D Norbert Becker R. Ph.

Medication Therapy ManagementMedication Therapy Management

• Medication Therapy Management (MTM) – An interactive service provided to beneficiaries to improve their

overall healthcare– Provided by pharmacists or other qualified health care

professionals

• The Centers for Medicare and Medicaid Services (CMS) has stated that MTM programs must “evolve and become a cornerstone of the Medicare Prescription Drug benefit”.

Medication Therapy ManagementMedication Therapy Management

• An extensive analysis of MTM programs was performed by CMS in 2008 to identify common practices.

• The decision was made to increase access to MTM and decrease eligibility restrictions.

• More specific requirements for 2010 associated with:– Enrollment– Targeting– Interventions– Outcomes-reporting

Requirements of Part D Sponsors to Provide MTM Requirements of Part D Sponsors to Provide MTM ProgramsPrograms

• Enroll targeted beneficiaries with an opt-out method only.

• Target beneficiaries for enrollment at least quarterly.• Target beneficiaries who:

– Have multiple chronic disease states– Are taking many Part D medications– Are predicted to incur a predetermined annual cost from Part D

medications

• Offer interventions for beneficiaries and prescribers.• Report specific outcomes data to CMS.

Requirements of Part D Sponsors to Provide MTM Requirements of Part D Sponsors to Provide MTM ProgramsPrograms

• The requirements do not apply to Private Fee for Service (PFFS) organizations.

• CMS strongly promotes that these organizations provide MTM programs in order to provide a quality Part D service to its beneficiaries.

EnrollmentEnrollment

• Part D sponsors must use an opt-out method only.– There is automatic enrollment for beneficiaries who

qualify unless they opt-out.

• Enrolled beneficiaries may refuse individual services and still remain in the program.

• If an enrollee opts out of the MTM program, the sponsor must still continue to apply their existing drug utilization management program.

Targeting FrequencyTargeting Frequency

• Target beneficiaries for enrollment at least quarterly every year.

• More than 95% of MTM programs in 2008 have already been targeting beneficiaries at least quarterly.

• CMS also expects sponsors to perform an end-of-year analysis to identify current beneficiaries who will meet the eligibility requirements for the next year for the same plan.

Targeting CriteriaTargeting Criteria

• MTM programs must target beneficiaries who:– Have multiple chronic disease states

– Are taking many Part D medications

– Are predicted to incur a predetermined annual cost from Part D medications

• If enrollee meets all three criteria, he/she should be targeted for enrollment.

• Sponsors may not include discriminatory exclusion criteria.

Targeting Criteria:Targeting Criteria:Multiple Chronic Disease StatesMultiple Chronic Disease States

• Sponsors cannot require a beneficiary to have more than 3 chronic diseases as the minimum number of multiple chronic diseases.

• For example:– Target people with at least 2 chronic diseases

• Set minimum threshold at 2

– Target people with at least 3 chronic diseases• Set minimum threshold at 3

• In 2008, most MTM programs already did target people with at least 2 to 3 chronic diseases.

Targeting Criteria:Targeting Criteria:Multiple Chronic Disease StatesMultiple Chronic Disease States

• Sponsors cannot require > 3 chronic diseases AND must target at least 4 of the 7 core chronic disease states.

• Core chronic disease states– Hypertension– Heart failure– Diabetes– Dyslipidemia– Respiratory disease

• Such as asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disorders

– Bone disease-arthritis • Such as osteoporosis, osteoarthritis, or rheumatoid arthritis

– Mental health • Such as depression, schizophrenia, bipolar disorder, or chronic and

disabling disorders

Targeting Criteria:Targeting Criteria:Multiple Part D MedicationsMultiple Part D Medications

• Sponsors cannot require more than 8 Part D drugs.

• Sponsors may set the minimum number of drugs anywhere between or equal to 2 to 8.

• Over 85% of programs already targeted beneficiaries with a minimum threshold of 8 or fewer Part D drugs in 2008.

Targeting Criteria:Targeting Criteria:Annual CostsAnnual Costs

• Current cost threshold– $4,000 per year

• Cost threshold for 2010– $3,000 per year

• Sponsors must target beneficiaries who meet prior criteria (i.e. number of chronic disease states and Part D medications) AND who are likely to incur an annual cost of at least $3,000 for Part D drugs.

MTM Interventions/ServicesMTM Interventions/Services

• Sponsors must offer interventions to:– Beneficiary – Beneficiary’s prescriber

• Interventions may be provided independently or in combination.

• Interventions may be provided by:– Pharmacist

– Other qualified providers

MTM Interventions/ServicesMTM Interventions/Services

• Interventions must be composed of an interactive component as well as continued monitoring and follow-up.

• Minimum interventions:– Comprehensive medication review (CMR)– Targeted medication review

– Interventions targeted to prescribers

MTM Interventions/ServicesMTM Interventions/Services

• Sponsors may include passive or ‘lower touch’ interventions such as:– Educational newsletters– Drug utilization review (DUR) edits– Refill reminders– Medication lists

• Passive interventions can NOT be the only offerings.

• Beneficiaries may refuse individual services without being removed from the MTM program.

MTM Interventions/Services: CMRMTM Interventions/Services: CMR

• CMR must be offered at least annually to all targeted beneficiaries.

• CMR assesses medication therapy in order to optimize patient outcomes.– Prescription medications– Over-the-counter (OTC) medications

– Herbal supplements

– Dietary supplements

MTM Interventions/Services: CMRMTM Interventions/Services: CMR

• CMR’s three necessary components:

– Review of medications

– Offer interactive consultation

– Provide consultation summary

MTM Interventions/Services: MTM Interventions/Services: CMR – Review of MedicationsCMR – Review of Medications

• Review of medications may be completed– Person-to-person OR– ‘Behind the scenes’ by a qualified provider and/or

computerized, clinical algorithms

• Purpose:– Assess medication use

– Identify medication related problems

MTM Interventions/Services: MTM Interventions/Services: CMR – Interactive ConsultationCMR – Interactive Consultation

• Sponsors must offer to provide an interactive, person-to-person consultation to each targeted beneficiary.

• Consultation may be:– Face-to-face– Other interactive method (e.g. telephone)

• Should assess additional information that may be outside of the claims data such as:– OTC medications– Herbal/dietary supplements– Health status– Adverse events– Other health related issues

MTM Interventions/Services: MTM Interventions/Services: CMR – Consultation SummaryCMR – Consultation Summary

• Sponsors must provide an individualized written overview or ‘take away’ of the consultation.

• May include:– Personal medication record– Reconciled medication list– Action plans– Monitoring recommendations– Education– Self-management

MTM Interventions/Services:MTM Interventions/Services:Targeted Medication ReviewTargeted Medication Review

• Sponsors must provide targeted medication reviews for each participating beneficiary no less often than quarterly.– Can be person-to-person or system generated

• Purpose:– Assess medication use since the CMR– Monitor whether any unresolved problems need attention– Monitor if any new drug therapy problems have arisen– Monitor if the beneficiary has had a transition in care

• Sponsor must then evaluate the reviews and determine if a follow-up intervention is necessary– Follow-up interventions should be interactive, but may be provided

via mail or other means.

MTM Interventions/Services:MTM Interventions/Services:Targeted to PrescribersTargeted to Prescribers

• Targeting interventions to prescribers is required in order to:– Resolve any drug related issues and/or

– Improve any other issues that may facilitate the patient’s medication use

• Can be passive (e.g. fax, mail) or interactive

MTM Interventions/Services:MTM Interventions/Services:LTC ResidentsLTC Residents

Long term care (LTC) residents• Do not require

– Interactive consultation component of the CMR

• Do require– CMR: Review of medications & consultation

summary– Quarterly drug reviews

– Offer interventions targeted to prescribers

Outcomes Measurement & ReportingOutcomes Measurement & Reporting

• Sponsors must measure and report the following to CMS:– The number of CMR’s

– The number of targeted medication reviews

– The number of prescriber interventions

– The change(s) in therapy directly resulting from the MTM interventions

• Continuous evaluation and subsequent improvement of each program is expected.

MTM Monitoring SupportMTM Monitoring Support

• Recently, an MTM monitoring contract was granted to Optimal Solutions Group by CMS.– Period of Performance is September 2008 thru

August 2010

– Monitor and evaluate MTM programs

– Assist in identifying MTM programs with the greatest positive impact to members

• Possible areas of evaluation in the future:– Drug utilization

• Example: drug interactions, polypharmacy, adverse drug events

– Beneficiary health • Example: clinical indicators, medical utilization

– Financial impact • Example: pharmacy cost and medical cost change

– Customer satisfaction

Outcomes Measurement & ReportingOutcomes Measurement & Reporting

• Possible areas of evaluation in the future:– Drug utilization

• Example: drug interactions, polypharmacy, adverse drug events

– Beneficiary health • Example: clinical indicators, medical utilization

– Financial impact • Example: pharmacy cost and medical cost change

– Customer satisfaction

Additional CMS ExpectationsAdditional CMS Expectations

• Once enrolled, a beneficiary will not be disenrolled if they no longer meet one or more of the MTMP eligibility criteria and will remain in the MTMP program for the remainder of the calendar year.

• MTMP will serve and provide interventions for enrollees who meet all three of the required criteria as defined above regardless of setting (e.g., ambulatory, long term care, etc.)

• MTMP will not include discriminatory exclusion criteria. If an enrollee meets all three of the required criteria as described by your plan, the enrollee should be eligible for MTM intervention.

Additional CMS Expectations Additional CMS Expectations

Sponsors will:

• Consider other drug quality improvement interventions to beneficiaries who do not meet the required criteria

– these cannot be considered for MTM reimbursement by CMS.

• Put into place safeguards against discrimination based on the nature of their MTM interventions.

• Drive participation and follow-up with beneficiaries that do not respond to initial offers for MTM services.

• Consider using more than one approach to reach all eligible patients who may wish to receive services.

• Analyze, evaluate and make changes to continuously improve their programs.

ReferencesReferences

• Centers for Medicare & Medicaid Services (CMS). Department of Health & Human Services. March 30, 2009. Call Letter 2010. P. 68-73.

• Centers for Medicare & Medicaid Services (CMS). Department of Health & Human Services. Sep 5, 2008. Chapter 7 – Medication therapy management and quality improvement program. Pub. 100-18 Medicare Prescription Drug.

• Centers for Medicare & Medicaid Services (CMS) memorandum April 10, 2009, Contract Year 2010 Medication Therapy Management Program (MTMP) Submission.

Questions?Questions?

If you have any questions about the information in this webinar, please feel free to contact us.

Diane Burman, R.Ph., CHCDirector of Medicare Programs/Compliance Officer

(215) 937-5061Diane.Burman@PerformRx.com

Margaret Shepherd, R.Ph.Formulary Manager

(215) 937-5314Margaret.Shepherd@PerformRx.com