2016 MTM Fact Sheet - Centers for Medicare and … webpages, beneficiaries found that it was often...

2016 Medicare Part D Medication Therapy Management (MTM) Programs

Fact Sheet Summary of

2016 MTM Programs

May 4, 2016

Discussion Topics

Background Highlights from 2016 Call Letter Annual Review Characteristics of 2016 MTM Programs Summary

2

Background

Under 42 CFR 423.153(d), a Part D sponsor must establish an MTM program that:

Ensures covered Part D drugs are used to optimize therapeutic outcomes through improved medication use,

Reduces the risk of adverse events, Is developed in cooperation with licensed and

practicing pharmacists and physicians, May be furnished by pharmacists or other

qualified providers.

3

Highlights from 2016 Final Call Letter (1 of 3)

MTM Program Completion Rate for ComprehensiveMedication Reviews (CMR) measure was added to the Part DStar Ratings for 2016 as a process measure (given a weight of1).

The specifications used for the 2015 display measure will also be usedfor the 2016 Star Ratings measure.

Part C and Part D Star Ratings and Display Measures are posted at: http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html

2016 Call Letter is available at: http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2016.pdf

4

http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2016.pdfhttps://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.htmlhttp://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2016.pdf


The MTM program annual cost threshold is updated for 2016 using the annual percentage increase of 11.76%, as specified in the Calendar Year (CY) 2016 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies. Therefore, the 2016 MTM program annual cost threshold is $3,507.

CMS is piloting program audit protocols in 2016, including compliance with Part D sponsors MTM programs.

5


We remind sponsors that our expectations for their MTM webpages are included in the annual MTM program guidance and submission instructions memo.

During a recent assessment of beneficiary experience using sponsors MTM webpages, beneficiaries found that it was often difficult for them to navigate to the MTM webpage using the search options and hyperlinks, sometimes requiring more than two clicks.

Increasing font sizes and using lay language will help beneficiaries to read and understand the content of the MTM webpage.

6

Annual Review (1 of 2)

A CMS-approved MTM program is one of several required elements in the development of a Medicare Part D sponsors bid.

Annually, sponsors must submit an MTM program description to CMS for review and approval in the Health Plan Management System (HPMS).

CMS evaluates each program description as part of a Part D quality improvement requirement (42 CFR 423.153(d)), to ensure that it meets the current minimum requirements for the program year (which are described throughout this Fact Sheet).

7

Annual Review (2 of 2)

In 2016, there are 623 Part D contracts with an approved MTM program. 495 Medicare Advantage prescription drug plans (MA-PDs). 67 stand-alone prescription drug plans (PDPs), including Employer

contract MTM programs. 61 Medicare-Medicaid Plans (MMPs).

All sponsors that are required to establish an MTM program have an approved program in place.

This analysis includes characteristics of 2016 MTM program applications approved during the annual review in Spring 2015 and changes approved during the September 2015 and April 2016 update windows as of April 8, 2016.

8

Eligibility Criteria Expanded Criteria

The CMS eligibility targeting requirements are established as theminimum threshold. Sponsors may also offer MTM services to anexpanded population of beneficiaries who do not meet the eligibility criteria under 423.153(d).

In 2016, almost 25% of MTM programs use expanded eligibilityrequirements beyond CMS minimum requirements. A slight increase compared to 24% of programs in 2015.

Table 1. Percent of 2016 MTM Programs with Expanded Eligibility Criteria

Eligibility Criteria Only target enrollees who meet the specified targeting criteria per CMS requirements

# of Programs

468

% of Programs

75.1%

Use Expanded Criteria: Target both enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteria

155 24.9%

Total 623 100.0% 9

Chronic Diseases

Percent of 2015 MTM Programs with a Minimum Number of multiple chronic disease

Figure 1

MA-PDPDPMMP

ALL CONTRACTSMA-PDsPDPsMMPsAll contractsMA-PDsPDPsMMPs

# of Diseases# of Programs% of Programs# of Programs% of Programs# of Programs% of Programs# of Programs% of Programs2 Diseases18.8%17.4%23.9%24.6%

211718.8%8617.4%1623.9%150.24590163933 Diseases81.2%82.6%76.1%75.4%

350681.2%40982.6%5176.1%460.7540983607100.0%100.0%100.0%100.0%

Chronic Diseases

2 Diseases

3 Diseases

Contract Type

% of Programs

Figure 1. Percent of 2016 MTM Programs with Minimum Number of Multiple Chronic Diseases

Top Diseases

Distribution by Specific Chronic Disease# of contracts623

Any Chronic Health Condition5

ALL CONTRACTSALL CONTRACTS

Specific Chronic Disease# of Programs% of ProgramsSpecific Chronic Disease% of Programs# of Programs

Diabetes61899.2%Diabetes100.0%623618Specific Chronic Disease# of Programs

Chronic Heart Failure (CHF)57392.0%Chronic Heart Failure (CHF)92.8%578573Diabetes653623

Dyslipidemia53886.4%Dyslipidemia87.2%543538Chronic Heart Failure (CHF)616578

Hypertension53085.1%Hypertension85.9%535530Dyslipidemia595543

Chronic Obstructive Pulmonary Disease (COPD)46274.2%Chronic Obstructive Pulmonary Disease (COPD)75.0%467462Hypertension591535

Asthma42868.7%0.6869983949Asthma69.5%433428Chronic Obstructive Pulmonary Disease (COPD)459467

Osteoporosis39663.6%Osteoporosis64.4%401396Osteoporosis408401

Depression30649.1%Depression49.9%311306Asthma392433

Rheumatoid Arthritis17928.7%Rheumatoid Arthritis29.5%184179Depression273311

Cardiovascular Disorders9815.7%Cardiovascular Disorders16.5%10398Rheumatoid Arthritis198184

HIV/AIDS9314.9%0.8%5End-Stage Renal Disease (ESRD)930

End-Stage Renal Disease (ESRD)9214.8%0.8%5HIV/AIDS750

Hepatitis C8313.3%0.8%5Cardiovascular Disorders71103

Osteoarthritis7011.2%0.8%56646860.9679300292Osteoarthritis610

Alzheimer's Disease569.0%0.8%56846860.9970845481Alzheimer's Disease490

Chronic Lung Disorders558.8%0.8%5Chronic Lung Disorders490

Bipolar Disorder436.9%0.8%5Chronic/Disabling Mental Health Conditions460

Chronic/Disabling Mental Health Conditions416.6%0.8%5Hepatitis C410

Schizophrenia406.4%0.8%5Multiple Sclerosis330

Chronic Noncancer Pain315.0%0.8%5Chronic Noncancer Pain320

Multiple Sclerosis304.8%0.8%5Bipolar Disorder300

Cancer203.2%0.8%5Schizophrenia280

Parkinson's Disease203.2%0.8%5Parkinson's Disease250

Chronic Alcohol and Other Drug Dependence193.0%0.8%5Any Chronic Health Condition220

Atrial Fibrillation162.6%0.8%5Chronic Alcohol and Other Drug Dependence220

Cerebrovascular Disease152.4%0.8%5Atrial Fibrillation210

Anemia142.2%0.8%5Cancer200

Anticoagulation142.2%0.8%5Cerebrovascular Disease200

GI/Reflux/Ulcer conditions121.9%0.8%5Stroke180

Coronary Artery Disease (CAD)111.8%0.8%5Anticoagulation170

Stroke111.8%0.8%5Anemia160

Neurologic Disorders101.6%0.8%5GI/Reflux/Ulcer conditions140

Benign Prostatic Hyperplasia (BPH)91.4%0.8%5Neurologic Disorders140

Dementia91.4%0.8%5Benign Prostatic Hyperplasia (BPH)130

Severe Hematologic Disorders71.1%0.8%5Coronary Artery Disease (CAD)120

Any Chronic Health Condition50.8%0.8%5Severe Hematologic Disorders100

Ischemic Heart Disease50.8%0.8%5Autoimmune Disorders80

Autoimmune Disorders40.6%0.8%5Dementia80

Transplant40.6%0.8%5End-Stage Liver Disease50

Cirrhosis30.5%0.8%5Cirrhosis40

Gout30.5%0.8%5Heart Attack40

Heart Attack30.5%0.8%5Ischemic Heart Disease40

Hypothyroidism30.5%0.8%5Transplant40

Benign Essential Tremor20.3%0.8%5Crohn's Disease30

Crohn's Disease20.3%0.8%5Insomnia30

End-Stage Liver Disease20.3%0.8%5Plaque Psoriasis30

Insomnia20.3%0.8%5Urinary Incontinence (Stress/Urge)30

Plaque Psoriasis20.3%0.8%5Benign Essential Tremor30

Urinary Incontinence (Stress/Urge)20.3%0.8%5

Acute Coronary Syndrome10.2%0.8%5

Angina10.2%0.8%5

Anxiety10.2%0.8%5

Edema10.2%0.8%5

Glaucoma10.2%0.8%5

Neuropathy10.2%0.8%5

Opioid Overuse10.2%0.8%5

Overactive bladder10.2%0.8%5

0

0

0

0

2 Diseases

3 Diseases

Top Diseases

Figure 2. Percent of 2012 MTM Programs with Top Ten Targeted Diseases

Figure 2. Percent of 2016 MTM Programs with Top Ten Targeted Diseases

PartD Drugs covered

Multiple Covered Part D Drugs

Distribution by # of Meds

Minimum Number of Covered Part D Drugs% of all MTM Programs% of MA-PD MTM Programs% of PDP MTM Programs% of MMP MTM Programs

21.4%1.4%0.0%3.3%

30.8%0.8%1.5%0.0%

43.0%2.2%7.5%4.9%

55.8%6.1%1.5%8.2%

613.3%11.9%16.4%21.3%

718.3%17.6%22.4%19.7%

857.3%60.0%50.7%42.6%

1111

100.0%100.0%100.0%100.0%

MA-PDPDPMMP

ALL CONTRACTSMA-PDsPDPsMMPs

# of Meds# of Programs% of Programs# of Programs% of Programs# of Programs% of Programs# of Programs% of Programs

290.014446227970.01414141410020.0327868852

350.008025682240.008080808110.014925373100

4190.0304975923110.022222222250.074626865730.0491803279

5360.0577849117300.060606060610.014925373150.0819672131

6830.1332263242590.1191919192110.1641791045130.2131147541

71140.1829855538870.1757575758150.223880597120.1967213115

83570.57303370792970.6340.5074626866260.4262295082

Total62314951671611

Freq. of ID

Identification

Distribution by Frequency of Identification

ALL CONTRACTSALL CONTRACTSMA-PDsPDPs

Frequency of Identification% of Programs

Quarterly48.5%

Monthly28.3%

Weekly13.6%

Daily9.6%

Every other month0.0%

Total100.0%

Freq. of ID

% of Programs

Figure 3. Frequency of Identification: Percent of 2016 MTM Programs

WrittenSummary after CMR

Distribution by Individualized, written summary of interactive consultation type

Description% of Programs

Individualized, written summary of CMR in CMS' standardized format100.0%

Alternative language translations32.1%

Medication Guide3.5%

Medication History1.1%

Brochures specific to discussion0.5%

Lab History0.5%

Educational Materials0.3%100.0%

14.4%0.6666666667

1.5%Education Pieces & Survey

0.8%Medication History

0.6%

0.6%

0.4%

Description# of Programs

Web Portal Access8.8%

Email17.3%

Fax19.7%

Hand delivery46.5%

Mail100.0%

ALL CONTRACTS

Description# of Programs% of Programs

Email10817.3%

Fax12319.7%

In-person Delivery Method29046.5%

Mail623100.0%

Method of delivery determined by MTM provider457.2%


199.7%

WrittenSummary after CMR

Figure 4. Materials Delivered to Beneficiary after CMR: Percent of 2016 MTM Programs

Bene Intervention

DescriptionALL CONTRACTS

# of Programs% of Programsdouble check against last year. Numbers are different than 2013

Interactive, person-to-person or telehealth consultation623100.0%

Interactive, Person-to-Person, Comprehensive Medication Review, annual623100.0%Description% of programs

Materials delivered to beneficiary after the interactive, person-to-person CMR consultation623100.0%Medication Guides1.4%

Targeted medication reviews, at least quarterly, with follow-up interventions when necessary623100.0%Refill reminder, beneficiary3.5%

Referral: Case Management14423.1%Referral: Specialty Management5.1%

General education newsletter, beneficiary6610.6%Referral: Disease Management8.8%

Referral: Disease Management558.8%General education newsletter, beneficiary10.6%

Referral: Specialty Management325.1%Referral: Case Management23.1%

Refill reminder, beneficiary223.5%

Medication Guides91.4%

Cost saving opportunities with dose optimization50.8%

Cost saving opportunities with generic utilization50.8%

Cost savings through formulary compliance50.8%

Review for use of high risk medications50.8%

Drug utilization screening40.6%

Phone consult with physician after TMR QTR PRN30.5%

Meidcation Guides20.3%212.7%

Referral: Care Management20.3%

phone consult with physician after TMR QRT PRN10.2%

Figure 5. CMR Written Summary Delivery Method: Percent of 2016 MTM Programs

Bene Intervention

% of programs

Figure 6. Beneficiary Interventions:Value Added Services Percent of 2016 MTM Programs

Prescriber Intervention

ALL CONTRACTSMA-PDsPDPsDescription% of programs

Description# of Programs% of Programs# of Programs% of Programs# of Programs% of ProgramsSupporting literature for recommendations0.2%

(blank)00.0%Medication Action Plan0.3%

Supporting literature for recommendations10.2%Polypharmacy screening0.6%

Method of delivery determined by MTM provider.10.2%Alerts on potential untreated drug therapy0.8%

Medication Action Plan20.3%Copy of Comprehensive Medication Review0.8%

Polypharmacy screening40.6%General education newsletter, prescriber3.7%

Method of delivery determined MTM provider40.6%Method of delivery determined by MTM provider6.4%0.0%

Alerts on potential untreated drug therapy50.8%Patient Medication list22.5%

Copy of Comprehensive Medication Review50.8%Prescriber interventions to resolve medication-related problems or optimize therapy100.0%

Method of delivery determined my MTM provider101.6%

General education newsletter, prescriber233.7%


Patient Medication list14022.5%

Prescriber interventions to resolve medication-related problems or optimize therapy623100.0%

Prescriber Intervention

% of programs

Prescriber Interventions:Value Added Services Percent of 2016 MTM Programs

Provider of MTM Services

Other9114.61%Provider Type% of ProgramsProvider Type% of Programs# of Programs

Physician's Assistant14222.79%Other14.61%

Nurse Practitioner15925.52%Physician's Assistant22.79%

Physician16025.68%Nurse Practitioner25.52%

Licensed Practical Nurse18429.53%Physician25.68%

Pharmacy Technician21334.19%Licensed Practical Nurse29.53%

Registered Nurse23637.88%Pharmacy Technician34.19%

Intern46073.84%Registered Nurse37.88%

Pharmacists623100.00%Intern73.84%

Pharmacists100.00%

Provider of MTM Services

% of Programs

Figure 7. Provider of MTM Services: Percent of 2016 MTM Programs

CMR Provider

ALL CONTRACTS

Provider% of Programs# of Programs

xMTM Vendor In-house Pharmacist47375.92%

MTM Provider of CMR% of ProgramsxPharmacy intern under the direct supervision of a pharmacist42267.74%

MTM Vendor In-house Pharmacist75.9%xMTM Vendor Local Pharmacist32351.85%

Pharmacy intern under the direct supervision of a pharmacist67.7%xPlan Sponsor Pharmacist24138.68%

MTM Vendor Local Pharmacist51.8%xRegistered Nurse19130.66%

Plan Sponsor Pharmacist38.7%xPlan Benefit Manager (PBM) Pharmacist17227.61%

Registered Nurse30.7%xLicensed Practical Nurse15524.88%

Plan Benefit Manager (PBM) Pharmacist27.6%xOther13822.15%

Licensed Practical Nurse24.9%xNurse Practitioner13421.51%

Other22.2%xPhysician12520.06%

Nurse Practitioner21.5%xPhysician's Assistant11518.46%

Physician20.1%Local Pharmacist8313.32%

Physician's Assistant18.5%Long Term Care (LTC) Consultant Pharmacist7912.68%

Local Pharmacist13.3%Hospital Pharmacist71.12%

Long Term Care (LTC) Consultant Pharmacist12.7%Disease Management Pharmacist30.48%

Cost Methodology

Incurred Cost for Covered Part D Drugs: $3000

Distribution by Costing Methodology

reasonpercentvolume

Incurred one-fourth of specified annual cost threshold ($3,507) in previous three months79.1%386

Incurred specified annual cost threshold ($3,507) in previous 12 months3.5%21

See Additional Information 12.7%14

Incurred one-twelfth of specified annual cost threshold ($3,507) in previous month1.3%6

See Additional Information 11.1%6

Detail listed in the Additional Info Section 21.0%6

See Additional 10.6%3

Incurred 1/4 annual cost in prev calendar qtr0.3%1

See Additioinal Informatin 10.2%1

Distribution by Costing Methodology

Specific Threshold and Frequency% of Programs

Incurred one-fourth of specified annual cost threshold ($3,507) in previous three months79.1%

Incurred specified annual cost threshold ($3,507) in previous 12 months3.5%

Incurred one-twelfth of specified annual cost threshold ($3,507) in previous month1.3%

Cost Methodology

% of Programs

Percent of Cost Threshold Incurred

Prescriber Interventions

Distribution by Prescriber interventions to resolve medication-related problems or optimize therapy type2015 data

Description# of Programs% of Programs

Description% of Programsface to face10.2%

Polypharmacy screening9.0%Face-to-Face10.2%

Emailed consultation9.1%Supporting literature for recommendations10.2%

Person to Person Resolution11.6%Person to person consultation10.2%

Electronic Medical Records (EMR)18.8%Person-person resolution of drug related problems10.2%

Mailed consultation92.0%person-to-person resolution of medication problems10.2%

Phone consultation93.7%Perosn to person resolution of med problems10.2%

Faxed consultation97.6%Person-to-person problem resolution10.001605136418.8%

Person to person resolution of med. rel. problems.10.0016051364

Patient Medication list10.0016051364

Electronic medical record consultation20.3%

Electronic medical record notification20.3%

EMR (eClinicalWorks)20.3%

In Person20.3%

Person to person resolution of medication problems20.3%

Person to person resolution of drug related issues20.3%

person to person resolution of medications20.3%

method of delivery defined by the MTM serv prov20.0032102729

person to person resolution of DRP20.0032102729

Person to Person30.5%30

Person to person resolution of med related problem30.5%

MTM summary, when appropriate30.5%

Electronic Medical Records if available.30.5%

Physician web portal communication40.6%


Electronic medical record messaging91.4%


In-Person Communication223.5%

Method of delivery defined by MTM service provider254.0%

Person to person resolution of medication related254.0%11.6%

Polypharmacy screening569.0%

Emailed consultation579.1%

Electronic data interchange consultation10116.2%18.8%

Mailed consultation57392.0%

Phone consultation58493.7%

Faxed consultation60897.6%

% of Programs

Prescriber Interventions

% of Programs

Prescriber Interventions to Resolve Med-Related Problem/Optimize Therapy

Exp Criteria

Eligibility Criteria# of Programs% of ProgramsMA-PDPDPMMPMTMP_submission_maxCONTRACT_IDA_TARGETlabelcode

Only target enrollees who meet the specified targeting criteria per CMS requirements46875.1%Only enrollees who meet the specified targeting criteria per CMS requirements3805137E0654Only enrollees who meet the specified targeting criteria per CMS requirementsMA-PD

Use Expanded Criteria: Target both enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteria15524.9%Expanded eligibility: Enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteria1151624E2630Only enrollees who meet the specified targeting criteria per CMS requirementsMA-PDMA-PDOnly enrollees who meet the specified targeting criteria per CMS requirements

Total623100.0%E3014Only enrollees who meet the specified targeting criteria per CMS requirementsMA-PDMA-PDOnly enrollees who meet the specified targeting criteria per CMS requirements

E4744Only enrollees who meet the specified targeting criteria per CMS requirementsMA-PDMA-PDOnly enrollees who meet the specified targeting criteria per CMS requirements

E7316Expanded eligibility: Enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteriaMA-PDMA-PDExpanded eligibility: Enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteria

H0022Only enrollees who meet the specified targeting criteria per CMS requirementsMMPMMPOnly enrollees who meet the specified targeting criteria per CMS requirements

H0028Only enrollees who meet the specified targeting criteria per CMS requirementsMA-PDMA-PDOnly enrollees who meet the specified targeting criteria per CMS requirements




H0141Expanded eligibility: Enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteriaMA-PDMA-PDExpanded eligibility: Enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteria







H0192Expanded eligibility: Enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteriaMMPMMPExpanded eligibility: Enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteria



727H0294Only enrollees who meet the specified targeting criteria per CMS requirementsMA-PDMA-PDOnly enrollees who meet the specified targeting criteria per CMS requirements












































H1099Expanded eligibility: Enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteriaMA-PD
































































H2228Only enrollees who meet the specified targeting criteria per CMS requirementsMA-PD


































































































































































































H5141Expanded eligibility: Enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific targeting criteriaMA-PDMA-PDExpanded eligibility: Enrollees who meet the specified targeting criteria per CMS requirements and enrollees who meet other plan-specific ta

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