Magazine article Drug Topics

Beneficiary Participation in MTM Services

Magazine article Drug Topics

Beneficiary Participation in MTM Services

Article excerpt

There was some uncertainty at the outset about whether the Medicare Part D program would attract an adequate number of health plans as participants. At the direction of Congress, CMS was careful not to offer plan premiums at levels that would discourage participation. There is no doubt that the number of plans that responded exceeded the most optimistic projections, indeed to the extent that there is now concern about too many options and too many choices.

There also was concern about whether networks would ensure reasonable access to a range of pharmacy choices for Part D enrollees. As OIG recently reported, virtually all community pharmacies participate in at least some plans. Most pharmacies deal with all of the Part D plans offered in their locale.

Now some information is available about eligibility and participation in the medication therapy management (MTM) programs that were a requirement of Part D. To meet the legal and regulatory requirements, MTM programs must be designed in cooperation with licensed and practicing physicians and pharmacists to ensure that covered drugs are appropriately utilized to optimize therapeutic outcomes and that treatment plans are designed to reduce the risk of adverse events.

Rules and regulations

Regulations specify that MTM programs are appropriately directed to enrollees who have multiple chronic diseases, use multiple Part D drugs, and are likely to incur annual costs of $4,000 or more. However, plan sponsors have considerable flexibility in the design of their MTM programs. CMS reviewed 613 different MTM proposals for approval in 2007, each with its own procedures for identifying and enrolling eligible patients, offering different service providers and a variety of interventions. The intensity of the services proposed by die plans ranged from refill reminders to individual education sessions.

The majority of plans screen either monthly or quarterly to identify those eligible for MTM according to the plan-specific criteria. Ninety percent of the programs focus MTM services on persons with one or more priority conditions-diabetes, heart failure, hypertension, asthma, COPD, dyslipidemia, rheumatoid arthritis, osteoporosis, osteoarthritis, and depression. Nearly half the plans offer a range of MTM services. Some MTM services are voluntary, and some plans give enrollees the opportunity to opt out.

Overall, 10% of Part D enrollees met the criteria for MTM services offered by the PDP and MA plans in 2006. …

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