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How Payers Can Develop a Medication Therapy Management Program

Payers can develop a medication therapy management (MTM) program that improves adherence by improving engagement with beneficiaries.

MTM programs leverage specialized engagement strategies to improve medication adherence.

Source: Thinkstock

By Thomas Beaton

- As the cost of medication non-adherence reaches over $300 billion annually, payers are increasingly challenged to provide new solutions to address the healthcare and economic impacts of non-adherence. Payers could develop a medication therapy management (MTM) program to address the healthcare and cost implications of non-adherence.

Improving medication adherence can help reduce costs and significantly improve outcomes for beneficiaries with chronic diseases. However, a large portion of the US population doesn’t adhere to their medications even when they have life-threatening conditions.

The American Heart Association estimates that 147 million Americans do not take their medications as prescribed. The AHA also estimates that 24 percent of patients that suffered a heart attack do not refill their prescriptions within seven days of a hospital discharge.

A medication therapy management (MTM) program could be an effective tool for payers to teach beneficiaries how to maintain adherence. MTM is supported by specialized engagement that addresses the financial and educational challenges beneficiaries face when taking medications as prescribed.  

What should payers understand about MTM and what are some best practices that payers can leverage in order to implement their own MTM programs?

What is a medication therapy management program?

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According to the American College of Clinical Pharmacy, a medication therapy management program is a distinct service, or a group of related services, aimed at creating the best possible healthcare outcomes for members.

An MTM program works by designing a medication treatment plan for each individual patient and monitoring a patient’s response to medications over time.

A patient’s MTM treatment plan is designed through a process called a comprehensive medical review (CMR). CMRs are initiated by a provider contacting a beneficiary by phone or through a preferred communication channel. The provider then asks the patient questions about current health status and medication use to collect relevant information. The information provided by the patient is then used to plan a beneficiary’s necessary services and treatments throughout a year.

Targeted Medication Reviews (TMRs) are follow-up assessments between pharmacies and patients following a CMR. TMRs take place four times a year and usually take about 15 minutes to complete.

MTM is an ongoing process that is managed throughout a year to address potential issues or changes with a patient’s medication plan or health status. An MTM program records changes in a patient’s health status and provides educational support to help beneficiaries properly adhere to their prescriptions.

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Pharmacies also participate in an MTM program and qualify as an MTM provider if they secure the proper certification. MTM allows payers to contract with both providers and pharmacists to make highly informed medication management plans for consumers.

MTM programs are available for all ages but are common for older beneficiaries that are likely to have multiple chronic conditions. MTM programs for older members enrolled in Medicare or Medicare Advantage (MA) health plans must follow CMS guidelines.

Commercial-sponsored Medicare plans or MA plans must provide MTM services at no charge to beneficiaries that have annual prescription costs of $4044 or higher. CMS also advises payers to target at least five chronic conditions members may have out of the nine they specify.

These conditions include:

  • Alzheimer’s disease
  • Chronic heart failure
  • Diabetes
  • Dyslipidemia
  • End-stage renal disease
  • Hypertension
  • Respiratory disease such as asthma or chronic obstructive pulmonary disorder (COPD)
  • Bone disease and arthritic conditions
  • Mental health disorders including depression and schizophrenia

In addition, CMS requires payers to monitor MTM performance, and analyze MTM data, to inform providers and beneficiaries of necessary MTM changes.

What do current payer MTM programs look like?

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Payers develop MTMs to target specific chronic diseases among beneficiary populations, but older beneficiaries enrolled in Medicare or MA health plans are usually targeted by payers for MTM.

Commercial payers allow beneficiaries to participate in MTM programs at will but emphasize the benefits that members may receive from participation.

Tufts Health Plan provides a free MTM program for Medicare beneficiaries that have multiple chronic conditions. The MTM is designed to optimize a beneficiary’s medication usage to improve the safety and quality of medication therapy. MTM beneficiaries also benefit in the form of reduced drug costs.

For 2019, Tufts requires that members have at least three out of six specific chronic conditions to qualify. These chronic conditions include diabetes, COPD, hypertension, dyslipidemia, chronic heart failure, and asthma.

Tufts Medicare beneficiaries also need to have healthcare claims for six types of Medicare Part D covered drugs and expected annual drug costs of $4044, per CMS guidelines.

Qualified beneficiaries then engage in a CMR over the phone to develop a more efficient medication therapy plan. The review allows providers to make recommendations or amendments to pharmacists based on a patient’s chronic conditions and prescription history. Members also receive quarterly TMRs.

The MTM program structure used by Tufts Health Plan is practically identical to other models used by large commercial payers.

BlueCross BlueShield payers, Cigna, Humana, and Aetna all use annual and comprehensive quarterly reviews to tailor MTM programs for Medicare members. The conditions that qualify a beneficiary for MTM slightly vary between each payer’s MTM program.

Payers can also position MTMs as a way for non-elderly beneficiaries with chronic disease risks to save on their prescription costs.

For example, Minnesota’s State Employee Group Insurance Program (SEGIP) provides employees over 18 with the option of enrolling in an MTM for diabetes care.

Diabetic beneficiaries that participate in the SEGIP program receive multiple financial benefits including waived copays for medications, a $50 credit in a health reimbursement account for enrolling, and a $200 credit health reimbursement account for members that complete a lifestyle wellness program. The lifestyle wellness program teaches beneficiaries how to manage their medications and properly adhere to their prescriptions.

SEGIP’s MTM program address clinical diabetes indicators such as A1C, LDL-C, systolic blood pressure, diastolic blood pressure, aspirin use, smoking status, and BMI to inform medication planning. Members also meet with MTM pharmacists every three to six months, or as needed dependent on a person’s health status.

How is MTM beneficial for reducing costs and improving outcomes?

Expert organizations believe that MTM can significantly lower healthcare costs and improve outcomes for members with multiple chronic diseases. MTM’s focus on targeted interventions allows payers, providers, and pharmacists to potentially address key healthcare issues for beneficiaries.

The CDC found that medication therapy management programs have potential to improve chronic conditions and lower healthcare costs when administered by community pharmacists.

The CDC considers MTM a chronic disease management strategy that creates targeted healthcare inventions for members within communities. The organization emphasized the potential of MTM as a cost-effective tool to improve chronic disease care if local pharmacists are available to administer MTM.

MTM is an effective way to lower blood pressure and cholesterol and improve healthy behavior among beneficiaries, the CDC added. MTM can promotes patient education and potentially lowers the number of medications a patient needs by teaching members critical self-care skills.

An earlier CMS analysis of MTM programs found promising results when payers enrolled their Medicare beneficiaries into MTM.

Medication adherence for diabetic patients enrolled in MTM was 15 percent higher than patients not enrolled. Adherence increased between 11 and 40 percent for members with congestive heart failure enrolled in MTM.

MTM also reduced medication for members with chronic conditions, the agency said. CMS estimated that MTM reduced medication costs for members with hypertension and lympidiamia by $500 annually.

What can payers do to enhance MTM engagement and adherence?

Medication therapy management requires an effective engagement strategy to conduct CRMs and improve MTM services for beneficiaries.

UHealth Solutions, an affiliate organization of UMass Medical School, outlines multiple engagement strategies that can boost MTM effectiveness.

UHealth recommends that payers should staff call center personnel with diverse members that can speak multiple languages to minimize language barriers. Payers should also leverage automated technology to streamline CRM outreach and ensure members receive CRM reminders. Payers should also work with unique personnel including community pharmacists that are credentialed to administer MTM.

Payers can also support MTM by introducing new payment structures and risk scoring methods to identify patients with the highest need for MTM.

Payers could increase medication adherence by conducting risk stratification for patients based on key factors, such as frequency of medication use, side effects, and anticipated barriers to medication access. Payers may then use this information to develop targeted engagement campaigns for individuals that may benefit from MTM.

In addition, payers can change payment structures to promote adherence by eliminating copays and tailoring cost sharing based on a patient’s most critical medical needs. MTM models like the one used by SEGIP use financial benefits and rewards to increase medication adherence and promote healthy behaviors.

Tailored cost sharing is also an effective way to reduce financial barriers that impede many beneficiaries from adhering to their medications, says Dr. Mark Fendrick, Director of the Center for Value-Based Insurance Design at the University of Michigan.

“While I support the idea of consumers paying their fair share, a substantial majority of public and private payers design cost sharing in a one-size-fits-all way,” Fendrick said. “The fact is that many patients are being asked to pay more than they are able to afford for necessary medications or the healthcare services they actually need.”

MTM provides an opportunity for payers to tackle several issues related to poor medication adherence. An effective MTM program could fit perfectly into a payer’s larger chronic disease management initiative to lower overall care costs and improve health outcomes.


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