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Managing prescription drug use (and the associated costs) is a perennial challenge for Medicare Advantage (MA) health plans. As the MA population continues to get older with worsening health conditions, plans are facing increasing pressure to ensure members are using prescription medications safely, appropriately and in a cost-effective manner.
The latest push for improving the prescription drug environment comes in the form of major changes from the Centers for Medicare & Medicaid Services (CMS) to the requirements for medication therapy management (MTM) programs. MTM is designed to ensure health plan members with polypharmacy and multiple chronic conditions have access to a personalized comprehensive medication review (CMR) and medication management services from a qualified pharmacist.
Starting in 2024 or 2025, CMS is expected to significantly expand the scope of eligibility for MTM services. Changes include lowering the number of qualifying drugs from 8 to 5, lowering the annual cost threshold from approximately $5,000 to $1,004, expanding the number of qualifying chronic conditions, and requiring an interactive CMR consultation as part of the MTM process.
This will dramatically increase the number of members who will need MTM services (CMS expects a 14% increase in the number of MTM-eligible members), putting pressure on health plans to appropriately fund the staffing and technology required to ensure all eligible members get the right MTM interventions at the right time.
Plans will need to enhance their ability to identify eligible members and conduct timely, effective outreach to these individuals so they can resolve potential drug therapy problems (DTPs), improve adherence and, ideally, reduce avoidable spending on more expensive health problems down the line.
By reducing costly hospital and specialty services, health plans can start to improve their medical loss ratio (MLR) and use the savings to fund expanded MTM activities—creating a cycle of positive outcomes that can result in exponentially greater savings over time.
Plans shouldn’t wait too long to get to grips with these changes and accelerate their investment in MTM and associated medication adherence strategies. The first steps are understanding the best way to approach the problem and choosing an MTM partner that allows for maximum DTP identification for the best possible health outcomes and future cost savings, plus capabilities that allow plans to scale up their MTM plans accordingly.
Preparing NOW to address the anticipated MTM changes
The new CMS rules will significantly expand the scope of MTM. On the surface, it’s easy to think that providing MTM services that expand to accommodate an influx of newly eligible members will mean more expenses and less time for staff to complete other tasks. But health plans should not underestimate the long-term savings that can be generated from resolving DTPs and improving adherence as part of an otherwise conventional MTM approach. More than 125,000 preventable deaths and over $500 billion in unnecessary healthcare costs each year are tied to improper medication use.
Health plans can position themselves for significant gains in the future by leaning into the potential of MTM efforts. By taking time now to incorporate capabilities that focus on maximizing cost reduction from MTM efforts, plans can bolster cost savings opportunities, which, in turn, can fund future MTM capacity increases. It all comes down to choosing an MTM partner that will enable plans to strategically address the new rules expected from CMS, while reshaping their MTM program to focus on and improve cost reduction and achieving maximum MTM Star Rating performance.
Capabilities of a strong MTM partner
When considering increased costs of future MTM programs as noted by CMS, plans may be able to realize relief in the MTM partner they choose. By addressing three key pain points that come part and parcel with the expected program expansion, plans can begin to get ahead prior to rollout of the new rules:
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- Scaling the MTM program to address new member influx. Changes announced by CMS will result in an enrollment increase requiring MA plans to address the scale and complexity of plan administration in order to accommodate enrollment growth. An MTM partner that allows for flexible program tailoring can meet plans where they are and accommodate their shifting capacity demands accordingly. This includes the ability to offer technology in the form of Software-as-a-Service (SaaS) for use with the plan’s own clinicians, or a full package that includes access to the platform and directly employed clinicians, or even a combination that flexibly meets the needs of the client. A strong MTM partner will also be able to scale up rapidly to help the plan address volume fluctuations throughout the year and provide the combination of MTM services required to address different population cohorts or a temporary uptick in CMRs.
- Executing the MTM program to achieve both the Star Rating performance goal and drive improved medical claims cost reduction. Once plans have addressed their ideal method for MTM program scaling, they will need to execute on the expanded MTM effort strategically. In this way, they’ll begin to blaze the trail toward a 4.0+ Star Rating on the MTM measure through the following:
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- Accurate identification of eligible members. CMS-driven criteria determines which members are eligible for the MTM program and the associated CMR. The MTM vendor must have the capability to review the plan’s data and identify eligible members based on CMS specifications, including specific social risk factors (SRFs). Availability of an “eligibility estimation” tool—that allows a health plan to accurately forecast how many newly eligible members may be present within their current population based on the expected CMS program expansion details—can help the plan forecast just how much the MTM program may grow and what the anticipated program costs could become once the rules are finalized by CMS.
- Maximized CMR effectiveness. An integral part of the MTM program is the pharmacist-led CMR, designed to provide a full picture of a member’s current medication profile, for resolution of any DTPs the member may be facing. And the stronger the tools available to help identify care gaps, the stronger a CMR interview and associated pharmacist interventions will be at improving health and reducing health plan cost burden.
- By leveraging both medical and pharmacy claims data to identify the broadest possible set of DTPs, plans can set the pharmacist one step ahead for the CMR. Utilizing a robust and powerful set of data available through the alignment of medical and pharmacy claims, the pharmacist is empowered to deliver a more meaningful conversation and impactful clinical interventions around the patient’s potential challenges. A CMR supported by a data-rich, intelligent clinical workflow helps simplify the pharmacist’s ability to understand and drive the most optimal conversation with the member. A simplified and easy-to-use interface also enables a more guided and positive experience for both pharmacist and patient.
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- Real-time analytics available through the platform during a CMR can also help the pharmacist capture additional information to guide the patient interview, such as ICD-10 diagnosis codes (available only if the vendor is able to ingest medical claims) that would require an accompanying prescription, and thus indicate a treatment gap if that prescription is absent. J-codes (also available through medical claims) are helpful to indicate a prescription for a high-cost specialty drug—and could trigger a potential transition to a lower-cost alternative or administration site. Additional details like these can lead to cost savings for the patient and plan.
- Robust program monitoring. Availability of Web-based management dashboards supports success with the revamped MTM parameters. Interactive dashboards and reports give insight into program performance for monitoring and adjustment that support continuous success. It helps when views are refreshed daily to provide client stakeholders with full transparency into plan- and member-level performance, plus all key aspects of the program, including identification of eligible members, attempted outreaches, successful MTM completion and claims-based evidence of DTP resolutions and cost savings.
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- Funding MTM program expansion. Considering the increased costs of the anticipated MTM program expansion by CMS, the selected MTM partner should help to provide some relief to MA plans. Capabilities that help plans uncover and resolve the maximum number of DTPs, like the alignment of medical and pharmacy claims, allow plans to have a positive impact on member health through empowered pharmacist-led interventions (as described above). By maximizing DTP identification and supporting pharmacists in the most effective CMRs possible, a plan can maximize its identification and resolution of DTPs, paving the way for improved health outcomes down the road and avoidance of costly related medical services.
The inclusion of other critical pieces of information within medical and pharmacy claims—such as J-codes, ICD-10 codes or NDC codes—provide additional information and guidance to the pharmacist. These additional pieces of data from medical claims allow for identification of additional savings opportunities (such as transition to a lower-cost medically equivalent drug) and can lead to bonus savings. Overall, this full range of vendor capabilities allows a plan to maximize the savings potential, and the greater the cost savings, the more funds available to support MTM program scaling.
Getting ahead of expected MTM program changes to achieve higher Star Ratings
The right data modeling tools and analytics platform is the backbone of a strong MTM partner. This way, MA plans gain access to the capabilities that help identify eligible beneficiaries, understand their needs and empower pharmacists with the data that drives exceptional and efficient MTM activities.
Treating MTM with its intended purpose to improve member health outcomes while driving down costs is the key to getting the most from the program, as well as achieving a higher Star Rating on the MTM measure.
To learn more about the unrivaled capabilities available as part of an AdhereHealth MTM solution and to prepare for upcoming CMS MTM changes, request a consultation today!
