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MTM Innovation

Medication Therapy Management: Past and Future

Megan Jolley Milne, PharmD, BCACP

Learning Objectives

• Describe the history of MTM to establish a foundation for where innovation can happen.

• Evaluate innovative strategies to improve MTM.

• Compare MTM opportunities in Medicare and Medicaid.

Timeline of MTM History

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Medicare Modernization Act of 2003

• Part D created

• MTM is born

• Statute:

• MTM is designed to promote

• Enhanced enrollee understanding

• Increased enrollee adherence

• Detection of adverse drug events

• May be furnished by a pharmacist

Asheville Project

5

pre

pre

2005: What is MTM?

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http://www.pharmacist.com/mtm J Am Pharm Assoc. 2005;45(5):566-72

2006: Part D Begins

7

2008

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J Am Pharm Assoc. 2008;48:341–353

Part D Manual

9

Chapter 7 Part D Manual

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MTM in Part D

Part D plans choose MTM features:

• Who?

• In-house or network

• What?

• # Medical conditions

• Which?

• Medical conditions ≥ 5/9

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• How much?

• # Rx Claims

• Chronic

• When?

• Frequency of targeting

• Min. quarterly

MTM Eligibility

Rx Claims # Rx Dx

12

• Part D only• Must reach threshold

• 2015: $3,138• Divided by frequency of identification• Ex: quarterly ID = $785 in last quarter

• Plans can limit to chronic or specific classes

MTM Eligibility

Rx Claims # Rx Dx

13

• Plan sets minimum:≥2 or ≤8 Rx

• Issue• Nonadherence

MTM Eligibility

Rx Claims # Rx Dx

14

• 2 or 3 Chronic Diseases• Plan can limit this to a

specific list• At least 5 of Core list:

• Alzheimer’s• Arthritis (OA, RA)• Osteoporosis• CHF• DM

• Dyslipidemia• ESRD• HTN• Bipolar• Chronic Mental Health

• Depression• Schizophrenia• Chronic Lung Disorder• Asthma• COPD

2010 - Affordable Care Act

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CMS Standardized Format

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Medicare Part D 2014 Timeline

January 2014

CMS proposes sweeping changes for Part D

February 2014

CMS releases draft 2015 call letter that builds upon proposed changes in proposed rule

March 7, 2014

Comments for proposed rule and draft call letter due

March 10, 2014

CMS announces rescission of most of Part D proposed rule

April 7, 2014

CMS publishes final 2015 Call Letter

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Used with permission from AMCP

Medicare Part D 2014-2015 Timeline

May 2014

CMS releases final rule for 2015 without most controversial provisions

January 2015

CMS releases final rule for 2016 without many of the controversial provisions from the proposed rule

February 2015

CMS releases draft 2016 call letter and does not include the controversial provisions

March 6, 2015

Comments due to CMS on the 2016 draft call letter

April 6, 2015

Final call letter release

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Used with permission from AMCP

Enhanced MTM Model

• CMS opened the MTM innovation floodgates

• Plans can be paid for innovative MTM solutions

• Non-bid $

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Enhanced MTM Model Timeline

Sep/Oct 2015

CMS announces Enhanced MTM Model

Nov 2015

CMS provides webinar outlining interoperability standards for HIT

Dec 2015

CMS provides webinar showing cases of team-based care coordination using HIT

Jan 7, 2016

Requests for Applications due

Jan 1, 2017

Enhanced Model begins

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Used with permission from AMCP

Health IT & MTM

• HIT = Health Information Technology

• CMS’ Enhanced MTM Model should rely on HIT-Enabled Team-Based Care Coordination

• Teams:

• Interdisciplinary care teams

• Within health plan: disease and case management RNs

• Community: prescribers and pharmacies

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Enhanced MTM Model Timeline

Sep/Oct 2015

CMS announces Enhanced MTM Model

Nov 2015

CMS provides webinar outlining interoperability standards for HIT

Dec 2015

CMS provides webinar showing cases of team-based care coordination using HIT

Jan 7, 2016

Requests for Applications due

Jan 1, 2017

Enhanced Model begins

22

Used with permission from AMCP

Health IT & MTM

• Referrals back and forth

• Information interoperable between EHR, Rx databases

• Find source of “truth” in MTM

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Case #1: Prospective MTM

• Part D MTM is currently retrospective

• Innovation: identify prospectively

• New members to a plan

• Star Ratings for noncompliance

• Case #1: Medicare Advantage Dual-eligible Special Needs Plan (D-SNP)

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Star Ratings

Purpose

• Creating a referral process between the telephonic health risk assessment by nurses and the MTMP allows for:

• Seamless care for the member with fewer telephone calls from the health plan

• Coordination of care between MTMP and healthcare services/case management

• Decreased medical and pharmacy costs

• Rein-in medication costs before expenses incurred

Lessons Learned

• Need data

• Pharmacy claims from prior insurer

• Communication is key

• Extra patients identified

• Testing, testing, testing

• Ensure criteria match up

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True or False?

• Medicare Part D plans must reimburse retail pharmacists to perform MTM comprehensive medication reviews (CMRs) for patients in their pharmacy.

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MTM PaymentPa

rt D

Admin Budget

Overhead

MTM

In-House Pharmacist

Third-Party MTM

PharmacyRx Budget Rx

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Provider Legislation Initiative

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MTM PaymentPa

rt D

Admin Budget

Overhead

MTM

In-House Pharmacist

Third-Party MTM

PharmacyRx Budget Rx

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Part B

Medicaid States with MTM*

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Blue = state with MTM legislation*Not a comprehensive list

Case #2: Medicaid MTM

• MTM helps Medicare members

• Why not Medicaid?

• Targeted Medicaid Aged, Blind, and Disabled (ABD) members

• Leverage existing expertise in another line of business

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Expansion of MTMP into Medicaid ABD

• What number of members would we like to target?

• What percentage of members?

• What cutoffs would we like to use?

• Opt-in or opt-out?

• Who will manage it?

• When to implement? Targeted go-live date?

• What data to share?

Steps in Implementation of MTMP

• Determine algorithm of precise criteria for targeting

• # medications, # conditions, specific conditions, % of members? Opt-in or opt-out?

• How will targeting be completed: inside or outside MTM database?

• Level of output: just member? Just physician?

• Determine information needed in MTM database

• Pharmacy claims

• Medical claims (ICD-9/10)

• Lab data

• Death dates

• Long term care status

• HCC risk scores

• Frequency of data exchange

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HIT Implementation of MTMP

Star Ratings

HIT Implementation of MTMP

• Negotiate a contract with MTM Vendor database based on needs

• Create a BRD outlining where data will come from and who be responsible for each set of data

• PBM: Rx claims

• Health Plan IT:

• Demographics, eligibility

• ICD-9/10 medical claims from member database

Timing: 3-4 months for implementation

HIT Implementation of MTMP

• Create a project request for IT support

• Wait for approval, allocation of resources

• Guide IT in appropriate implementation

• Validate data in MTM Database, IT testing

• Deployment of formal files

• Training

• Go Live

Timing: 4-6 months for implementation

Inputs and Outputs

• Care coordination: what does each team need to know?

• Nurses: MTM MD and patient documents

Export PDF to case management software

Interoperability: field-to-field transfer

• CMR date, pharmacist’s name, drug therapy problems

• Pharmacists: level of case management care

Export list of patient’s care level, nurse’s name

Interoperability: case management issues, dates

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MTMP Integration within Medicaid

• MTM pharmacist-created progress notes are loaded into case management database and visible within member summary database for nursing staff

– Personal Medication List

– Medication Action Plan

– MTM Summary for Physician with action items

• Medicaid MTMP Pharmacists goal: provide care for members along with rest of Interdisciplinary Care Team

Need More Information?

Megan Jolley Milne, PharmD, BCACPmeganrph@gmail.com

Resources:

Academy of Managed Care Pharmacy

http://www.amcp.org/MTMResources/• • •

American Pharmacists Association MTM Central

www.pharmacist.com/mtm

www.pharmacistsprovidecare.com• • •

Center for Medicare and Medicaid Services

http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/MTM.html